Podcasts about specialty stories

Have you had trouble finding clinical experience during the pandemic? Does a crisis text line count as clinical experience for your application? Links:Full Episode Blog Post (https://medicalschoolhq.net/opm-246-is-crisis-text-line-during-covid-actually-clinical-hours/) Meded Media (https://medicalschoolhq.net/meded-media/) eShadowing.com (https://medicalschoolhq.net/eshadowing/) VirtualShadowing.com (https://virtualshadowing.com/) WebShadowers.com (https://webshadowers.wixsite.com/website) Nontrad Premed Forum (https://forums.medicalschoolhq.net/c/nontraditional/16) Premedforums.com (https://forums.medicalschoolhq.net/) Specialty Stories (https://medicalschoolhq.net/specialty-stories-podcast/) Mappd.com (http://www.mappd.com)

Session 116 Residency director and pathologist Michelle Dolan, MD joins me to talk about how to get the most out of your residency and what it means to slap glass. Specialty Stories is part of Meded Media. If you haven’t yet, please do check out all our other podcasts geared towards helping premeds, medical students, and residents along their path to medicine. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:45] Interest in Medicine Michelle initially didn't know what to do back in medical school until during her second-year pathology course. One of their lecturers encouraged them to do a pathology rotation. So she did and she loved it. She had to choose between Internal Medicine and Pathology. What drew her to Internal Medicine was hands-on patient care. But there were also some things that she didn't like. One of those five years could be a clinical intern year. So she decided to do an internship in internal medicine and she realized she really likes hospital care. This was before the advent of the hospitalist. She didn't like the clinical aspect but she liked the slower pace of pathology. [04:30] Traits That Lead to Being a Good Pathologist The ability to focus is an important trait to have in order to be a good pathologist. For instance, you need to be able to sit in one place for an extended period of time at the microscope or the computer screen. If you're going into anatomic physiology, a good chunk of your day is going to be spent "slapping glasses" where you just sit at the microscope and look at a lot of different cases. But not every field in Pathology is like that. One of the things that she likes about the field is how varied it is. You just have to be able to find that good fit for yourself. Because pathology is so varied, there are people who are very visual and love learning by seeing. There are also other parts where it's much more conceptual where you learn a lot by reading and thinking. There are other areas where you can learn by doing. To help you figure out which area to go into is to know yourself. [Related episode: The Pathologist as Medical Detective] [06:45] Pathology as a Varied Field There are not many trained pathologists that are cytogeneticists. One of the benefits of the Pathology residency is the exposure to every area within pathology. You can see what you like and you don't like, or what's a good fit and what isn't. Then you can plan your career from there. Pathology is a broad field in that they can look at a variety of patients from prenatal through geriatrics patients. They look at the entire lifespan. Moreover, pathologists get to know clinicians from a huge number of different fields. Michelle is also boarded in Molecular Pathology, which now goes hand in hand with Cytogenetics. There are so many tests now coming on board for molecular testing, most of which are housed in Pathology laboratories. Those connections among the different fields of medicine are only going to grow. [09:50] Increasing Exposure to Pathology All those being said, Pathology is not a required rotation in medical schools. This is a huge challenge because there's a striking decrease in the number of U.S. medical school graduates choosing Pathology. There's so much curriculum change in medical schools now that Pathology is getting shorted on some face time so it's difficult to engage students. To overcome this challenge, they try to be creative in coming up with ways to engage students. One of which is through a Pathology interest group. They also offer a Post-Sophomore Fellowship (PSF). It's an entire year spent between the first two basic science years and years 3 and 4. It's sort of a hiatus year where the PSF works like a Pathology resident. While a number of people who have done their PSF program have gone on into Pathology, there's also a good number of those who have gone into different paths.  It's a great year to learn your clinical medicine because Pathology requires a lot of knowledge of clinical medicine. Because they test a pretty broad patient spectrum, it's very helpful for people going into other fields to have a firm understanding of Pathology. [12:40] Breaking the Stigma There could also be this ego among students where they go into medicine thinking they want to save people's lives. So why go into something they "assume" can't have a big impact on people's lives. There is this weird stereotype around Pathology where people think they're sociopaths. And Michelle admits to still hearing interviewees for residency being questioned by other specialties on choosing Pathology when they're so good with people. This is a big point of contention for a lot of them in Pathology. So much of their jobs require interaction with clinicians. There's a very strong drive now in Pathology to be out there more interacting with patients.  They have initiatives like the "see, diagnose, and treat" put forth by the College of American Pathologists. Women from underserved areas would be able to come in and have a pap smear done. They'd be able to see those cells underneath the microscope. A diagnosis would be made at that time and interaction with the pathologist to be able to help them move forward with their care. Most pathologists don't have day-to-day interaction with patients. This was even hard for Michelle initially since she liked working with patients. That being said, there are also some downsides. You can't romanticize the daily work involved in dealing with patients.  [16:10] The Effect of Reimbursement Changes on Pathology Michelle admits she's being protected from this being in academia since they take care of billing for her. However, insurance companies don't reimburse well for some of the more complex testing that they want to do have. So they try to subsidize these by the bread and butter stuff so they can generate funding that will support some of the more esoteric testing. Pathology has a very large professional footprint in the College of American Pathologists that they have a very strong advocacy role in Washington. They've pushed very strongly for better reimbursement for pathologists. [18:50] Message to Medical Students on Rotation A lot of their resident applicants actually found themselves being less interested in the surgery, procedure, or direct patient care than they were about seeing what happened to that specimen they took. They were curious about what those cells were in the fluid. Typically, attendings on those other rotations are quite supportive when they realize someone has an interest in Pathology. They actually encourage them to follow it up in the Pathology lab. Michelle recommends that third and fourth-year medical students on rotation should familiarize themselves with their hospital laboratory. You have to understand how tests are properly validated. Know the strengths and limitations of those tests as well as the positive predictive values and negative predictive values. These things seem esoteric but they're very important to know. Much that goes into laboratory medicine is knowing the backstory of those results. A lot of test results are automated results. But you can't just buy any instrument out there. There are extensive validations needed.  You need to understand false positives, false negatives, sensitivity, specificity, etc. How low can you go to detect someone with minimal residual leukemia? How confident are you in saying that there's no disease or there's a little bit of disease? These are all important things that are easy when you're on the wards, you say all those numbers. But there's a lot that goes into it. The more that you know about that, the better off you and your patients will be. [22:50] A Day in the Life of a Pathologist A typical day of a pathologist primarily depends on their type of rotations. They offer both anatomic and clinical pathology. The anatomic pathologists look at tissues coming from patient in surgery. Clinical pathologists are involved in hematopathology. They look at bone marrow biopsies. They are the clinical chemists, cytogeneticists, molecular diagnosticians, immunologists, and blood bankers. So it depends on what rotation the resident is on. If they're on anatomic pathology rotation, they are looking at slides most of the day. They may be grossing in specimens. This means they're processing specimens so they can cut them and get them onto the slides. Then they look at them under the microscope. They may be doing frozen sections running back and forth between the O.R. and the grossing room where they do immediate evaluations of tissues. In cytopathology, they may be out doing a fine-needle aspiration or an adequacy assessment if someone is having a procedure done under ultrasound or interventional radiology guidance. In a clinical pathology rotation, they're on blood bank. They may be out doing transfusion reaction workups. They may be consulting on apheresis patients. If they're a hematopathologist, they may be out doing a bone marrow biopsy or evaluation bone marrows under the microscope. Michelle clarifies that although they're not directly involved in patient care, they still want to help patients. They're helping patients by looking at and processing all of these specimens properly. [25:10] How to Be a Competitive Applicant Some of their applicants will almost do a mini-residency where every one of their rotations has been skewed towards pathology. This is not a bad thing actually. But she tells them that they have four years to become a pathologist. What she really likes them to learn well is clinical medicine. So really do good, focused clinical rotations. They will help you become a pathologist. Of course, you should do a basic pathology rotation. This will allow you to figure out if you're a good fit. And also, this will help you develop a good working relationship with a mentor who might be able to give you a good letter of recommendation. It is helpful for program directors to know that the applicant actually knows what pathology is all about. So they don't come into it thinking it's all just forensics or autopsies. Again, know clinical medicine as best as you can. Moreover, pathology has the aura that your answer to a given specimen is the only answer. But this is not true. They consult themselves a lot. There's not just one answer to things. There's often not a definite answer that people are expecting. [28:00] Overcoming Bias Towards DOs Michelle says that they've never seen any bias towards DOs. In fact, a lot of DOs come through their program. They have a lot of applicants who are DOs. One of their strongest residents was a DO who just left for a cytopathology fellowship. So she gives the same advice to interested DO applicants to know clinical medicine. That being said, she has never come across any bias towards DOs. [29:05] What Makes a Great Pathology Resident No matter what field of medicine you're in, you will get out of residency what you put into it.  So they want to see someone who's really interested in Pathology. One has to have the drive and they want to see things, participate, and actively do things. A resident can't be exposed to every entity that's in pathology textbooks. They're going to have to do a lot of independent learning and reading. They have to look at the great images that are now available online. They want to see some of that initiative. Get early, stay late. Participate in as many as different conferences as possible. Ask questions. Moreover, they've had people who would seem they'd struggle if it were just based on paper. But they've overcome that. They're stronger for it. Michelle explains that they are liberal in the sense of not judging people on paper. They're willing to give people a second chance.  Another misplaced emphasis is trying to do a mini-path residency as explained earlier. You have multiple areas you've done rotations in instead of just focusing on your clinical knowledge.  [33:15] What She Would Have Told Her Younger Self Michelle would probably tell her younger self that just because you're looking for the perfect fit, don't worry, you will find that square hole eventually. Keep an open mind. For instance, Michelle kept her forensics rotation to the very end thinking she was going to hate it. But she loved it! Had she just had an open mind and done it a bit earlier, her whole career might be very different since she was already doing her fellowship at that point. Be patient with yourself. They met a number of applicants every year that didn't find anything that really clicked until they did their pathology rotation. [36:02] The Most and Least Like Things Michelle loves interacting with clinicians. She finds it very rewarding as she's able to get a sense from them as to what their struggles are. This way, they'd be able to determine what is needed for them to make a diagnosis and how to help them. They've made some calls that have literally been life-saving. Those may not happen everyday, but they do happen frequently. On the flip side, what she likes the least is the feeling that there is so much in pathology that you can't master. There's just so much to know. And it's becoming more subspecialized. They also have to realize the fact that they're not immune to making mistakes or misses that have significant negative ramifications on patient care. It can be a difficult, almost paralyzing fear that you can develop. You just have to make the best decision and best diagnosis you can and move forward. [37:50] Major Changes in Pathology Michelle thinks that all of the major advances in genetics and genomics is huge. Most of these targeted drug therapies are driven by molecular diagnostics. It's a specialty field you can do a fellowship in Pathology. Personalized medicine and informatics are two other huge areas. Particularly, computational pathology is tied into informatics. [39:35] Final Words of Wisdom Pathologists constantly encourage students to be interested in pathology. They're saddened by why U.S. grads are not turning to pathology as both a great career choice and a great lifestyle choice as well. They have many switchers to Pathology. So just try to get to know a pathologist. Call the lab director. Call the hematopathologist and ask if you can review the slides with them. There are insights that you can get that you cannot get just from reading a report.  Understand what it is that you're seeing so you can understand the patterns. So when you're on a medicine rotation or a peds rotation, you can understand these things without necessarily going into Path. Links: Meded Media

Session 24 We're joined by Dr. Karen Shackelford from BoardVitals as we talk about hepatitis and how antigens and antibodies appear and disappear during the course of infection. Please also check out Specialty Stories, a podcast dedicated to helping you figure out what specialty you want to practice. Listen to different physicians as I interview them about why they chose their specialty, what they like and don't like about it, and much more. Maximize your Step 1/Level 1 prep by checking out BoardVitals. Check out their 3 or 6-month plan where you get access to there over 1700-question QBank. Get detailed explanations and rationales for every question targeted to the Boards. Use the promo code BOARDROUNDS to save 15% off. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [02:20] Question of the Week A 45-year-old male presents a sudden onset of flu-like symptoms and yellowing eyes which he thought looks scary to him when he saw his reflection on the mirror. His past medical history reveals positive Hepatitis B infection and his lab's elevated ALT and AST levels. The consult suspects that he may not be superinfected with Hepatitis D. Hepatitis D virus can only propagate in the presence of Hepatitis B. The presence of which of the following components of Hepatitis B viral protein is necessary to allow Hepatitis D infection? (A) HpX (pX antigen) (B) Hepatitis B core antigen (HBcAg) (C) Hepatitis B surface antigen (D) Hepatitis B  e-antigen (E) Hepatitis B virus DNA polymerase [Related episode: What Does Academic Infectious Disease Look Like?] [03:35] Thought Process Behind the Correct Answer The correct answer here is C. Remember the actual viral structures. Hepatitis D envelops single-stranded RNA virus. It can't make its own surface antigens. So it requires Hepatitis B surface antigen. Hepatitis D can only be acquired either by co-infection or superinfection of an HPV carrier of co-infection. But this only resolves in 2% of the cases. HPV is a virulent pathogen.  Superinfection results in chronic hepatitis in over 90% of cases. Often, hepatitis with rapid progression of cirrhosis in about 80% of cases. But the influx of this type of viral infection has significantly declined since the development and widespread use of the Hepatitis B vaccine. However, this is still a problem in developing countries. In a lot of underdeveloped countries, it's passed on through migrants from more developed countries. It's therefore important for people to be aware of their Hepatitis B immunity and their potential for this really virulent superinfection. [Related episode: USMLE and COMLEX Prep: Tropical Medicine—Dengue Fever] [07:35] Understanding the Wrong Answer Choices Hepatitis pX is pX protein of Hepatitis B virus. It's implicated in viral transcription, replication, and increased risk of hepatocellular carcinoma through the expression of this X protein gene. The core antigen is the indicator of active viral replication. It's also a determinant of whether an individual is able to transmit the infection. But this is not the necessary component for the protein. Hepatitis B e-antigen can act as a marker of our replication infectivity but this isn't the necessary component either. Hepatitis B virus DNA polymerase is not necessary for HPV to replicate. HPV is the host hepatocyte, while the polymerase works to produce that complementary RNA. Links: BoardVitals  (Use the promo code BOARDROUNDS to save 15% off.) Specialty Stories

Session 102 Dr. Ryan Matika Residency Program Director in Anesthesiology talks about what he's looking for in his applicants. He also shares what his residents look for when students are doing rotations. Specialty Stories is part of the Meded Media. If you haven’t yet, please check out all the other resources we provide to help premeds, medical students, and residents on their medical journey! [01:07] Interest in Anesthesiology Ryan got interested in anesthesiology when he was in his second year in medical school. They had a program where they were assigned a mentor who happened to be an anesthesiologist.  He went into medical school not thinking about anesthesiology. In fact, he was leaning into internal medicine. But from his rotations, he eventually got drawn towards anesthesiology. He thought about this halfway through his third year because of his mentor. Ryan thinks there is a major element in picking your specialty based on the personality and that element of finding your people. There's a certain type of personality that's a better fit for a specialty than others. But that said, he doesn't think any specialty has one personality. [03:10] Traits that Lead to Being a Good Anesthesiologist The longer he has done this, the more he thinks that there are more traits to being a good doctor. Those traits pretty much transcend the type of residency. He thinks all residents of different specialties have a lot of things in common. First is what drives you, what keeps you up in the morning. That type of work ethic and that type of positive drive would make good residents. For anesthesiology in general, they're meticulous. Although being OCD is not necessary, but you might notice a lot of OCD behaviors evident in anesthesiologists. [05:10] What an Anesthesiologist Does They say that the only thing an anesthesiologist does is putting patients to sleep and waking them up after surgery is one of the misconceptions. There are times your services are requested by a surgeon and part of that is keeping patients calm. But one of the most important things is delivering the anesthetic methods essentially rendering someone in a medically induced coma to tolerate surgery. Also during that time, you're managing the patient's physiology, most importantly the cardio and pulmonary physiology. They could give medications to make patients very hypotensive. The patients can be put through all kinds of cardiovascular difficulties and you have to manage them through. The anesthetics would give necessary poisons and the management they do is to offset those poisons in a healthy patient. And this could get even more tricky for patients with chronic, significant or uncompensated diseases. A lot of the time is focused on physiology and the vitals. While a little bit less time is spent on ensuring that patients are in a medically induced coma as they have to ensure patients are asleep throughout the surgery. [07:40] The Residency Training Path There are two types of programs – the categorical and the advanced programs. Almost everything was advanced in the good old days. Then categorical has gotten more popular. the difference is how you treat that first or intern year. About 75% of the spots are categorical. When you match with an anesthesiology program, you're doing a four-year program. But the first year is essentially mostly off-service rotations. Its purpose is to meet the qualifications of your intern year which is either a medicine year or a surgery year. The advanced year is where you match those two years into separate ones. So you have the intern year where you match into a medicine transitional or surgical year. Then you start your formal anesthesiology three-year training afterward. During those three years, you do the same cases over and over again. You do more simplicity, a lot of airway work. You're getting the basic skills you need for anesthesiology. During the latter half of your residency, you're doing subspecialties. You deal with much sicker patients such as cardiac cases. Each program has a different way of doing that but essentially, there are more similarities than there are differences. After four years and you've met all of your requirements, you can then sit for your final written boards. [09:50] Manual DExterity for Procedures: Is This Necessary? The most important thing you have to have is your mind. The cerebral side of it is the hard part. In terms of the procedural part, anybody with two hands can be trained to do the procedures as you will be doing it over and over again. In fact, Ryan has never seen a resident that has not completed training because of a procedural aspect. 90% of the problem with residents would be medical knowledge or professionalism. And 0% with procedures. There are some people who are better sooner than others but everybody will get there. [11:05] What They Look For in Applicants Generally speaking, one thing that has changed about applicants is the basic exam, which is part of the American Board of Anesthesiology done at the end of your PGY. You need to pass this exam to be able to complete your residency. So they always look at your USMLE scores. They essentially tell you how good you are in studying and passing an exam. Many programs have a certain average score they're looking at. If you have a lower score than that, then you may have to make up for it with different qualities. Ryan personally looks a lot at the Dean's letter, your medical school transcripts, the comments made, grades on your clerkships (particularly medicine and surgery). Most people have positive letters of recommendation. There are various levels of strength on that. So this may be a little bit less important than the other two mentioned above. Another thing that gets underestimated is the volunteering aspect. They want to see students getting more involved with different activities at their medical school or at their local communities. They basically want to see what you were doing during your medical school time beyond just studying and getting the best grades possible. Research is not necessary. But Ryan takes this into account in looking at grades and scores but it doesn't necessarily overcome a bad grade. [16:10] On Pass/Fail System Ryan admits that the ability to evaluate students based on the pass/fail system can be more challenging. A large percentage of medical schools has already gone to not give a class rank. The opposite effect is what they were going for. There's only one score to tell you about their academic abilities.  Making USMLE's into a pass/fail is fine. But now they're going to have to put more emphasis on different factors. They want more information. The board exam process is very difficult. It's not something to be taken lightly. [18:49] On Away Rotations Ryan has done round table events at their schools and he's one of the few people who think that away rotations aren't much help. He personally thinks that away rotation only helps you at the program you're interviewing at. It doesn't really help much when you're going out on your interviews. If there's a program you're really interested in or if you have a place to stay with then that's totally fine. But with the medical school debt and the financial concerns in medicine, the cost of it to go somewhere and rotate wouldn't pay the dividends unless you're really set on one location. [21:55] On Osteopathic Medical Students The osteopathic medical students have been increasingly been more successful in getting anesthesiology spots over the last 10-15 years. You're now seeing DOs in spots that you won't previously see.  Ryan says that the DOs at their programs typically have a little bit higher board scores than the allopathic residents in general. But it's only a minor difference. [23:35] What Makes a Good Anesthesiologist Ryan explains that they look for qualities like work ethic, personality, and professionalism. A lot of anesthesiologists are introverts. So you don't have to make small talk or be the most likable person in the world. You must be willing to help, want to know more, and ask questions. Another important thing is for residents to be able to follow directions. But procedural skills are often emphasized by applicants than they are by their faculty. Hence, you really don't have to worry about the procedural aspect. If you really don't enjoy the procedures and dread doing it hen it's a nice thing to know that this is not a great fit for you. You should enjoy it but you don't necessarily have to be good at it.  [28:00] Personal Statement Tips After reading so many personal statements, you start to see certain trends in personal statements. The most important thing outside of the why and "tell me about yourself" is explaining any kind of deficiency in your application. Ryan needs you to explain what went on in a greater context. This needs to be explained and acknowledged in the personal statement. Ryan isn't sure if a great personal statement makes up for any trouble on the application. But a bad personal statement could raise a few eyebrows and lose you a few interviews. Bad personal statements are going to be things that are too negative. [30:45] A Typical Day in the Resident's Life When you're on your medical student rotation in anesthesiology, you're already getting a piece of it. The classic anesthesia medical student rotation is you come in early and leave early.  The residency is not going to be like this. You've got to come in early and you've got to stay late. This means long hours. As an attending physician, you come in early in the morning. As a resident, give yourself around 20-30 minutes to set up for your case. This means getting your medications, monitors, and equipment ready. If you have morning didactics, you'd have to come in earlier. Then you'd have to go see your first patient in the morning. You can look up the patient the day before so you can have a plan. The next morning, you see the patient and ensure they're ready for surgery. You get their IV in (depending on the institution). When it's time to go back, you're going to take that first patient back. If it's a cardiac case, it's going to take longer since there is more pre-evaluation. Throughout the day, you're going to be doing a variety of cases if you're in the operating room. It's a lot of work to stay vigilant. It's a lot of work to get different cases going. Just like you're taking off and landing, you're going to be doing that for each patient. You really need to individualize things. If you're at a tertiary care center, you're going to have some very complex patients. Each patient needs a careful evaluation. As for the resident level, this needs to be done the night before so they have time to prepare, research, and plan out. The simplest part of it is how to keep them asleep. But the most difficult part of it is how to keep them safe throughout the surgery. [34:20] Taking Calls Calls vary greatly between residencies. They can be specific to a rotation or they can just be a general pool for different services. At their program, different rotations have different calls. When you're doing the general emergency cases, usually residents do one to two nights a week and one to two weekend nights a week. [35:40] Final Words of Wisdom There are a lot of spots for anesthesiology. There are about 1400-1500 spots in the country per year. So your chances aren't bad even if you have some issues with your grades. In general, applicants with lower board scores have to really focus on their clinical rotations. Make this your priority. Also, take a month off after your third year is over. Really dedicate yourself to the Step 2 exam. A much higher Step 2 and a low Step 1 is fine with them. But it can be concerning to have two low Step scores. Ultimately, they need residents that they know are going to pass the boards. If possible, try to get some face time with a program director or someone involved in the selection process. Links: Meded Media

Session 19 Today, we have Dr. Karen Shackelford from Bard Vitals, joining us as we break down another question. Meanwhile, have a look at Meded Media for more resources available to premeds and medical student. Another podcast medical students could listen to is Specialty Stories, where I talk to different physicians about their career and their specialty. They talk about why they chose it and what they like about it. Also, learn about what you as a medical student could be doing to make yourself more competitive for this specialty. [01:40] Question of the Week: A young woman is 26 weeks pregnant. She's 25 years old. Gravida 1 Para 0. 26 weeks gestation. She came into the emergency department complaining of leaking vaginal fluid for about three days, not huge, just some leaking. She's had some intermittent contractions but they're fairly infrequent. A sterile speculum exam is performed. It revealed some pale, yellow, watery fluid in the vaginal valve. Her cervix is dilated 4 cm. The vaginal fluid is tested, has a pH of 7.1. This is at an academic center where they still do the Fern test with arborization when the fluid is examined under a slide. An ultrasound is performed and it reveals oligohydramnios.   Which of the following measures is appropriate in the management of this patient? Her lab results and her pee is negative for Group B Strep. (A) Ovarian section (B) Flush immediate delivery (C) Antibacterial prophylaxis for Group B Strep (D) Tocolysis (E) Supplemental progesterone [03:30] Thought Process There is a premature rupture of membranes (PROM). If it were a placental abruption, we can take it to a C-section. But for PPROM (preterm PROM) before 37 weeks, you want to delay the delivery as long as you can. So the correct answer here is the antenatal steroid therapy to mature the lungs. Most women who have PPROM deliver within a week. If it is within 7 days, you should initiate the steroid therapy. The management of PPROM would depend on factors like the gestational age, the presence or absence of infection, presence or absence of labor, any sign of abruption. Fetal stability and heart monitoring should also be managed. The American College of Obstetricians and Gynecologists (ACOG) recommends that women who have PPROM who are more than 34 weeks of gestation should deliver. But it doesn't need to be a C-section. Normal spontaneous or induced vaginal delivery is fine. In women less than 34 weeks, the pregnancy should be managed expectantly just until fetal maturity development. As long as the fetus is stable, the fetus will benefit by prolonging time in the uterus. Having the antenatal steroids will improve lung maturation. But you have to balance that with the benefits like expectant management against the risks associated with like a prolonged PPROM. Placental abruption is an increased risk as well as cord prolapse or cord compression. [06:40] Looking at the Other Answer Choices In the lab results, the patient had a negative Group B Strep test. Antibacterial prophylaxis for Group B Strep is indicated if somebody delivers within 48 hours in an unknown status or a positive test. But you give these patients antibiotics as it prolongs the latency of the pregnancy. It's generally associated with better fetal results. It reduces respiratory distress syndrome and neonatal death. It reduces the risk of intraventricular hemorrhage, necrotizing enterocolitis, and all preemie problems. It also reduces the duration of neonatal respiratory support needed. There's no increase in maternal or neonatal infection to balance that. ACOG recommends the corticosteroids that present between 24 and 34 weeks of gestation. And if you had an earlier pregnancy, you would give antibiotics in those cases. So Group B Strep prophylaxis is indicated. ACOG would recommend erythromycin. Some doctors will prescribe Zithromax because it's easier to take. They also recommend IV ampicillin and oral amoxicillin. There are no data to support so it going to cover a large variety of vaginal pathogens. So the antibiotics would not be for Group B Strep but to prolong the pregnancy latency. Tocolysis is inappropriate in this case because the patient is in active labor with cervix dilated to 4cm. With any woman who has more than 4cm of dilation or signs of chorioamnionitis or nonreassuring fetal stress test, these signs of abruption are the same thing. The only setting for tocolysis to be indicated in this setting is to delay delivery again for 48 hours to allow the glucocorticosteroids to take effect. But this should never be given for more than 48 hours. So you're not going to delay delivery that long given that most women deliver within a week. [10:00] BoardVitals Check out BoardVitals and use the promo code BOARDROUNDS to save 15% off your QBank purchase. Whether you're studying for the COMPLEX or USMLE, BoardVitals has the QBank you need to help prepare you the best possible way. Text BOARDROUNDS to 44222. Receive a URL and the coupon code you can use to save 15% off of BoardVitals QBanks. They have some of the most comprehensive QBanks out there. Get 24/7 access to over 1,700 questions in their USMLE Step 1 QBank and get detailed explanations and rationales for all the answers (both wrong and right). A vaccine will be donated with every new purchase. Links: Meded Media BoardVitals (use the promo code BOARDROUNDS to save 15%)

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

Session 70 Dr. Daniel Clearfield is a Family Medicine trained physician who specializes in Sports Medicine. Listen to how he got into the field and what he loves about it. First off, The Premed Playbook: Guide to the MCAT is now available on Amazon, Kindle, and Paperback. Just a reminder, you don't have to have a Kindle device to read a Kindle eBook. You can use a Kindle app on every device you have. It's $4.99 for the Kindle at this point and $9.99 for Paperback. Please help us find guests for this show. If you have physician friends, family, and people you work with whom you think would be a good guest here on Specialty Stories, where we also haven't covered their specific specialty and setting, shoot me an email at ryan@medicalschoolhq.net. Listen to The Premed Years Podcast Session 273, especially if you still have some questions about osteopathic medicine. Dr. Daniel Clearfield is a family sports medicine physician who's been out of training now for seven years. He used to be in Academics nut now is in Private Practice. He's going to talk about his specialty with us today. [02:00] Interest in Kinesiology Daniel found Kinesiology as a major in college during his Sophomore year. He started studying mechanical engineering but didn't like it. Then he started doing Kinesiology and just loved it. At that time, he was already a personal trainor and learning about the anatomy and biomechanics exercise and physiology. Trying to figure out how he can continue with it, he found there were different paths you can take. A lot of people in his major ended up becoming coaches or personal trainors. Others started looking into physical therapy as well as other paths until he found primary care sports medicine as something that appealed to him the most during externship. Although he was open-minded to other specialties, it was still something he was passionate about and it was what he ended up doing still. "It was like that whole scope of family medicine where you can see from cradle to grave. You're not really limited as to what you can see or do." Daniel did consider different specialties but what really drew him to sports medicine is the fact was being able to see patients of all ages. Plus, the fact that you're not limited to what you can see or do. In some sense, you will have a limited scope. That being said, Daniel says primary care sports medicine allowed him to delve into all of the different things that can involve a family doctor they might see from a broad scope of things, and focusing more into the sports/ movement aspect. Daniel also shares that one of the things he sees a lot of physicians suffer burnout from is noncompliance of patients, who are just apathetic about doing things to better themselves. "One of the things he sees a lot of physicians suffer burnout from is noncompliance of patients." [06:10] Traits that Lead to a Good Sports Medicine Doctor Daniel says that you have to be a personable as you'll be seeing a wide range of patients. And although you don't have to be an athlete to be a sports medicine doctor, it helps. Daniel's main sport in high school was wrestling. He has also done football and other different sports. He experienced suffering from a lot of sports injuries so he's able to empathize more with his clients. "Being an athlete, having that mindset, that definitely is something that helps in sports medicine. Anybody who was an athlete gets that mentality and is able to better connect with their patients." In fact, Daniel recently attended the annual sports medicine conference and he saw that everybody was in great shape. [08:00] Types of Patients "I tell people I'm not a surgeon.I'm not looking to try to do surgery. I know my limits." Daniel says he covers patients from toes to nose. He will see anything from broken stub all the way up to nose fracture. He sees fractures, dislocations, etc. He tells people he's not a surgeon. In fact, an ankle fractured patient was referred to him today and knowing his limitations, he referred it over for a surgical evaluation. He explains that most fractures don't have to go see an orthopedic surgeon necessarily since they know how to manage this type of things. That said, he sees the common sprains, strains, fractures, dislocations, concussion. Daniel has become recognized as one of the concussions experts in his area (north Texas). And he considers this as both a blessing and a curse. Although he knows what to do with it, some of the cases they have to deal with are so complex. What Daniel really likes about how mentally stimulating his practice can be. And just like any part of medicine, it's a lifelong learning experience. So he still keeps on learning, teaching, and going to conferences. And this is the reason his scope of practice continues to grow. "Unless you really limit your practice, you're going to be challenged. You're mentally going to be very stimulated...just like any part of medicine, it's a lifelong learning experience." [11:20] % of Patients Coming In Who Are Already Diagnosed Daniel actually corrects this question as to how many patients are coming to him with a diagnosis that's correct and need further verification. He adds that it sometimes depends on who your referral source is and what setting you're in. Daniel also says he's able to figure things out because he reads and learns a lot. He has even seen patients that have been to the Mayo Clinic, were not diagnosed there, and he was able to figure it out. Not the best diagnostician, but he admits he's pretty good who can figure out some things others can't. [13:15] A Typical Day Daniel has a variable schedule but he works 5 days week with a 40-hour week schedule. This is part of his routine. During football season, he would start working Friday nights and if needed, he'd go to a training room with the athletic trainors at one or more of the high schools he covers. He covers them at least once a week to try and go see some of the athletes just at point of care at the school. Outside of football season, his schedule varies depending on events happening around his area. He does have plenty of weekends where he's free but there's also plenty of time that he'd be working at tournaments. "There's plenty of times where I have my weekends free but there's plenty of times that I find myself working at tournaments." A lot of these events he's just volunteering at. It's a mix of being a wrestler and loving those combat sports and being a team doctor with USA wrestling and judo. He found himself covering those events when they come to Texas. It's a passion that he enjoys. He likes to bring medical students and residents so they can experience and see what goes into the mindset of the sports medicine doctor covering those things. There would still be times that he'd be doing a procedure on every single patient in a single day. Other days, he would not be doing any procedures all day long. More commonly than not, he'd be doing procedures. For example, he did 11 procedures from 8:30am to 2pm. [16:20] Taking Calls and Work-Life Balance Daniel doesn't take calls and he says it basically depends on the kind of practice you're in. He's the only sports medicine doctor in a family clinic. Typically, there'd be a call one night a week and then a weekend call once a month, which isn't that bad. But for the most part, he doesn't get too many calls and never had any really serious calls that he had to go after. One time, he recalls getting a call and he was out in Colorado rock climbing with his friends. He was half way up the mountain, heard his phone ringing, so he had to stop what he was doing. So he answered the call while he was about 100 feet up in the air. Not the smartest thing, but a cool story to tell. Back when he was also teaching, they would also be in a similar call which wasn't too bad. Orthopedic surgeons realized there were three of them not orthopedic with two sports medicine doctors and one of his colleagues was a primary care sports med. They also had one physiatrist (PM&R) doctor with them. None of them took the ortho post operative call from the hospitals but they took any of the clinic call. So they had to divide it into clinic call and hospital call. They weren't part of the hospital call. Daniel says he has enough time for family. Being a single father, he has full custody of his daughter. Looking at the type of job he's in, he makes sure he has time to watch his daughter grow up and be there for her. This is a huge priority for him. Earlier in his career he'd always say family was first but there was a time especially while he was going through his divorce where he was just investing his time in his work because he didn't want to go home. So he began shifting his priorities when he got custody of his daughter who is his absolute number one. So he set up his schedule in a way that affords him a lot of time to be spent with her. [19:05] The Path to Residency Training Going through medical school and you know you want to be a sports medicine doctor, it's good to start doing some coverage opportunities especially when you're in your first couple of years because that where's there's a lot of opportunities. "It's good to start doing some coverage opportunities especially when you're in your first couple of years because that's where there's a lot of opportunities." This means getting on the sideline for football games, showing up at pre-purchase patient physical events. Make sure you go out there and be in boxing or wrestling tournaments. Get saturated with those sports medicine experiences in your first two years to figure out if this is something you're interested in doing. Initially, Daniel wanted to do a sports medicine rotation but he knew he had to figure out what he really wanted to do and where he wanted to go. And once he figured out he wanted to do family medicine in his third year, then he figured out where he wanted to go. He then used a lot of his elective rotations in fourth year to do auditions all over the country before he was able to settle on a good program for it. "The thing is sports medicine is not a primary specialty, it's a subspecialty." Currently, there are six different paths to primary care sports medicine that you can take - family medicine, internal medicine, emergency medicine, pediatrics, physical medicine & rehabilitation. Then in the osteopathic world, you can do neuromuscular medicine/osteopathic manipulative medicine. From the neurology end, there's one program at the University of Michigan where they have a sports neurology fellowship that you can do from there. For orthopedic surgery, after you do a five-year ortho residency, you can do a 1-2-year  sports medicine fellowship from there. For physiatry (physical medicine & rehabilitation), they have their own specific sports medicine program as well. Then you can do either a primary care sports medicine fellowship or a physiatric sports medicine fellowship. Additionally, before you can be a good sports medicine doctor, Daniel says, is that you need to be good at whatever your primary field is because you're going to branch off from that. "You need to be good at whatever your primary field is because you're going to branch off from that." As to competitiveness, Daniel describes the subspecialty as a pretty competitive one. He was fortunate to get into one himself but he really worked hard to set himself up to be a very good candidate. He has had mentees that has gotten sports fellowships and one of them he thought to be a really good candidate. But he didn't get in for whatever reason the first year he applied but got into second year and re-applied. He was persistent, went back and worked for a year. Now, he's out in practice and doing well. That being said, you have to be able to groom yourself to be good. Show that continuity. Even if you did well on your boards but if you didn't show that kind of passion for this field then it's going to sway program directors from taking a look at you. From a research standpoint, there are programs that have academic-type requirements where you need to make sure you have some sort of academic work. As a fellowship director back then, he made sure their fellows produce at least one case presentation and one research project and looking to get those published as well. At the very least, have a presentation you put together or a podium or poster presentation to make you a better candidate. [25:35] Bias Against DOs Daniel admits he felt discriminated as a DO in some places. For the most part, a lot of the ACGME allopathic programs have open arms and they openly accept DOs into their program. A couple they found were a bit restrictive where they would have wanted you to have gone through an ACGME residency program. Although this could already be changing with the ACGME merger happening. "For the most part, a lot of the ACGME allopathic programs have open arms and they openly accept DOs into their program." He adds that when he goes to national conferences that are both DO and MD, he finds that people that have buyer's remorse on their allopathic degrees are primary care sports med docs and physiatrists. They realize the value of learning the osteopathic manipulative medicine and that having that extra tool to treat people is so helpful. And so many of the athletes appreciate this. When he did his olympic internship at the Olympic Training Center in 2013, he would evaluate them and figure out what's going on. Then he'd do some treatment. So if you can treat them just with your hands, they would appreciate that just to shy away from taking any pill to prevent any controversies with regards to doping. "Especially Olympic athletes, they love the fact that you can treat them with your hands because they don't want to take a pill." [28:30] Working with Other Primary Care Doctors and Other Specialties Daniel explains a lot of people think they can't refer over to sports medicine or that patients think the same thinking they're not athletes. They think they only take care of athletes, primarily elite-level athletes. But he says to them that anybody who moves as an athlete, they can practically see anyone who has aches and pains. There's a little crossover into the pain management realm here too. They can do things other than pharmacologic means only to be able to keep them moving and active. He sees a lot of their arthritic patients that need therapy and rehabilitation. Mostly, it's about looking at their whole kinetic chain. They try to see where they have deficiencies and what is transferring their energy through their body that doesn't enable them to do certain activities or what's keeping them from being active. He further believes that family medicine should have a panel of patients and they should be lifelong patients. What he likes other primary care doctors to know about what they do, there is actually so much to learn. Daniel now has a broader scope of things and he now has a better look at how to get people moving and get them active. For instance, in tendinopathy, he was aware of three things that he could do to treat chronic tendon injury or an acute tendon injury when he was just going through residency. But after going through fellowship and being out in practice for several years, he can probably name 16 things off the top of his head that he could do for chronic tendon type of injury. Other specialties they work the closest with include physical therapy and athletic trainers, rheumatology, and orthopedic surgeons. [34:15] What He Wished He Knew that He Knows Now Being a kinesiology major, one of the paths he could have taken is an athletic training path and become a certified athletic trainor while he was going through his undergraduate degree. He thinks this would have been cool. Just having a little bit of that knowledge was something he would have wanted. He also wanted to learn more of how to run a business and if there's a combined MBA program, this would be a very good thing as well. This way, you'd be able to manage your business in your practice and be able to manage your money better too. "I see plenty of people who are awesome at what they do but they're not awesome at managing their finances." What Daniel likes the most about being a sports medicine physician is that he can sleep well every night knowing he's doing the best for his patients. He's helping people to the best of his ability and he has good humility about what he knows and what he doesn't. He knows he's doing his best to try to keep his patients moving and keeping them active. He likes all those little wins. "Medicine can be a frustrating to be in but if you know you really want to do this, you have to be passionate about it. You need to know that this is what you love." And if he had to go back and do this again, he would absolutely. But what he likes the least on the flip side is that they're volunteering so much at events that he'd describe it as not a very lucrative field. Also, he practice with very good ethics and morals so he doesn't do things just to do them. He makes sure it's medically necessary. He has seen sports medicine physicians that do things similar to him but doing them irresponsibly. But he makes sure patients need those type of things. All this being said, he is comfortable and happy. [39:20] Final Words of Wisdom Daniel recommends to premed students listening to this who might be interested in sports medicine is to find a sports medicine mentor and just maintain good contact with them. Just check in and make sure it's still something you're passionate about. Make sure that you're doing the kind of things that set yourself up for this type of future. And just get involved. Volunteer at events and find events. As with him, he actually created an event to be able to cover the sport he was passionate about. And this was how he became s team doctor with USE Wrestling which was one of his dreams and he made this happen! Links: The Premed Playbook: Guide to the MCAT ryan@medicalschoolhq.net The Premed Years Podcast Session 273

Session 59 Looking at the Psychiatry Match data, it's easy to see that it is becoming a more popular field. I discuss all the data in today's Specialty Stories podcast. Finding physicians for this show has been a challenge so we'd like to ask for your help. If you know a physician who would be a great addition to this podcast, shoot me an email at ryan@medicalschoolhq.net . Go to medicalschoolhq.net/specialtiescovered and you'd find a list of physicians that we've already covered here on the show. Today, we cover Psychiatry match data based on the 2017 NRMP Main Residency Match Data. [03:20] General Summary There are 236 programs in psychiatry. Comparing it with other specialties, pediatrics has 204 programs. So there are 32 more psychiatry programs than there are pediatric programs. The total number of positions offered for Psychiatry is 1,495 spots. This means a little over 6 spots per program. Whereas pediatrics is much bigger with twice as many spots of 2,738 in 204 program. So it's almost 13 1/2 spots per program - almost double the size of psychiatry programs. There were 3 unfilled programs in 2017 and the total number of U.S. Senior applicants for those 1,495 spots was only 1,067. These are the students at MD medical schools who are still in school, and not those that have graduated. So there were less students applying to those spots than there were spots available. There were 2,614 applicants. It's almost 1,200 more applicants than there were spots available. This is still pretty competitive to apply. Looking at the number of those that matched, only 923 of those 1,067 U.S. Seniors did match while over a hundred of those did not match into Psychiatry. It was only about 61.7% of those that matched are U.S. Seniors. Looking at other fields that matched, Anesthesiology was 66.8%, Dermatology at 92.3%, and PGY-2 positions for dermatology is 81.8%. [07:05] Types of Applicants and Growth Trends Table 2 of the NRMP Match Data for 2017 shows the matches by specialty and applicant types. For Psychiatry, there were four spots that went unfilled, 923 were U.S. Seniors and that's about almost 62%. 49 were U.S. Graduates. These were students who went to anMD school but had graduated already. Maybe they didn't get in the first time or they were just taking a gap year doing some research or travel, whatever. "A good percentage of osteopathic students are getting into Psychiatry." There were 216 osteopathic students, 166 U.S.-Citizen International Medical Graduates, and 137 non-U.S.citizen International Medical Graduates. There were four unfilled positions. Table 3 shows the growth trends covering 2013 to 2017. Psychiatry is growing a bunch, about 5% every year. In 2017, it grew 5.2%. Table 7 shows positions offered and number filled by U.S. Seniors and all applicants from 2013 to 2017. There's an interesting trend in Psychiatric that it's becoming more popular among U.S. graduates. When you go back to 2013, it was only about 52% of the class who were U.S. graduates. "If you're interested in Psychiatry, it seems to be growing. Hopefully there'll be spots for you as you continue down your training path." In 2017, U.S. Seniors comprised 61.7% while in 2013, it was only around 52% and been going up year over year. Table 9 shows you how big a specialty is int he grand scheme of specialties. Ophthalmology is a separate match so that's not included. For Psychiatry, 5.4% of all students who matched, matched into Psychiatry. Just to give you a scale, Anesthesiology was only 4.1%, Emergency Medicine is 7.4%, Internal Medicine is 25.6%, Family Medicine is 11.6%. OB/GYN is 4.7%. [11:40] Osteopathic Students And if you're an osteopathic student interested to know your chances, Table 11 will show it to you. 7.4% of all DO students who matched into an MD program, matched into Psychiatry. Compared to the rest, Family Medicine and Internal Medicine are huge, Anesthesiology is 5.6%, Emergency Medicine is 9.6%. So the ratios are very similar. Figure 6 shows the percentages of unmatched U.S. Seniors and Independent Applicants who ranked each specialty as their only choice. If you are only ranking Psychiatry, there's a total unmatched percentage of 30.8%. But don't let that scare you if you're a U.S. Senior. Because their unmatched percentage is only at 7.4%. 52.9% of those who are independent applicants (ex. DO students, U.S. citizen and non-U.S. citizen international medical graduates, Canadian students) did not match [13:13] SOAP Let's go to the SOAP (Supplemental Offer and Acceptance Program). There were four unfilled programs, when you look at the data. But interestingly, when you look at the SOAP for 2017, there were only three available positions. One of those positions was either filled or taken off of the board. So there were two programs with three positions available. And all three of those spots were filled through the SOAP. [13:45] NRMP Charting the Outcomes 2017 - Contiguous Ranks Based on the 2016 NRMP Charting the Outcomes, Table 1 shows the number of applicants and positions in the 2016 match by preferred specialty. Psychiatry has 1,586 spots, 2,134 applicants, number of all applicants per position was 1.54, as one of the highest on this list. There are a lot of International Medical Grads and DO students are applying for these spots. Specialties like vascular surgery only has 56 positions and the total number of applicants per position is 1.91. The only one here above Psychiatry other than that is Neurosurgery which is 1.58. So there are a lot of applicants for those spots. Chart 4 tells the median number of contiguous ranks of U.S. Allopathic Seniors. Those who matched in Psychiatry ranked 9 programs in a row; while those that did not match only ranked 5. "You need to apply to a lot of programs and rank a lot of programs. That is the same across the board for every specialty." Further down the report is Table P-1 is the summary stats for Psychiatry. The mean number of contiguous ranks for those who matched is 9.6 while those who didn't is 5.6. Mean number of distinct specialties ranked is 1.1 for those who matched and 1.3 for those who went unmatched. For those who did not match were a little bit wishy washy with their specialty choice. [16:30] Step 1 and Step 2 Scores, AOA Members, and PhD Degree Step 1 scores for Psychiatry is not as high as some of the other programs. Psychiatry has 224 for mean Step 1 score and 214 for those that did not match. For Mean Step 2 Scores, 238 for those that matched, and 226 for those that did not. For AOA (the honor society for medical students) members, only 6.2% of the students who matched were AOA members while none of those that did not match were AOA members. 4.4% had a PhD degree and 0 unmatched had a PhD degree. You could look at that saying that you have to have a PhD degree to match into Psychiatry or you have to be an AOA member to match. But you have to look at the data yourself. [18:00] 2018 Medscape Lifestyle and Compensation Reports The 2018 Medscape Lifestyle Report shows the highest outside of work is 61% for Allergy Immunology and the lowest is Cardiology at 40%. Psychiatry is right in the middle at 51%. But let's also look at the 2017 NRMP Main Residency Match Data. Psychiatry and mental health are at the bottom for burnout at 42% versus Emergency Medicine at 59%. How severe is the burnout, they're much lower at 4 on the scale. "Not surprisingly, the question which physicians are most burnt out, Psychiatry and Mental Health are at the very bottom. They probably have some coping skills." Which physicians are happiest outside of work and at work? Psychiatry is lower on the list with 66% happy outside, and 37% are happy at work. And they're found on the lower end of the scale. Looking at the 2017 Medscape Compensation Report, Psychiatry is on the lower end. That's understandable because usually, the more procedure-heavy specialties are compensated more. Their average annual compensation is at $235K while Orthopedics is up at $489K. So that's a big difference. Pediatrics is the lowest at $202K. However, they're getting 4% salary increase year over year. Slide 18 shows which physicians feel fairly compensated and Psychiatry is top 3 at 64%, next to Dermatology and Emergency Medicine (first). Slide 38 is a question about whether they'd choose medicine again and Psychiatry is top 2 at 82%, Rheumatology is at 83%. 87% of Psychiatry also say that they would choose the same specialty again. The highest is Dermatologist and Orthopedics is next. [21:38] Final Thoughts As mentioned earlier, we are in need of more physicians to interview. Please help us find out which physicians are interested in coming on the show. Go to medicalschoolhq.net/specialtiescovered and see which ones have been done. Links: medicalschoolhq.net/specialtiescovered 2017 NRMP Main Residency Match Data 2016 NRMP Charting the Outcomes 2018 Medscape Lifestyle Report 2017 Medscape Lifestyle Report 2017 Medscape Compensation Report

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

Session 54 Dr. Esther Koai is an academic general OB/GYN. Listen to what drew her to OB/GYN, what she recommends you do if you're interested in it and so much more. She talks about her role, why she chose the specialty, and what you should be thinking about if you're interested in getting into OB/GYN. Also, check out all our podcasts on MedEd Media. For suggestions of physicians you want interviewed here on the Specialty Stories, shoot Ryan an email at ryan@medicalschoolhq.net. [01:07] An Interest in OB/GYN Esther says she likes working with women as well as the comprehensive care OB/GYN's provide. She also loves surgery. Specifically, she loves working with women and women's issues, women's health, and women's sexual health. She does a lot of contraceptive counseling in the office. She finds a lot of women who may not feel comfortable of talking to their friends or mothers/family, or even a male provider about certain aspects of their sexual health. And they'll open up to a gynecologist or open up to someone listening specifically for certain things. "It's a good mix of both the patient side, the continuity of care, and the surgical aspect of care." She realized this was the path for her during her four year of medical school. She finished her OB/GYN rotation on the third year. It was towards the end of her third year that she applied to all of her neuro electives as she was going into neurology. Then her last rotation of third year was Pediatrics and she realized in the middle of that rotation that she was much more interested in the maternal fetal aspect of things. She missed the labor floor since she had so much fun at her OB rotation. So she ended up canceling all of her fourth year electives and reapplying for OB/GYN. [03:47] Traits that Lead to Becoming a Good OB/GYN Esther thinks that in order to be a good OB/GYN, you have to be a good clinician and have that clinical acuity. You also have to be able to act fast. Similar to emergency medicine where you have to be able to respond fast. You have to be able to recognize that this is an emergency and you've got to call your team in and all that. Additionally, you have to be able to be flexible and be able to go between your OB and GYN patients. That means you have to switch back and forth from doing prenatal care to doing a paps smear and all of that. As an OB/GYN, she can decide whether she wants to focus on GYN over the other and vice versa. She explains it depends on your department but you can say you can focus more on GYN and do more teaching. There are people who refer their hysterectomies to her. "In order to be a good OB/GYN, you have to be a good clinician and have that clinical acuity." [05:18] Academic vs. Community Setting Part of the reason she chose to go into academic medicine versus going out in the community is her love of teaching. She loves teaching both her patients and residents and medical students, which you can only get in the academic setting. They do a lot of grand analysis and statistics and a lot of academic activities sprinkled in throughout her week. And she enjoys those. She did interview at a couple private practices but she found they just weren't for her. Part of it too is the thrill of just being in a high, action-packed, high risk academic center. Because you can see all the cool, crazy stuff out there. You get all the referrals for the intricate medical puzzles. [06:37] Types of Patients, Typical Day, and Taking Calls Being at a big academic center, Esther is seeing a wide range of patients. They're an accreta center so they see a lot of placenta accretas. They do hysterectomies. They have a Level 1 NICU. So they're able to deliver very premature infant. Their MFM (Maternal Fetal Medicine) team is well-developed so they have a larger referral base. A typical day for Esther would be Mondays, she would have a morning off for paperwork. Monday afternoons, she precepts the residents in clinic. Tuesday mornings, they have their academic days - stats, rounds, etc. And they usually have their own panel in the morning and then in the afternoon, she precepts again and do continuity clinic. By panel, she means her own patients. So Wed-Thurs, she sees her own patients. Usually, two Wednesday nights per month, she'd be on call. So she would be post call on two Thursdays. And then Fridays, she's in the hospital either doing labor and delivery cases and OR cases. It's her personal preference to have clinics just by herself on days and with residents other days. She chose to be a clinic preceptor and she enjoys teaching and seeing patients with the residents. Esther takes three overnight calls a month. One is a 24-hour shift on a weekend and the other two are 15-hour shifts. It's an in-house call where she's there with the residents. They see all the patients, triage them, and present them to her. Then she will go and reevaluate and go over things they may have missed or they may have not thought about. "It can get pretty busy to where I get no sleep at all. And it can also be every once in a while, very chill and laid back." [09:45] Percentage of Patients in the OR For Esther, the percentage of patients that come from her clinic ending up in the OR is higher. During Wednesdays and Thursdays, she's at a site where she's the GYN consult. So all the patients she sees have already been screened by a family medicine or internal medicine provider. They refer them to her because they need additional workup of they're a little bit more complicated. So she only sees GYN patients that are more complicated on those days. She thinks she has a disproportionately high number of GYN patients that she ends up doing procedures on. She estimates it would be a third to a half, she ends up looking for cases. Everything else is either medical management or routine. [10:44] Work-Life Balance Esther feels like she never has enough time for family. For her the work-life balance is what you make of. Like when you're able to utilize your vacations well. She has one weekend of call a month so she gets to spend time with family for most weekends. And she thinks this is better than if she were in private practice. "Work-life balance is what you make of." [11:25] The Training Path to Become an OB/GYN and Competitiveness After medical school, you have four years of residency. Then if you want to specialize, they have two to three year fellowships including Family Planning, GYN Oncology, Maternal Fetal Medicine, Urogynecology, Minimally Invasive Surgery, Reproductive Endocrinology, and Infertility. Family Planning Fellowship involves contraceptive counseling, IUD placements, dilation curettage, dilation evacuations, terminations, etc. Esther doesn't think it's one of the more competitive residencies. Rather, it depends on the program so she'd describe it as mid-range, much like Emergency Medicine. What they're looking for in applicants are those who are willing to put a lot of time and effort into the residency. It does suck up a lot of your time. As far as research and things go, they're not really a huge research center so applicants can do academic research at their program. But it's not the program that turns out into academic literature. But they're looking for people who are able to see a high volume patients and are willing to deal with patients with high morbidity and who are obese. They're able to deal with patients with multiple medical problems. They're looking for people who are ultimately going to be happy. For someone doing an elective rotation as a medical student, it can be hard to look for these qualities. But part of it is just the general feel. The residents are pretty clear about whom they click with. So her first move is to usually ask the residents what they think of the applicant or the sub-I. She'd find out whether they seem interested or engaged or they just checked out in the corner. "People always put their best face forward, or at least, should be putting their best face forward." Esther explains that the mark of a good sub-I is someone who is just very much part of the team, very self-motivated, and somebody you would rely on just as much as your own intern. [14:35] Bias Towards DOs and Working with Primary Care and Other Specialties Esther hasn't seen a lot of negative biases towards DOs. And part of that is because one of their MFM's at their program who is highly respected and he ended up being the director of the department at their site, is a DO. That said, they haven't had any DO residents so she hasn't really encountered any other DO OB/GYNs. Alternately, she does see a lot of DOs in Anesthesiology and they're doing just fine. What she wished primary care providers knew about OB/GYN to better serve their patients is that they knew more about contraceptive counseling for one. And in general, she wished more people felt more comfortable talking about and dealing with female anatomy. It's a daunting idea to people who don't routinely work in that field so it's something that people tend to shy away from. But there's nothing scary about it, Esther says. Other specialties she works the closest with include Urology, Emergency Medicine, Family Medicine, and Surgery. "There are a lot of misinformed statements floating around out there about contraceptives." [17:02] Special Opportunities Outside Clinical Medicine, What She Wished She Knew, and the Most and Least Liked Things Special opportunities outside the clinical world for OB/GYN may include work in patient safety. They have so many obstetric emergency situations. So there are opportunities in patient safety in QI. What she wished knew that she knows that you've got to really work really hard. But it's all going to be worth it in the end. The amount of knowledge that you gain and the amount of surgical prowess you gain are just unbelievable. It's so rewarding to be able to apply that on a day to day basis. What she likes most about the job is the patient counseling. She likes having that sit-down conversation with them where she's able to connect with them and they understand things about their own health they may not have understood before. She adds it's an aha moment for every patient when they find out something they've never known before. She finds this very rewarding. And for selfish reasons, she says she loves doing surgery and for her, it's an immediate gratification. What she likes the least on the flip side is chronic pelvic pain in terms of the types of patients and treating them and all the stuff that goes with it. She finds it cumbersome and difficult to treat. She thinks it's very multifactorial and patients usually get bounced around from place to place. Then they come to you very frustrated because they've tried everything. [19:20] Major Changes in the Field of OB/GYN and the Future of Residencies She thinks there's a lot of tracking going on and in other fields as well. Especially in OB/GYN where they're two very separate fields meshed together into one. And this is reflected a lot in the way that the entire field is moving both in the academic and in the private world. Before, you'd see more generalist doing both OB and GYN, but now you're seeing people doing OB only as laborists or GYN only in the clinic. And it's becoming more of a divisive field, Esther puts it. So this is the general trend of things and a lot of academic centers are doing it. "You have your OB side and then you have your Gynecological side. If you weren't dealing with the same organs, they'd be almost totally separate fields." Although she's not yet seeing this as of the moment, but potentially down the line, there is that possibility of students applying to OB-specific residencies and GYN-specific residencies. Esther says that if she had to do it all over again, she would still have chosen the same. She loves the people and the patients. She thinks it's a great field and it's fast-paced and can be very intense. But you can also make it very calm and inviting. So it's a very versatile field. Lastly, she leaves the premed students with an advice to do it. Be enthusiastic. Be curious and ask questions. Seek out the puzzles and really dive right in. There's no better way to experience something other than just committing 100%. It's so rewarding to be able to talk to a patient and have them really hear what you're saying and have them light up. Links: MedEd Media

Session 23 Medical school is hard. You don't have to be a genius, but you have to work a lot. Does it leave time to work? You shouldn't work during medical school. In this episode, find out why. [00:22] Worried About Finances Rose from the Medical School HQ Facebook Hangout, asked a question about working while in medical school. Still a couple of years away from applying, she's thinking about the long term financial consequences of being a medical student and leaving her current job as a nurse. So she's trying to figure out how much money she needs to live on as a student. Finance is a common worry among lots of medical students. I think this is even one of the biggest reasons we don't see more lower income people or minorities applying to medical school. They look at that bill and the debts students have coming out of medical school. Then they decide it's not for them. They find the tuition bill as too much. And this is a huge disservice to our patient population and to the students who are giving up their dreams of becoming a physician. "Student loans will cover the cost of medical school.You're not going to go hungry in medical school." You will come out with debt. But if you've heard, being a physician pays pretty well. Depending on what specialty you go in, it pays pretty well. [02:10] You Have Help There's the public service loan forgiveness. There are some different scholarship programs like The National Health Service Corps Scholarship Program. There are a bunch of things to help you pay up those loans. Another way is if you go to a Academics and you're getting grants. The NIH helps pay for a lot of the student loans. "There are a lot of programs out there to help pay back loans. Don't worry about money going into medical school." [02:51] Working During Medical School In my case, I worked before I was a medical student as a personal trainor at a gym. When I started medical school, I continued working as a personal trainor. I needed to work because I was not very responsible with money. I had a credit card debt and a big car payment. Loans didn't cover that. In short, I was irresponsible with money. "Don't be irresponsible with money is rule number one." While it was doable, I ultimately felt that it was one of the biggest things that hurt me in my quest to become an orthopedic surgeon. It was was the specialty that I wanted coming in and even when I graduated. It's what I applied for in residency. But orthopedics is a competitive specialty along with dermatology, radiology, ophthalmology. Your Step 1 scores (USMLE or COMLEX Level 1). So your board scores is one of the biggest determining factors of your ability to get an interview for those residencies. Take a listen to the Specialty Stories podcast where I cover the match data in some of the episodes. In that match data, there are Step scores and everything else. "You need great scores to get to those more competitive specialties." Because I was spending ten hours a week working,my Step 1 score was much lower than what it could have been if I had dedicated my time to studying. It was my dream to be an orthopedic surgeon. And although I'm grateful for where I am now, it was devastating at that time to not be able to go into orthopedic surgery. Working was the problem. [05:50] Medical School Is Your Job Don't go to medical school thinking that you're going to work or that you can work. You need to figure it out so that school is your job. Student loans will take care of that as long as everything else is set up. It would be more challenging for nontraditional students. You have kids. And most loans don't have child care built into the budget of the school. That's how loans are determined. They're typically given to you based on the budget the school sets. If child care is in there then you need to figure out how to get in there. It's even harder if you have spouse who doesn't work. There are a lot of other things that go into it. But don't plan on working while you're a medical student. It will only hinder you in the future. Your goal here is not to survive medical school. You're working towards something. Work towards that dream. Do the short term sacrifice of not working and pinching your pennies for your long term goal. "Don't plan on working. It's not worth it." By the way, the episodes in this podcast are recordings of our Facebook Live that we do at 3pm Eastern on most weekdays. Check out our Facebook page and like the page to be notified. Also, listen to our other podcasts on MedEd Media. Follow us on Instagram at @medicalschoolhq. Links: MedEd Media Medical School HQ Facebook page Instagram @medicalschoolhq Medical School HQ YouTube channel Specialty Stories

Session 22 Aerospace Medicine is a subspecialty of Preventive Medicine and very unique usually to the military, though there are civilians equivalents. If you are a premed student and you're getting ready to prepare for your medical school interviews, check out The Premed Playbook: Guide to the Medical School Interview. Its paperback version will be released on June 06, 2017. Preorder the book at Barnes and Noble now and you will get about $100-worth of free gift including a 1-month access to our brand-new mock interview platform (only currently available to those who preorder) and a 13-video course on the medical school interview. Text PREORDER to 44222 to get notified with instructions on how to get on this. Back to today's episode, I will be interviewed by Ian Drummond, a fourth year medical student and the host of The Undifferentiated Medical Student podcast. Ian interviewed me back in Episode 24 of his podcast about aerospace medicine and I'm playing a part of his interview with me specifically relating to aerospace medicine. [03:29] What is Aerospace Medicine? AAMC's Careers in Medicine didn't actually have a description of aerospace medicine although it was listed under Preventive Medicine. Ian, however, will refer to this description provided by the Aerospace Medical Association and we will take it from there. "Aerospace medicine concerns the determination and maintenance of the health, safety, and performance of persons involved in air and space travel. Aerospace Medicine, as a broad field of endeavor, offers dynamic challenges and opportunities for physicians, nurses, physiologists, bioenvironmental engineers, industrial hygienists, environmental health practitioners, human factors specialists, psychologists, physician assistants, and other professionals. Those in the field are dedicated to enhancing health, promoting safety, and improving performance of individuals who work or travel in unusual environments. The environments of space and aviation provide significant challenges, such as microgravity, radiation exposure, G-forces, emergency ejection injuries, and hypoxic conditions, for those embarking in their exploration. Areas of interest range from space and atmospheric flight to undersea activities. The environments studied cover a wide spectrum extending from the microenvironments of space to the increased pressures of undersea activities. Increased knowledge of these unique environments of “Spaceship Earth” helps aerospace medicine professionals ensure participants are physically prepared, physiologically safe, and perform at the highest levels." [05:28] Building Trust and Relationships with Patients I agree with all of it as a great representation from the organization. One of the biggest things missing which is unique to aerospace medicine is the relationships with patients. In fact, it is a huge factor in aerospace medicine which I think deserves its own call out there. I will speak specifically to the Air Force although it's pretty similar for the army and navy which also have civilian flight surgeons. There are AME's (Aviation Medical Examiner) out in the real world that do physical exams for pilots. There is a civilian equivalent, just a little bit different for the military. For the military, specifically for pilots, they usually go and see the flight surgeon for a few things. One is the mandatory annual physical examination (crossing their fingers that nothing is found). Second, if something is really wrong and they need help. Typically, a pilot doesn't want to go and see the flight surgeon outside of those two things because every visit to the flight surgeon is an opportunity to lose their wings, which means they would no longer be able to fly. Because a flight surgeon has that control to make sure pilots and other people interacting with aircraft are safe operating the aircraft, it's their job to make sure that if they have any medical condition, we have to determine if they should continue flying or not. As a flight surgeon, I was a rated flyer where I got to wear a flight suit and had wings. I was required to fly four hours a month to be part of the air crew to build that rapport and build that trust. I went for an MRI one day because I was having some symptoms and I got diagnosed with MS so eventually I was no longer allowed to go up in an airplane for the Air Force. Because of that fine line between being allowed to fly and have your career or you're not allowed to fly out anymore, it's such an important relationship to have that trust and rapport. It's one of the best parts about being a flight surgeon. There could be cases they're lying and hiding things from us, like a cat and mouse game, because they want to fly. They love their jobs and they love the camaraderie that comes with it and everything else so it's a large part of who they are. Personally, I thought it was a stupid rule that I got grounded. MS is one of those weird things for aerospace medicine. The Israeli Air Force lets their pilots with MS fly. Ours is less progressive so they worry more about the cognitive decline since 75% of MS patients have some sort of cognitive deficit and that's what worries them. I did argue for a while but I lost. [11:32] Flying the Plane There are a couple of caveats here. In the navy, flight surgeons go through some of the pilot training courses. The army may do it like the air force where you go through a little bit of ground pilot school. For instance, they get to ride in a small Cessna plane and fly to see what it's like. The whole point of the flight surgeon is to make sure that pilot and other people can do their job so you have to understand what they're going through. Then you get to see how much there is to do. I have my private pilot license. I have always been fascinated with airplanes so when I had the opportunity to get my private pilot license, I jumped on that. As a flight surgeon where I had to fly four hours a month, it meant being part of the aircrew. So the majority of aircraft that I was in were bigger airplanes so I would just hang out in the back or in the cockpit but not actually controlling anything. Sometimes I would talk on the radio and help them with the radio stuff. The one time I got to fly something was in the backseat of an F-16 because the controls are right there. When you have wings, it means you're in some way affiliated with the airplane. So it's not just the pilots, but also, load masters, navigators, flight surgeons, etc. having wings is just a designation that you're like a "real" Air Force and you're part of the plane considering there are other jobs in the air force that have nothing to do with planes (ex. bus driver, cook, etc.) [16:08] Civilian Physician vs. Air Force Physician When you're, say a Primary Care physician, there is almost never this thought about what job a patient does or can they continue to do it. It's usually the patient that asks for some time off because they don't want to work. But as a flight surgeon, that's always the first question at the top of my mind. I have to know what your job is and whether or not you can continue to do it. So if you're a pilot and you come in with a knee pain and I know that if an engine goes out and you need to push full rudder to keep the plane straight and land it, you're probable not going to be able to do that with how bad your knee is. So you can be grounded for a week or two to make sure your knees are better and then come back and see me to reevaluate. *There is no such term as a "flight surgery" but it's an old name that's been held out for a long time. The actual practice is aerospace medicine and there are aerospace medicine residencies but you are a "flight surgeon" as an aerospace medicine specialist. There is flying but there is no surgery and there's definitely no surgery while flying.  [18:44] A Typical Weekly Routine and Patient Types A typical week for a flight surgeon is an ambulatory setting where you're seeing patients depending on what based your stationed at as an active duty flight surgeon. In some bases, you see dependents (the family members of the active duty member) while in others, you see retirees. So the types of patients you're seeing vary but you're seeing normal clinical stuff. You're seeing a lot of occupational health visits. When a pilot comes in for their annual flight physical exam, it's an occupational physical where you check their vision, hearing, and other things making sure their healthy. But a lot of them are occupational-based which means making sure they meet the qualifications for continued flying. If seeing dependents and retirees, flight surgeons are basically a family practice physician so family members are treated for normal aches, pains, and colds, etc. Depending on where you're at, 50% is seeing patients and another 50% is hanging out with air crew and building rapport, doing "shop visits." As a flight surgeon, you're an occupational health physician so if your base has airplanes and you're visiting the flying squadron to make sure things look good there and the facilities are clean. You go to the maintenance squadron and make sure people working on the airplanes are keeping a clean environment and not working with lead-based paint and bring it into their offices and where they eat. You're simply making sure the base stays healthy. So you're basically outside of the clinic a lot of times and interacting with the rest of the base population which keeps things varied and you get a lot of diversity. When you go to site visits, it's like carrying a clipboard with a checklist like making sure they keep separate wipes for their masks or have separate sinks for different things. So a lot of the things are structured that way while some of it is just using your intuition and question-asking skills. Usually, you go out with a team consisting of public health or bio environmental engineering while you're focused on the health side So it's a very collaborative team-based approach. [23:16] Flight Surgeon as a General Practitioner 50% of the time, a flight surgeon is basically a practitioner except of the military. Also, a large majority of flight surgeons are general practitioners which means they're only internship-trained. This is the way the Air Force gets flight surgeons wherein a lot of them are fresh out of their internship. There are also a lot of flight surgeons with residency training, like OB/GYN, Orthopedics, Family Medicine, or Internal Medicine. You can actually have any specialty and be a flight surgeon if you choose to. And if you have specialty training and become a flight surgeon, you have to go through all the aerospace medicine training before becoming a flight surgeon because it's unique and different. Aerospace medicine is a subspecialty available to everyone in the military. They usually need flight surgeons so there are several physicians that jump ship from their specialty and subspecialty and come over to the aerospace medicine world. [24:50] Patient Outcomes Typical outcomes would be just like a family practice doctor where you're seeing people with their aches and pains, sniffles, and flu so you're treating an acute thing for a week or two and grounding them for a week or two and then they come and see you and things are better. Although there are also some unique things that could happen like somebody losing their vision or has a random new diagnosis. There are a lot of bad things that can happen to cause somebody to lose their wings. As a flight surgeon, you also take care of firefighters, which is another big occupational health job. The outcomes are usually normal healthy people but when you get those random diagnosis, it's a life-changer. [26:23] Most Exciting and Most Mundane about Aerospace Medicine The most exciting is being able to go out and be part of the aircrew and fly around the world or fly an F-16 or do all sorts of missions, experiencing what the rest of the base is doing. Conversely, the most mundane part is dealing with normal aches and pains like dealing with blood pressure management or diabetes management, basically the boring normal doctor stuff. [27:10] Wish I've Known About the Specialty When I got the call to say I was going to be a flight surgeon, I didn't know what it was. When I was in it and now that I'm out of it, I don't think there's really anything that I had wished I had known about other than I wish I would have known about it. Consider doing aerospace medicine especially those who are on an HPSP scholarship. It's an amazing job and there are so many things you can do. Even if you're interested in a specialty, go be a flight surgeon for a couple of years and then go live the rest of your life. The stories I can tell now, having been a flight surgeon, are going to stay with me forever. [28:40] What is HPSP Scholarship? HPSP refers to Health Professions Scholarship Program that offers about 150 scholarships a year where you get into medical school and you apply for the scholarship. Once you get accepted, they pay for medical school and then you owe them a year for a year of scholarship, where you can do a 3-year or 4-year scholarship. [29:28] Combat, Non-Combat, and AME's Because it's more of a military-based career, I will divide this into a non-combat and combat. As a non-combat flight surgeon, depending on where you're stationed, you can be stationed anywhere throughout the world. You can be stationed at a place without planes. But majority of your job is to make sure that the population of that base is healthy. It's always an ambulatory setting. There would be no need for an in-patient hospital-based flight surgeon. When you're deployed in a combat setting, you can run different parts of the medical evacuation triage tents and stations along the way. When somebody gets injured in combat, they're evaluated and triaged to see if they need to be evacuated out to a bigger hospital or if they can just be treated where they are. As flight surgeon doing that evaluation and determining what kind of aircraft they need to fly on, meaning is this an injury that is going to get worse at altitude or do they need at low altitude, do they need to be in a helicopter and stay low or stay in an unpressurized aircraft at a low altitude. So you're basically doing a lot of cool triage in trying to figure out what's best for the patient based on aircraft, altitude, and other things. An AME is an Aviation Medical Examiner, a designation where you get certified through the FAA. As an AME, you're usually a family practice doctor or an internal medicine doctor or somebody interested in aviation. It's a cool job because it's usually a cash-based business. You can see Class 1, 2, and 3 pilots which need a certain number of physical exams depending on the class. You have to go through FAA training which is free. The population of AME's has significantly decreased over time so it's now getting more difficult for pilots to find an AME and get their physical exams. An AME is very similar to a flight surgeon where there are strict guidelines that determine whether or not you're able to fly and bases your evaluation on those guidelines and makes recommendations based on that. FAA training is not the same as an aerospace medicine residency. It's a week to two-week long course that the FAA puts on. You can be a flight surgeon at NASA. I've been down to the space center in Houston and visited the world's largest swimming pool where the astronauts do all their training for weightlessness. And as a flight surgeon in the air force, I did see people that wanted to be astronauts and I would do their initial physical exams before they would go down to Houston to get their full physical. [36:15] Pilot Physician Moreover, you could be a Pilot-Physician of which the Air Force gives 20 spots. A student I'm working with is in the Air Force right now and wants to go back to medical school but she's also a pilot, not in the Air Force but she is a private pilot with 600 hours and she flew with the academy on their stunt team. They typical path for a pilot physician is you're a pilot and if for some reason you get interested in medicine and you go to medical school and you still want to be in the military, you become a pilot physician. So you're a physician first but you have the pilot training and usually, you're doing a lot more higher level things than just seeing patients in a clinic but you're looking at a lot of the regulations being written, research into new technologies, etc. Since there are only 20 slots in the Air Force, it's a highly sought-after position and because there are not enough pilots are going on to be physicians, they're looking for physicians that may be interested in going into pilot training through the air force to be pilot physicians. I did look into this but I didn't pass the age requirement. I was too old to start since 29 is the oldest to start the training and I was already 30 or 31. The Air Force is taking any physician but you obviously have to go through their aerospace medicine training at some point. The unique thing a pilot physician offers is the research and more of having the deep knowledge base and foundation of having both careers under your belt and being able to make those regulations and see things from both sides. [39:56] The Biggest Challenge and the Future of Aerospace Medicine One of the biggest challenges of aerospace medicine is that a lot of people don't understand us so there is much pressure for us to start doing more and seeing different types of patients. Apparently, there is a lot of misunderstanding from the greater Air Force of what our job is. What the future holds for aerospace medicine in 10-20 years would be that as we go to more and more autonomous aircraft, where we have drones, majority now are remotely piloted. They are not unmanned aircraft, they're manned, just in a different location. Because of that, interest in aerospace medicine will go down. Part of the lure is being able to go fly and so why would you be doing it if there is no plane to fly. There could also be unique psychological challenges that come into play for drone pilots. We're going to fighter planes (F-22 and F-35) that are only single-seat planes, which means the flight surgeon can't go up there and the less experience they get. There will be the heavier aircraft like the C-5 and C-17 and re-fuelers. [44:35] Final Words Aerospace medicine is an awesome and great job! Although pretty much specific to the military, there are civilian residencies for aerospace medicine. For this podcast, I'm not going to dive into all medical specialties in the military for two reasons. First, the practice of Pediatrics in the military is not very different than pediatrics in the civilian world and really, there aren't that many military premeds out there to warrant individual episodes. I'm a huge advocate for doing the military to pay for medical school and to serve but I don't think I'm going to dive into it here on the Specialty Stories. Links: The Undifferentiated Medical Student The Undifferentiated Medical Student Episode 24: Aerospace Medicine with Dr. Ryan Gray Careers in Medicine Aerospace Medical Association HPSP FAA AME training Pilot-Physician

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

Help Ian interview all 120+ specialties by referring him more physicians! Show notes page! Dr. Gray is a former United States Air Force Flight Surgeon who has since retired from the military and clinical practice to pursue his passion for helping med and pre-med students on their journey to and through medical school. Dr. Gray completed his undergraduate degree at the University of Florida in 2002; his medical degree at New York Medical College in 2009; and his intern year at Lemuel Shattuck Hospital in 2010 after which he served 5 years in the Air Force, the first 2 as a flight surgeon and the last 3 as Chief of Aerospace Medicine. Dr. Gray is best known for his podcasts which have combined for over 1.2 million downloads and which include The Premed Years podcast, The OldPreMeds Podcast, The MCAT Podcast, and most recently Specialty Stories, a podcast that features stories of specialists from every field of medicine. Dr. Gray is also the author of The Premed Playbook: Guide to the Medical School Interview. Through his book, his podcasts, and his website at medicalschoolhq.net, Dr. Gray has helped thousands of students successfully navigate the path to and through medical school. Dr. Gray lives outside of Boulder, CO with his wife Allison, who is a Neurologist, and their daughter Hannah. Please enjoy with Dr. Ryan Gray!

Session 56 In this episode, Ryan breaks from what he usually does here on the podcast where he pulls up a questions directly from OldPreMeds.org forum as he talks about this HUGE announcement this past week from the AACOM that affects nontraditional students more than traditional students. Osteopathic medical schools are more favorable to non-traditional students, You may have struggled in the past, did poorly in undergrad or at a community college, gave up on your dream, only to find that passion again and want to try to fulfill that dream and become a physician. You've probably heard that as a nontrad applicant with poor grades in the past, applying to DO schools would be beneficial to you. Historically, that has been the case. NO MORE GRADE REPLACEMENT AACOMAS Application had a grade replacement policy for repeat coursework. However. effective May 1, 2017 (applying in 2017 to start school in 2018), AACOMAS will no longer replace your old grade with your new grade. As per AACOM.org: "Effective May 1, 2017, AACOMAS will include all course attempts in the GPA calculation. This change applies to students matriculating into the 2018-2019 academic year. In the event of multiple attempts of the same course, AACOMAS will no longer drop initial course attempts from the GPA calculation." Read full notice on AACOM.org Here are the insights from Ryan: This will affect a lot of you who are currently in school retaking classes because you were going to rely on this grade replacement policy. The American Association of Colleges of Osteopathic Medicine (AACOM) did you wrong. If they were planning this policy change, they should have given you a transition period so students currently in school and in the process of repeating classes would have 2-3 years to apply to use the grade replacement policy before it changed. If you applied in 2016 to start in 2017 but you didn't get into medical school, when you reapply this year, your GPA will change according to the new policy assuming you had repeated coursework. The Silver Lining Osteopathic medical schools may continue recalculating weighing your GPA per established admissions practices. Problem: This puts the work onto each of the medical schools which have a lot of work to do to begin with. They usually have filters in place where they can filter out based on a GPA cutoff or MCAT cutoff. If you're a student where your GPA is going to drop from, say 3.6 to 2.6, guaranteed, your 2.6 is going to be filtered out. Solution: Advocate for yourself and speak out to the medical school and ask them to consider taking a look into your application. Major takeaway from this episode: If this is affecting you, keep your head up. Just keep doing well. Advocate for yourself. If this is truly what you want to do, you'll make it work. Links and Other Resources: Read the actual notice from AACOM. Check out the Specialty Stories podcast on www.medicalschoolhq.net