Specialty Stories

Latest Episodes:

119: What Does It Take to Be a Surgical Oncologist? Oct 30, 2019

Show notes

Dr. Arora specializes in surgical oncology, and she's here to tell us about workflow, lifestyle, and what's on the horizon for this interesting specialty!

Links:

Full Episode Blog Post

Meded Media

The Premed Years Podcast

The MCAT Podcast

The MCAT CARS Podcast

Board Rounds

118: In the Internal Medicine Specialty, Sky Is the Limit! Oct 23, 2019

Show notes

Session 118 Where will you see the most variety of patients? Internal Medicine, of course! Dr. Hilary Ryder gives us a peek into subspecialties and the IM lifestyle. Hilary is the Internal Medicine program director at Dartmouth-Hitchcock Medical Center. She shares her internal medicine residency experience, how to pick a program, and how to stand out in your applications and rotations. If you haven’t yet, please do check out our other resources on Meded Media. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:13] Interest in Internal Medicine Hilary was initially unable to make a decision about what specialty she wanted to go into. Into her fourth year, she thought she wanted to be a dermatologist. What drew her to it was the lifestyle having no nights and weekends. It felt like a lifestyle specialty that she could get into. During her third year clerkship in medicine, she really loved what she was seeing but she wasn't sure if she could handle the 30-hour shifts they were doing. Eventually, she did a medicine sub-internship in hospital medicine that didn't have any overnight shifts. She ended up falling in love with her team and with how diverse the cases she was managing. She started to take on more ownership of patients. She found it so rewarding that she found the 30-hour shifts to be all worth it. The'res this idea of spending of 6-12 weeks on Internal Medicine doing some hospital medicine work, ambulatory care work, etc. Then you're going to figure out this is what you're going to do. And so a lot of people choose IM since they haven't really made their decision. But then when you're in your residency, you're stuck making another decision because there are so many different ways to be an internist. You have the breadth of opportunities all over again within internal medicine. [Related episode: What is Private Practice Internal Medicine-Pediatrics?] [05:45] Types of Patients Hilary explains that the types of cases an internist might manage basically depend on your geographic location. She's from New England and a lot of their primary care doctors are internists. If you travel more to the midwestern states, you're going to find that most of the primary care doctors are family medicine doctors. So you go into internal medicine planning to subspecialize. You can do an internal medicine residency and go into Sports Medicine, Allergy, Interventional Gastroenterology, Interventional Cardiology, Geriatrics, or Critical Care. If you go into Anesthesia or Psychiatry, you're going to do just a couple of months of medicine. If you're going into Neurology or Radiology, you're going to do a year of internal medicine. If you want to be an Endocrinologist, you're going to do a three-year IM residency. And then spend some more time in a fellowship subspecializing even more in terms of the types of patients you're going to take care of. Many of the mentors you're going to see in your second year are internists. In your preclinical years, a lot of the physiology and the pathophysiology are going to be taught by internists. In Nephrology, you're going to learn your acid-base. And you're going to learn your electrolyte disturbances from internist. They completed their three years of internal medicine and they went on to a Nephrology fellowship. [Related episode: 5 Traits Patients Want Their Doctors to Have] [09:30] Typical Day Their internal medicine residents rotate through a variety of different specialties within internal medicine. A third-year clerkship student rotates through a variety of different departments. In their program, they have residents in the intensive care unit for a month. They have residents on the interventional cardiology service. They have those taking care of bone marrow transplant patients. They have residents in clinic and residents doing home visits. In general, students know what the inpatient experience is, the interims of pre-rounding, then the rounding with the residents and seeing patients. What they may not see are some of the other work residents are doing. Their residents do homecare visits with geriatric populations on their mandatory geriatrics rotation in the second year. They have dedicated rotations on medical education to try and make their residents better teachers. Because they're an academic program, they want residents to be able to teach medical students. So they spend some time on medical education. In medicine, they work in teams. So residents are going to have to go through a lot of teamwork and leadership. They expect residents to not only provide medical care but also, to teach others and lead teams that provide medical care. The resident is going to need to learn how to interface with the social worker, the discharge coordinator, the primary care physician, and the student and the nurse. They have to keep those balls in the air and keep the team moving forward. They need to make sure there's a great plan of care for the patient and the patient's plan of care is being moved forward. [Related episode: Resident Duty Hours and the Ripple Effect] [12:40] Taking Calls Taking calls is different depending on where you practice. In general, call for people who haven't done a lot of clinical exposure would be this long-term, multi-day experiences. You live in the hospital and you admit a lot of patients that you cared for longitudinally. Some programs are have gotten away from the 24-hour calls. This means you're in the hospital admitting for 24 hours. You can be in the hospital for up to 4-6 hours after that cleaning up before you go home the next day. Other programs like the night programs have gone to shift-based work where there is no long-term call. Residents will stay in the hospital and admit patients for a certain amount of time. They sign out to an overnight team who comes in to cover the patients and do the admissions overnight. [15:20] The 3 Kinds of Medical Students There are medical students who have no idea of what they want to do coming into their IM residency. There are also those who are pretty sure and they're right. They end up doing what they think they wanted to do in the first place. Then there are medical students who are pretty sure and they're wrong. They try something out and realize it's not for them. Some of the disease processes you learned about as a medical student may be intriguing. But the most common diseases in a specialty, you might not find all that appealing. Figure out where you think your career is going. If the residency program you think you want to go to has never sent anyone to an Allergy-Immunology Fellowship and you're determined to be an allergist, you really need to think if that's going to be the right place or you. Consider what your experience is going to be like. Are you going to be with like-minded individuals? Are you going to have the clinical experiences and support you want? Is it going to get you where you want to go? The best way to determine that is if there's a track record of other people going there. Look at the schedule and who the leadership is. Look at where people went after residency. [Related episode: The Nontraditional Medical Student: A Different Path to Med School] [19:10] The Training Path After Hilary finished medical school, she went into residency. She was undecided and she was one of the students who loved everything in medical school and thought she wanted to do everything. So she had difficulty choosing. You spend 36 months in your residency program. You should get exposed to a wide variety of different specialties. If you choose not to go into fellowship, you're ready to practice. You can then practice as internist without further training either in primary care or hospital medicine. But even these two are broader than you think. A hospital medicine doctor is going to practice exclusively in the inpatient realm of things. [Related episode: The Role of Residency Training For Physicians] [21:08] How to Be a Competitive Applicant Looking at the 2019 match data, 97% of internal medicine spots filled and only 42% are filled by U.S. Seniors from allopathic medical schools. There are a lot of DO students entering IM as well as international medical graduates. To be most competitive, as with other specialties, they look at the internal medicine grades. Often, there's an IM clerkship, a primary care clerkship, and at least a sub-I in either medicine or one of the subspecialties. They also look at the surgery grade. Hilary believes in the holistic review of the application. They look at the Step scores as a marker of someone's ability to pass the boards. They're also looking at experiences. It doesn't have to be a lot of research. Some students worry that they're in an institution that focuses more on clinical excellence or QI than basic science research. But what they're really looking for is curiosity, leadership, and desire to learn. They want someone who has done research in GI and inflammatory bowel disease and can talk passionately about that. Or someone who has been involved in medical education, curriculum design, volunteer work. Other traits to be competitive include enthusiasm, eagerness, and a desire to make the world a better place. They also look at the letters and they want to see whether the person is a team player. Is the person able to carry a decent patient load? They look at the medical knowledge and clinical decision-making. And the letters or the Dean's letters are often the best way for them to see this. You may not match into neurosurgery or orthopedics so you need a backup. However, more than anything else, they want eager residents who want to be at their program. They can help you with things like if you have less exposure to a certain patient population or certain disease. But if you'd really rather be somewhere else, there's not a whole lot they can do about that. They look at any significant evidence that this student actually wants to be in a different specialty. And sometimes, this can be a bit subtle. [Related episode: 9 Med School Application Tips That Will Give You an Edge] [28:20] Common Mistakes Students Are Making in their Sub-I's and Away Rotations There are some specialties that you need to do away rotations for you to demonstrate that you're passionate about it. But you don't need to do this for internal medicine. In fact, an away rotation can even backfire. That being said, Hilary thinks that an away rotation as an audition rotation makes a lot of sense. You just have to be careful and recognize that you're signaling to all the programs you're applying to that you have that interest. When it comes to sub-internships, the biggest mistake is not bringing in your enthusiastic game with you. It's a hard month. And if you only the minimum that's asked of you, the sub-I is the opportunity to do more. Hence, you need to bring your A-game. Bring in your enthusiasm. Do more than what's expected of you. Be a team player. If an attending asks you a question, make sure you're researched that and you can answer that the next day. Be the A-plus version of yourself independent of how tired you are and what else is going on in your life. [31:50] IM as a Team Sport Internal Medicine is a team sport. They're working in teams, not just teams of physicians but also multidisciplinary teams. When they say bring your A-game, it's not the student who's jumping over the other student to answer questions. But it's someone who is assertive and willing to help out other people in the team. They want to see that you care about the patients, about your team members, and also, you care about yourself. They're going to notice a student trying to get early everyday so they can study for their Shelf. Compared to someone who makes sure the patient is updated and see if there's anything else they can help with. [34:54] Common Application Mistakes One thing Hilary observes that students are doing is panicking. If you're planning to match in Internal Medicine and you have good mentorship, you're going to be okay. But students tend to over-apply. Personally, Hilary would see applications for people who she really doesn't think would be happy at their program. Hence, think about what you want in a residency program. Look and ask your mentor how competitive you are. Think of whether there are geographic restrictions. Or there's a certain population type that you want to take care of. Make sure that the residency programs you are applying to and interviewing at are going to give you that. Get as much information as you can. You don't want to be applying at programs you wouldn't actually be happy at. Stick to the ones you think are going to give you the experience that you want. [38:15] Thoughts on the Pass/Fail System Hilary doesn't think medicine is as impacted by the USMLE pass/fail. And that this system will help the people who are extremely dedicated but may not be great test-takers. What she worries about more is the trend of withholding all information from residency programs. More and more medical schools are going pass/fail in their clinical years. But if you don't have grades, it would be hard for them to tell whether you're going to do well in their program. [40:45] Final Words of Wisdom Be your authentic self. Be eager, enthusiastic, engaged, and a hard worker. Find a mentor. Wake up everyday thinking about what you can learn and how you can make the world a better place. Look for ways to engage and participate. And the path will become clear to you. Surround yourself with like-minded individuals. Seek your joy. Find out what diseases make you happy and what patients make you happy and what other providers you want to be with. Then you will figure out what the right place is for you. Links: Meded Media

Full show notes at the publisher

117: Microscopes Aren't Magic: Liver and Transplant Pathology Oct 16, 2019

Show notes

Check out our 25% Black Friday Sale now through 12/1/2025 at https://medicalschoolhq.net including our 1-on-1 advising and MCAT Winter Immersive Course!

Dr. Adeyi's journey began in his native Nigeria. He joins me with insights into the workflow, lifestyle, and training involved in transplant pathology.

116: A Closer Look at the Pathology Residency Oct 09, 2019

Show notes

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

Full show notes at the publisher

115: Making an Impact as a Pediatric Orthopedic Surgeon Oct 02, 2019

Show notes

Session 115

Dr. Matthew Dobbs is a pediatric orthopedic surgeon specializing in foot deformities.

Several weeks ago, I had a pediatric orthopedic surgeon on the show but someone specialized more in spine care and spine surgery.

Today, we get a somewhat different point of view from someone who went through the same training path of becoming an orthopedic surgeon specializing in pediatrics, just a liking to a different part of the body.

And if you haven’t yet, please listen to all other podcasts on Meded Media as we continue to help premeds and medical students along their path through medicine.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:48] Interest in Pediatric Orthopedic Surgery

Matthew got initially exposed to pediatric orthopedics earlier on in medical school. He went to the University of Iowa and met people who later on were going to be his mentors, some giants in the field of Pediatric Orthopedics.

He still didn't know what he was going to do but he was able to work alongside one of them on a research project. This piqued his interest and this really took him into orthopedics after medical school.

Once within orthopedics, he spent more time with those particular mentors. He soon developed a love for the field and respect for what his mentors were able to accomplish on a daily basis.

What he loved about his mentors was that they were able to embody everything he wanted to be as a physician. They were caring and inquisitive. They combined a clinical career with never stopping to ask questions and have the curiosity. They always wanted to figure out what they could do better for their patients. Moreover, he likes the interaction with not only with patients but also with the parents.

[04:38] Interest in Foot Deformities

Matthew's greatest mentor was a fellow named Ignacio Ponseti. He was a faculty member at the University of Iowa orthopedics. He was already semi-retired when Matthew came into residency.

Ignacio came out of retirement to go on and train a group of people that could "spread the word" on a nonoperative method for clubfoot treatment.

Matthew was very fascinated by this technique that was developed back in the 1960s and published in a journal. But it didn't change anyone's practice. The surgeons wanted to keep operating on clubfeet.

Matthew saw this as a beautiful, artistic process that he wanted to be a part of. And so this was led him into this specialized area. Currently, much of his career is spent on going out and teaching this particular method on clubfoot treatment to others.

[06:40] Types of Patients

Matthew loves the fact that he gets to treat his patients as babies which he finds to be so much fun.

He treats infancy all the way through young adulthood. He treats patients with clubfeet that are already in adulthood as well. So he gets the whole gamut, further adding that he treats foot from birth to the grave.

Aside from clubfoot, they see a lot of other foot deformities. They see flatfoot, which is common in the general pediatric population. Another condition is the cavus feet, which is a more problematic issue that requires surgery.

They also deal with other congenital foot deformities such as children born with extra toes or missing toes, and the congenital fusion of bones of the bones.

[Related episode: 5 Traits Patients Want Their Doctors to Have]

[08:30] Academic vs. Community Setting

Matthew chose the academic route over the community setting and it wasn't difficult for him to make this decision. He was able to combine his love of taking care of patients while also having the ability to ask questions and do something about it through research. He enjoyed the combination of patient care and translational research.

[Related episode: 6 Tips For Improving Patient Communication]

[09:55] Typical Day/Week and Percentage of Patients for Surgery

Half of his week is spent on the operating room and half in the clinic. Then he spends a little bit of time from each half on academic work and research. But mostly, his time is between the two.

They roughly take one patient to the operating room every 15-20 patients they see.

[11:10] Taking Calls and Work/Life Balance

Matthew handles calls covering everything in pediatric orthopedics so it's not just isolated to the foot. There's a lot of trauma.

They're a Level 1 trauma center so they encounter cases like high-speed car accidents with broken bones as well as injuries from sporting events. They also see bone and joint infections. These are the majority of things they see on call.

Matthew finds trauma very interesting. It's fun to take care of the kids that are hurt. In general, the bodies of kids know how to heal. All they want to do is get back to playing so they're very motivated patients. You treat them, fix their bones, and they get back to doing what they want to do.

Matthew explains that you can strike that balance with pediatric orthopedics. The calls can be out of your hands but you can control your clinic schedule, you're elective ORs, and how much you work to some extent.

But the nice thing about the children is that you don't have to come in the middle of the night for the most part. So it's very conducive for you to plan out your family time. Those fractures are typically splinted in the emergency room and you're able to take care of them the next day or the next week in the office.

[14:10] The Training Path

After medical school, you take a 5-year orthopedic surgery training. This is general orthopedics, which covers everything within the field of orthopedic surgery, including pediatrics. Then you do one more year of strictly Pediatric Orthopedic fellowship. So it's six years in total. Foot is covered within that training.

But in this day and age of increasingly subspecialization training, there needs some additional training in these other areas.

Many people are now doing a six-month extra fellowship in Foot or in Sports or in Spine. All these things are strictly within peds because it's hard to dive deep into one particular area within a period of one year.

[15:45] Residency in Orthopedic Surgery

The first two years of training are the busiest as it's the adjustment period. You're still learning and everything is new to you at that time. And that's the most overwhelming part as you're trying to learn everything.

For Orthopedics, on your 3rd to 5th year, it just gets better and better each year. You know what you're doing more and you get more comfortable. You gain more independence. You're building your confidence and skillset as you go along.

By the time you're a chief resident in your 5th year, you're really comfortable and independently handling many of the common things you see in Orthopedics.

[Related episode: Orthopedic Surgery Match Data Deep Dive]

[16:45] How to Be a Competitive Applicant and Finding Mentors

The biggest thing to do as a medical student is to have some elective rotations so you could meet professors and get a feel for the specialty itself.

You can do a clinical research project. It doesn't have to be basic science research. Get involved with developing a relationship with somebody that can write you a letter of recommendation.

We've heard time and time again from other physicians on this podcast that mentorship is the driving force behind a lot of specialty choices. And it's a common dilemma for many students to find a mentor and reach out to someone.

How do you begin that relationship?

Matthew points out that there's no one recipe for that but you will find that the people you're associated with are at these institutions for a reason. They enjoy teaching. They want to be approached.

If a student shows interest, then you're going to see the professors open up their doors and welcome you. It's just about being willing to take that step. Know that you're going to have an open door and that's the key.

Additionally, there are so many interesting things to do in medicine that you're going to run across those mentors. You're going to figure out an area that piques your interest and those relationships tend to blossom.

Your calling can be so many different things. So it's really about what path you happen to go down.

[Related episode: Getting a Mentor to Guide Your Premed Path]

[19:34] Overcoming Negative Bias Against DOs

Matthew has many good orthopedic colleagues who are osteopaths as well as fellows who are osteopaths in their own pediatric program. So don't think there are going to be balls in front of you.

That being said, it all comes down to relationships. If you find mentors within that field, whether they're osteopaths or MDs, develop those relationships. They're going to know people in the field. They'll write you letters and give you opportunities for projects. Do the best you can in school and extra projects hold the same.

[20:30] Working with Primary Care and Other Specialties

25% of primary care practice are orthopedic complaints so they're really huge in primary care. So they really want to encourage primary care physicians to get more of that training within medical school. That's because orthopedics is not always even in the medical school curriculum.

Matthew strongly encourages students to take electives in an orthopedic area because they're going to have orthopedic patients in their practice.

Other specialties Matthew works the closest with include Pediatric Neurologists and Pediatric Geneticists.

They try to figure out whether these congenital deformities in the legs and the feet have any underlying cause for them. They try to figure out whether there's a syndrome or a peripheral nerve disorder or central nervous system disorders.

Those are really two groups he works with the most in terms of medicine. He also works a lot with physical therapists and physiatrists and other specialties.

[22:26] Special Opportunities Outside of Clinical Medicine

There are not so many industry opportunities with pediatric foot as much as some other fields within orthopedics. They don't use as many implants among the kids. They basically take advantage of the fact that kids could heal in casts.

Being an entrepreneur himself, he developed a clubfoot brace that's now used in over 100 countries. There are opportunities to do these things and be innovative in the industry side. There are also consulting opportunities that are possible.

[23:43] What He Wished He Knew About Pediatric Orthopedics

Matthew would tell his old self to pay attention to the long-term effects. How you do in a specialty has a long-term outcome. There's long-term stuff they don't know about such as the effects of the surgeries you do or the natural history of conditions. There's just not much many studies out there that show these things.

So he would tell himself to be one of those people that gets involved in trying to develop level 1 evidence data. Give good, long-term data to know the effects of what we do today and how that impacts a child's life as an adult. Try to really understand the natural history of, not only the disorder but the treatments as well.

[25:05] Most and Least Like Things

Matthew loves being able to see a clinical deformity and be able to address this in some magical way with casting, gentle manipulations, minimal surgery, and create feet that fit well on the ground. You get to see feet that are mobile and you get to watch the children you've developed relationships with over time.

What he likes the least are the things that they can't fix. And they all have those sad stories in their specialty. These could be things that involve tumors or injuries beyond repair and long-term physical deficits. And it's hard to deal with that on a regular basis.

[26:30] Major Future Changes in the Specialty

Matthew does basic science research, specifically genetics research. He studies and identifies genes for different pediatric conditions. So he absolutely can see changes in the future.

We're actually seeing personalized medicine now among adults. They can get their blood pressure medicine now based on their own genetic profile. They want to take this to the orthopedics standpoint in personalized treatment.

After they've casted and corrected clubfeet, they wear braces worn at nighttime for four years. And they know all kids don't need braces for that long but they also know that some kids need it longer.

They've gotten down with a ten-year clinical trial over randomized children in the different links of bracing. They're developing a new classification system that's now prognostic.

So you can see a baby at birth and based on clinical exam findings, you can now tell how long should they be wearing the brace. It's a much better, personalized treatment that what they currently offer.

[27:45] Final Words of Wisdom

If he had to do it all over again, Matthew would still have chosen the same specialty without a doubt. Ultimately, he wants to tell students interested in this path to definitely explore and follow your interests and passions.

Do readings on this. Find mentors within your training facilities, within pediatric orthopedics. Go for a research opportunity. Develop that interest and good things will happen.

Links:

Meded Media

114: Occupational Medicine and Its Many Applications Sep 25, 2019

Show notes

Session 114 Do you know what Occupational Medicine is? Although the specialty has been around for a long time, it’s not very well-known. If you like variety and a detective type of work in exploring what could be causing someone to be ill, Occupational Medicine is an amazing specialty you should check out. Dr. Jacqueline Moline is an Occupational Medicine specialist in an academic setting. She’s here today to help us understand what they do, why such specialty is very important, as well as the ins and outs of the specialty. If you’re a premed student, please do check out all of our other podcasts on the Meded Media. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:50] What is Occupational Medicine? Jacqueline didn't know about Occupational Medicine when she was in medical school. She first got interested in the specialty during her Internal Medicine residency program. She had the opportunity to rotate through and meet with faculty. At that point, she thought it was the career choice that appealed to her. Occupational Medicine is a discipline that deals with how the work environment can affect health. It's a global type of specialty in the sense that you have to have an understanding of what the person does, workplace hazards, and how the body is going to be affected. Jacqueline explains that occupational medicine involves not only treating the "what's" but also the why's." They can treat your "what" but they also need to understand "why" you have this. What can they do to identify what might be causing it? For instance, an adult presents to you with new-onset or a sudden exacerbation of their childhood asthma. The first question they would ask is what are you exposed to know that you weren't exposed to before? So they can treat your asthma and give you the appropriate inhalers or whatever medications needed. But they're also concerned with identifying why you have it. If they can identify why you have it and work in a way to avoid that exposure then you don't have asthma anymore. Just a little backstory here. I used to work as a flight surgeon in the Air Force and we deal with Occupational Medicine all the time. We evaluate the mechanics working on planes and the paint shops where they're dealing with all these chemicals. Occupational Medicine is a specialty within Preventive Medicine. If you can identify the hazard, you can prevent it. [Related episode: What is Preventive Medicine? A Look at Academic Prev Med] [06:35] Occupational Medicine as a Residency and Fellowship Occupational Medicine is a residency/fellowship. It's called a residency because technically you only need to do an internship and then join the two-year training program. Or it can be called a fellowship if you have done three years of training in Internal Medicine or Family Medicine. She wanted to get the additional training because she wanted to learn more about the things she didn't know about like toxicology, epidemiology, etc. You could actually play several roles as an Occupational Medicine specialist. You could have a policy role or work to help foster new policies in the federal or state government. You could work for a large corporation or be in academia. You could work in a clinical practice and do clinical Occupational Medicine all the time. Moreover, Jacqueline wanted to know how to take an occupational history and practice it because this wasn't something they had time for in internal medicine due to time demands. [08:05] Traits that Lead to Becoming a Good Occupational Medicine Specialist Curiosity is important. Try to figure out what's going on. Often, you're like a detective. It's going back to being really curious and just asking questions and having an open mind. [10:12] Types of Patients Jacqueline works in an academic setting and has a more specialized practice. She sees patients who've had asbestos exposure or patients were exposed 30-60 years prior. Then they've developed an asbestos-related disease. Or they've had the exposure and they monitor their health to make sure they don't develop diseases. She covers a range of patients from those with asthma to manufacturing people exposed to various chemicals. She takes care of painters who might be exposed to solvents. She had also looked at folks who've had exposures to mold, heavy metals, or molten lead. Based in New York City for many years, she had a uniquely New York type of exposure. They did a study on the health effects of theatrical smoke on actors on Broadway to see if that was impacting their voice. They also looked at any health effects related to the special effects used on stage. They looked at whether wood preservatives can cause cancer. They've done studies on firefighters looking to see at increased rates of cancer. One of the things she has been doing for the last 18 years is monitoring the health of folks exposed after 9/11 at the World Trade Center site. Some people in her field see more ER-type, urgent care stuff where they may see people with slips, trips, and falls at work. Jacqueline had taken care of folks with repetitive strain injury from overuse of the computer. It could also be something they developed as court stenographers or those who had to punch tickets on the train where they had to use their hand repetitively and developed thumb problems. What she loves about her specialty is that she never knows what kind of exposure she's going to encounter through her patients. [Related episode: 6 Tips For Improving Patient Communication] [13:45] The Importance of Occupational Medicine Jacqueline explains the difference between Internal Medicine physicians and Occupational Medicine specialists treating specific occupational-related cases. As an Internal Medicine physician, you're not going to be necessarily well-versed in the regulations that are going to be the underpinnings. How often should you be monitoring someone who has been exposed to lead? Do you know when they can go back to work? What does their lead level need to be? If they're exposed to asbestos, do you know what you should be looking out for on a regular basis and how you should be screening? Are there any regulatory requirements depending on their job that you have to fulfill? So they have worker's compensation and are you treating them according to the guidelines that might be present in your state? Do you have time to take the full history to figure out what's going on in someone who's presenting rather than just treating them? Jacqueline spends about 80% of her time or more, talking to the patient to figure out what's going on with them. The exam part is usually much shorter as well as the test-ordering and results. Every discipline has its acronyms. There have even been primary care physicians who came to her and didn't know how to begin to do it. And she'd be happy to work in tandem with them. Jacqueline underlines the importance of thinking in terms of what the person is doing for a living or what their hobbies are. The exposure might be the same, and it's just the location is different. If it's in your home, it's considered environmental exposure. If it's at the workplace, it's called occupational exposure. But it's really a continuum which is why the specialty is usually called Occupational and Environmental Medicine. [18:30] Having Real Human Interaction One of the beauties of this specialty, Jacqueline expressed, is that there is so much appreciation from your patients that you're having a conversation with them. It's not only transactional. It's not just clicking a bunch of boxes but actually having a conversation about your life. People might be asked about their family history but, for instance, it's usually whether their dad died of heart disease, diabetes, or cancer. It's never like asking what their dad does for a living. Because if your dad was a shipyard worker then they need to know that because then they would know you're at risk for asbestos-related diseases. [19:34] Typical Day Currently, Jacqueline is the department chair so she has more meeting time than the normal person, plus she's in academic medicine. Part of her time is spent doing research projects and research protocols and working on getting the date and the results. Then she'd have to write the stuff up. She also runs large clinical programs so she has to make sure the staff is doing the right things and make sure everything is running appropriately. Her favorite part of the week is seeing patients. She gets to do what she had always wanted to do in medical school. She loves taking care of the patients and meeting up with them. She also mentors both her faculty and other doctors. They're trying to cascade where they're trying to begin to mentor other people to have opportunities that will allow them to grow. [21:34] Academics vs Community Setting Jacqueline initially thought she'd be more hospital-based. She actually went to the University of Chicago, which is very academic-based, and she did her Internal Medicine residency at Yale. At the former, you’re considered a faculty member when you’re seeing patients there. While at Yale, there were both private physicians and Yale physicians, more of a mixed model. She had always thought of staying in academic medicine. She likes the idea of doing clinical research. So she didn't think she would necessarily want to see patients five days a week. She wants to mix it up and do some other things to feed her curiosity. The field has allowed her to do all sorts of different things in her career from lead exposure to projects looking at bone lead turnover. She was looking at actors, firefighters, and 9/11-related stuff to working with asbestos-exposed individuals. On the corporate side of things, one can work as a corporate medical director or a company staff physician. Some physicians also get involved with travel medicine and government roles. Jacqueline found academics to be the right fit because it allowed her balance between patients and research. Plus, she gets to do policy and influencing along the way. [24:22] Taking Calls Jacqueline doesn't take calls and she has not really done it since her Internal Medicine days. She considers the specialty as having a nice lifestyle. It's more of an 8-6, 9-5, or manageable shifts. It's very much an outpatient specialty. [25:22] The Training Path Occupational Medicine is a 2-year training program. During this time, you also get a Master of Public Health or its equivalent. So you will be doing MPH work and studying with other students. You will be taking courses in the core requirements. Then you begin to see patients as you would with an attending physician in the specialty. You have supervised patients that you see and you begin to work on various research projects. In Jacqueline's case, she did a variety of projects with a mentor. One of which gave her early exposure to working with pesticides. This allowed her to learn about pesticides and their health effects. In some programs, you need to do a thesis. Other programs require a capstone project. It's a multidisciplinary project. Not only do you need to interact with your medical team, but you also have to be well-versed in industrial hygiene. So when you get a report, you would understand it. For example, you may do a worksite visit to understand how people can get exposed. You might work with a safety engineer and figure out what processes could be improved to make it a safer environment. You will be working with occupational health nurses as well. So you need to think about it in terms of multidisciplinary and interdisciplinary. [28:30] How to Be a Competitive Applicant for Residency Do a primary care specialty first. This provides you with the foundation that it's hard to gather without having those years. Ideally, this would take three years, but if you can't, do two years to just get more experience. Then you transition over to Occupational Medicine. Jacqueline used to be a residency director and says they've had some amazing trainees who came from different fields. Some came from Radiation Oncology where they didn't feel it was the specialty they wanted so they transitioned over to Occupational Medicine. Try to find folks around the country who would be willing to work with you and maybe you can do a project form afar while you're a medical student. And if you just want to do an internship and go to Occupational Medicine, that works as well. [Related episode: How to Think About Choosing a Residency & Specialty] [30:50] What She Wished Primary Care Physicians Knew About Them Jacqueline wished primary care physicians knew they could work together better to identify what's going on with their patients. They should think about the external factors that might be affecting health. But they don't have a lot of times as their days are so busy. Jacqueline encourages primary care physicians to use them so they can better care for their patients. Let them at least take that long history and identify if they can find a reason why their asthma, for instance, isn't getting better, or potentially cure it. If someone comes with a new-onset unusual condition and they just switched jobs, send the patient to them. This way, they can do an inventory of what they might be newly exposed to in the workplace that might explain why their blood count is unusual. [33:14] Doing Inventories If a patient is a member of the union, often the union can help and assist. But by law, the workplace has to provide the information. But you can also work with your patients. You can find what is called MSDS's (Material Safety Data Sheets) online to get a sense of what they're exposed to. Sometimes, they will lean into what is actually in that particular substance as it may have proprietary secrets. You can call the company and they have to tell you as a health care provider what it is if it could be causing adverse health effects. This can be time-consuming and this is one of the challenges they have. But that's part of identifying the mystery of why someone might be sick. If they're using a substance, they have to have it available to all their employees and that's the law. [34:50] Working with Other Specialists Jacqueline deals with pulmonologists a lot as well as ENT and GI. They also deal with mental health as some exposures have led to mental health issues such as PTSD, anxiety, stress, or burnout. Other specialties they work with include thoracic surgeons, dermatologists for rashes in the workplace, and orthopedics and physiatrists for ergonomic issues. [36:10] Fun Opportunities Outside of a Clinical Workplace There are government roles you can do whether on a state, federal, or local level. There are corporations looking to hire doctors. There are always tons of job opportunities available in Occupational Medicine. There are also corporate medical director positions available. There's also the academic setting. [37:10] What She Wished She Knew About Occupational Medicine No one knows what Occupational Medicine was and she wished she knew about it going into medicine. When she went to Yale and there was Occupational Medicine, she felt it was the natural fit for her. Over the years, she has found it to be a challenge that she would always have to describe what she does. Part of the reason is that they're not a specialty that's direct from medical school. It means that people choose something else first before they go into Occupational Medicine. Jacqueline encourages people to contemplate on the curiosity and thinking outside of the box. Think about…

Full show notes at the publisher

113: The Combined Pediatrics and Emergency Medicine Residency Sep 18, 2019

Show notes

Session 113 Dr. Aaron Leetch one of the program directors at the University of Arizona for a combined residency in pediatrics and emergency medicine. It's actually a very rare residency program with only four programs in the country that offer this. Find out more about this, how it's different and much more! Dr. Leetch is the host of the Arizona EMCast. Also, check out all our other podcasts on Meded Media. Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:27] Interest in Combined Pediatrics and Emergency Medicine Aaron has always been certain he was going to be a pediatrician as he loves working with kids. He also liked the compassion of it. It was when he started working at one of the local ERs as a scribe that he felt torn between pediatrics and emergency medicine. He loved the acuity and multitasking aspects of emergency medicine. In fact, he likens it to waiting tables which he used to do. Then he met the program director at the University of Arizona who trained at the combined emergency medicine and pediatrics program in Baltimore and started the program there. He asked Aaron why he wanted to do both and thought it was everything he had wanted to do. After five years of doing the training program, he still loved every minute of it and knew it was the kind of thing he wanted to do for the rest of his life. Aaron has always been amazed at people being torn between two specialties that are very dissimilar. For some people, pediatrics and emergency medicine are not the same. But he explains that there are aspects of both sides that he really liked. Aaron later realized that his pediatric training would be applicable when he sees children in the emergency department. To help them navigate that system in the ED is incredibly helpful to the patient. [Related episode: What Does the Pediatric Residency Match Data Look Like?] [06:40] Traits that Lead to Being a Good Combined EM and Pediatrics Physicians You have to be patient considering that it's a five-year training. Be sure that you're willing to do five years since you can just do emergency medicine and still trained to see children. The first thing he looks for in applicants is why they want to do both programs. He also wants to know people have considered what they want to do after they're done with training. There are lots of EDs that can't afford to hire somebody who's only certified to see children and they need to see both. [Related episode: Advice From an Emergency Medicine Residency Director] [08:38] Getting Exposure for the Program Considering that there are only currently four programs doing this kind of training in the country, they're hoping to gain visibility through doing medical student podcasts. Plus, they also get the opportunity to talk to people about this. The most common for pediatric/emergency medicine is doing a peds or emergency medicine residency and then doing a fellowship. This is great as long as this is what fits with what you want to do. However, if you want to be a rural doctor and you want the general pediatrics knowledge or the subspecialty time with pediatric nephrology or neonatal ICU, you wouldn't be able to get this by just doing an emergency residency and the pediatric fellowship for two years. It would not give you the same level of intensity if you want to be a broader trained person rather than narrowing and being a specialist. [10:50] Types of Patients The types of patients you see depends on where you go. In Aaron's case, he does 60% peds and 40% adults. You have the potential to work in any emergency medicine department across the country. If you want to work in a pediatric-specific emergency department, that depends on the needs of that emergency department. You could open up your own clinic if you wanted to or work in places that need a general pediatric physician as a hospitalist. You can do a fellowship on the emergency side or on the pediatric side. Or you can do both. In their program, they've had people who did fellowships in pediatric critical care, simulation and medical education, toxicology, sports medicine, and some other ones. You've got a lot of opportunities when you're done assuming you keep your options opened for geography. Make sure you've got a good idea of where you're headed. As fellowships are becoming more common after residency training, you need to be able to stand out. However, you don't want to do this just to stand out because it's a long chunk of your life to spend. There are better things you can do. But it does help and it gives you a different philosophy for how you're approaching things. [Related episode: 5 Traits Patients Want Their Doctors to Have] [14:20] Trend in Medicine for More Specialized Specialties If you have an idea of where to go, then you need to email that institution and ask what you need to do to get the job. That said, there are plenty of places that are still clamoring to get somebody who is a specialist and wants to take ownership of pediatrics. There's a lot of literature suggesting that people who have done the pediatric EM fellowship stay in large academic centers. They don't go out into the community and work as they had hoped. In fact, many have now questioned whether centralizing everything at the children's hospital is still the best way to go. Aaron feels that if you've got extra training, you feel more comfortable seeing children. You feel more prepared to see a really sick kid out there because that's where the majority of these kids are going to end up going. For their program, Aaron explains you have to have the pediatric experience. You've seen kids, especially the really chronically ill kids, and the tech-dependent kids. You've seen them in the clinic. You've seen them at the subspecialist's office. You've seen them when they're really sick in the ICU. You've got a background on how to take care of children that you can pull from. And then you've got procedural competency and that critical care emergent time-management mindset from emergency medicine. The other five years of training just becomes a part of you. [18:30] How to Know If You Have the Procedural Competence If you can get any experience during medical school, you will decide very quickly whether you love procedures or you don't. There are a handful of environments where residents and attendings tell you how they've walked into X environment and they knew they're home. For some people, that's the O.R. For some, that's the clinic or the ICU or the ED. If you have the opportunity to do any kind of three-week elective or some experience ahead of time, do it. Email a physician and ask if you can shadow them even just for one shift or overnight or for one time that will allow you to get the best exposure. A lot of what they do in pediatric emergency medicine is to convince their kids are going to be okay as well as a lot of return precautions. If you don't like doing this then pediatric emergency medicine is probably not great for you. You're not constantly having critical children coming in. Regardless of what you're considering, try to get some experience early and that will help you make your decision. [21:00] Work/Life Balance and Taking Shifts Aaron still gets to have a life outside of the hospital. But he believes you have to make time for it. He makes it a point to take time out apart from doing anything related to work to recuperate and refresh. With shift work, you've got to work 365 and somebody's got to work the holidays. Somebody's got to work the overnights. So you adjust to it. And if you're considering emergency medicine of any kind, you have to determine whether you can function at 2 am. And are you somebody that someone wants to be around at 2 am? Or do you turn into a werewolf that nobody wants to work with? You have to make it a point to do something that is not medical after work in order to restore yourself. At their program, they've got a handful of people that just do nights. They're offered a pay differential so you can make a little more. But they would usually split between mornings and evenings. The morning shift can start as early as 6 am. They work 9-hour shifts. And it can start as late as 5 pm and you get off at 2 am. But in an emergency, you get off when everything is done, especially as a resident when you're still trying to learn your flow and your management. But you will get better over time and things will get tolerable. As a resident, everybody rotates through in a circadian fashion so that you do as much as you can. But you do a lot more evening shifts because that's when the patients come in. Even if your sign out is done is at 4 and your relief comes in at 4, then you're not done for another 30 minutes so that the transition of care is appropriate. And this is expected. Aaron gets off when he's supposed to probably 60% of the time. Especially in pediatrics, most of the kids they see are not critically sick. So when he works his adult shifts, he always buffers knowing that a lot more adults are going to be critically sick and they're going to need his time. But you're never really prepared for that stuff. [Related episode: Balancing Family Life with Being a Premed and Medical Student] [26:45] The Training Path If you want to do pediatric emergency medicine, you can do a three-year pediatric residency and the three-year pediatric emergency medicine fellowship. You can do a three or a four-year emergency medicine residency. Then another two or three years in pediatric emergency medicine fellowship. At their school, they have a five-year program where you have to fulfill all of the requirements for emergency medicine and all of the requirements for general pediatrics. They're doing this concurrently. They do somewhere between 2 and 6 months in the emergency department doing trauma surgery, ICU at the VA, emergency medicine, anesthesia. Then you'll flip and do 2-6 months of general pediatrics, neonatal ICU, pediatric pulmonology, inpatient wards, clinic. Then you keep flip-flop back and forth until you reach your five years. Aaron likens their training to children growing up in a bilingual household. They don't necessarily keep the same verbal milestones compared to a kid growing up in a single language household. They're learning two different words, two different idioms, and two different ways to say the same thing. But once they do, they catch up pretty quickly and they speak two languages. With their program, they're going to teach you how to speak pediatrician and how to speak emergency physician. Although, it takes a little bit longer. It's a different growth curve of how you're going to progress along in your understanding of both specialties. But once you do, you're going to catch up. You may even surpass some of the residents from either the emergency medicine or the pediatrics program itself because you now speak two languages. [29:45] How to Be Competitive for This Program The four programs that offer the combined residency include the University of Arizona, University of Maryland in Baltimore, Indiana University in Indianapolis, and LSU in Louisiana. There are only 8 or 9 spots in country. Aaron says that you have to consider if you're crazy enough to do five years. You have to love this enough that you want to do five years To make yourself competitive, have a backup either in pediatrics or emergency medicine. Some people choose both. And even if you don't match into one of these spots, you can still do emergency medicine and a fellowship or pediatrics and a fellowship. They've even had several residents that graduated from one program and then re-entered the match and did the other ones. So they did six years to do the same. Well, it's not quite the same because you're taking it in chunks instead of intermingling it. Aarons recommends that you strengthen your application packet towards whichever is going to be your backup. So if your backup is emergency medicine, then strengthen your packet towards emergency medicine. Show that you're going to be a good emergency medicine resident. Doing away rotations is great as well as interview rotations to have a good idea of what's there. Do pediatric emergency medicine or pediatric ICU as they're going to be helpful whether you do the combined EM/peds program, EM on its own, or pediatrics on its own. Both are going to intersect with peds/EM and peds-ICU. This will help strengthen your packet for the combined program and for whatever your backup is going to be. [33:40] Applying as a DO and How to Stand Out in Rotations Two of their residents at their program are osteopaths and they're fantastic. If you're applying to a place that already has unfavorable opinions set on osteopaths, go for it if you want to be the trailblazer and try to rotate there. Otherwise, consider if it's really the best place for you if you're not going to be viewed as an equal with the other residents. Aaron adds that you can strengthen your application just as you would for any other place. But if you feel like that may be a hindrance for you, doing an audition rotation is a great way to show how good you are. To stand out at these rotations, you have to show initiative and that you can work well with a team. They want to see that you've done some of the work on your own. There's also the 2 am test. Are you somebody they want to be working with at 2 am? You have to be reliable. A fit in personality is also important to consider. Their program wants to see that you fit well. So you have to consider whether you're a good fit at a certain program and determine if you like them. [Related episode: The One Thing You Need to do to Stand Out as a Premed] [37:30] What He Wished He Knew That He Knows Now Aaron wished he had done a much better job with self-care and making sure that he took time (that he now takes) for family, for friends, for hobbies, and for things that help maintain his sanity. Although residency is not as a brain-drain that medical school can be where you feel like you're drinking from the firehose, it is time and energy-taxing. You have to put effort into the things that you want to be around when residency is around like family and friends. Because you can't just push pause and come back in 3 to 5 years and feel like everything is still going to be the same. [38:50] The Most and Least Liked Things What Aaron likes the most about the combined residency is that they are people who like to have fun and have a broad perspective of medicine. What he likes the least about the pediatric emergency medicine is that when it's bad, it's really bad. They deal with cases like child abuse, pediatric sexual assault, drownings, SIDS, and cancer diagnosis. Often, those will happen in the ED. What he realized that really affected him is that they can't help everyone. They want to take care of everybody that's there. They want to try to help every person that comes into the emergency department. But there are so many people that come in with complaints that they can't help. He tries to provide hope for people in a hopeless situation when they come in at midnight on a Saturday. For him, this is frustrating when you can't offer what they want. [42:35] The Overlap of Pediatric Care and Adult Emergency Medicine Especially during residency, you spend a lot of time in the clinics and on the wards. They even joke around that kids are not little adults but adults really are just big kids. Aaron says he can do a lot of the same things that he does with children. He…

Full show notes at the publisher

112: A Pediatric Emergency Medicine Physician's Story Sep 11, 2019

Show notes

Pediatric Emergency Medicine is a chance to treat diverse populations in a fast-paced setting. Dr. Donna Mendez tells us why she finds peds ER so gratifying.

111: The Possibilities in Pediatric Orthopedic Surgery Sep 04, 2019

Show notes

Session 111

Pediatric orthopedic surgery is great for inquisitive doctors who love working with kids. Dr. Philip Ashley joins me to talk about subspecialties and more. Out of training for a few years now, he shares his path as he changed careers mid-college and how he reached out to a mentor which changed his trajectory in life.

Are you a premed student? Check out The Premed Years podcast where I feature physicians, medical students, admissions committee members, and more. Everything you need to know about your premed path is right there.

If you're already a medical student, check out Board Rounds, where I partnered with BoardVitals, a test prep company. We're breaking down questions to help you with your USMLE Step 1 and COMLEX Level 1 test preparation.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:45] Interest in Pediatric Orthopedic Surgery

Philip went to medical school already wanting to be a pediatric orthopedic surgeon He changed his career track in the middle of college. He initially took engineering and did a summer internship at NASA. At that point, he looked to other options.

He broke his finger bone when he was still a child. The person who operated him ended up being his mentor. He contacted him and consulted him about changing careers so he asked if he could shadow him over the holidays. Philip got hooked after that.

Philip loved the idea of being able to work with hands and do something in the operating room that made an immediate difference in somebody's life. As a pediatric orthopedic surgeon, he loves being able to develop a relationship with the patient and be an inspiration for them.

[04:15] Traits that Lead to Becoming a Pediatric Orthopedic Doctor

First off, one has to enjoy being around kids. Attention to detail is also required because you will be doing something that could impact the rest of their lives. You will be interviewing and examining children who oftentimes are in pain.

Although he also looked into trauma as a subspecialty in orthopedics, he ended up getting into pediatrics.

[Related episode: Orthopedic Surgery Match Data Deep Dive]

[06:17] Types of Patients and Typical Day

Philip gets to be a generalist operating on the spine, hips, feet, and broken forearms. The bread-and-butter is taking care of fractures in kids, the most common is humerus fracture.

You may also be taking care of clubbed foot which involves a lot of casting as well as some procedures down the line. Other common cases include hip dysplasia, herpes, and scoliosis.

His typical day would involve two different kinds. Some days, he's in the clinic and some days, he's in the operating room. His clinic starts at 8:30 am. He takes care of any loose ends from the day before. He sees 35-40 patients on any given day.

Usually, he has a resident working with him where they both collaborate and discuss cases. Their clinic days typically end at 4:30 pm and dictate clinic notes until they get home before 5 pm.

On O.R. days, they get in at around 6:30-7am to check people in the operating room. By 7:30, they start with the operation and handle as many as 3-4 cases or 1-2 big cases.

1 in 10 patients that he sees on a given day ends up in surgery. Some of them may also be follow-ups from prior surgeries. But for new patients, he estimates 1 in 5 of them end up being in surgery.

In pediatrics orthopedics, it's a lot more clinic-heavy than adult orthopedics since most kids recover from fractures and can be managed conservatively.

[Related episode: 6 Tips For Improving Patient Communication]

[11:00] Taking Calls and Work-Life Balance

In his practice, Philip has three partners and they share calls in their institutions. They do it one week at a time and take one week every four weeks.

Philip says he has great work-life balance. Part of the reason he went into pediatric orthopedics is that most of the pediatric orthopedic surgeons tend to care a lot about their family life.

Pediatric orthopedic surgeons get paid less than other orthopedic surgeons. This is because they're not working as much as their counterparts. They essentially make the conscious decision to spend time with their families.

[12:40] The Training Path

Most orthopedic surgeons finish medical school and then get into a 5-6 year residency program. There are also some programs that give you a year to do research.

After that, you're going to apply to a one-year pediatric orthopedic fellowship. In some of the bigger centers, you may have to take a second fellowship to subspecialize.

Philip recalls pediatric orthopedic fellowship as one of the less competitive programs to apply for from a fellowship standpoint.

Moreover, there are many fellowships that have opened up so you have an almost one-to-one rate of applicants to fellowship positions.

To be competitive as an applicant, some interest in research has been shown to help. Also, be able to work closely with the orthopedic surgeons at your institution and develop relationships with them. Get good letters of recommendation from them. Overall, just make sure that you're well-respected within your institution.

[15:55] Subspecialty Opportunities

Another area people are interested in is limb deformity. There is only one or two that can do a specific fellowship in limb deformity correction. Other subspecialties include neuromuscular conditions (e.g. cerebral palsy), pediatric hand fellowship.

[18:25] Overcoming Bias Against DOs

Philip thinks there's a good number of orthopedic residents that get in because they rotated at that institution. And the faculty of that institution got to see their work ethic, their interaction with patients, and their fondness of knowledge. Additionally, your interpersonal skills and your drive can help overcome that.

[19:55] Working with Primary Care and Other Specialties and Special Opportunities Outside of Clinical Medicine

Philip wished primary care providers knew about tibial torsion where he gets a number of consults for. It's normal and it will improve on its own. And so they're more than qualified to see and evaluate that.

Other specialties he works the closest with include PM&R, Anesthesia, Prosthetics & Orthotics.

In terms of special opportunities outside of clinical medicine, you could do research. In any field of orthopedics, you can deal with the legal side of things.

You could also get involved with companies that sell products specifically for pediatric orthopedics. Currently, people are developing monitoring devices for different orthotics.

[23:05] The Most and Least Liked Things About the Specialty and Major Changes in the Field

Philip loves getting to know families and see how their children grow and respond to their treatment. What he likes the least, on the contrary, is an infection or complication as a result of something they've done.

In terms of major changes in the field, there are a lot of research and efforts focused on how to deal with the growing spine and scoliosis. There are now treatments for correcting scoliosis without fusing the spine.

[27:00] Final Words of Wisdom

If he had to do it all over again, Philip would still have chosen the same specialty. Finally, he wishes to impart to students that while it's worth it in the end, it's certainly a long road. So you and your family have to be prepared for that.

It's a big-time commitment on the front end to do orthopedic residency and afterward. Be prepared for a difficult and challenging residency that will test your stamina. But be willing to do it and approach it with a cheerful attitude and inquisitive mind.

Links:

The Premed Years

Board Rounds

110: What Makes Geriatrics so Stimulating for This Doctor? Aug 28, 2019

Show notes

Session 110 Geriatric medicine is both stimulating and satisfying for Dr. Shannon Tapia. We’ll talk about housecalls, mortality, and the importance of having a sense of humor. Meanwhile, be sure to check out all our other resources on Meded Media for more help as you journey along this awesome field of medicine! Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points. [01:20] Interest in Geriatrics Having a father who's a geriatrician was Shannon's first exposure to medicine. Growing up, medicine was different back then but she got to witness how it was being a physician. She liked the cognitive aspects of medicine. She could do procedures but she just never really got stoked about it. Being exposed to it early on and realizing how cognitively challenging geriatrics is, she was essentially drawn to it. Shannon compares geriatrics with being the Sherlock Holmes of doctors. Aside from a huge kinetic variability if they live long enough, they also have a lifetime of choices. With geriatric patients, many of them could be suffering from dementia and other cognitive issues, making it difficult for them to express how they feel. So geriatricians have to get a collaborative history from their family and know the environment. Shannon finds this to be very interesting, challenging, and satisfying. Half the time, it's med side effects from the specialists. They throw a med at them which they should never have been on. You will also realize there's not an answer so you need to be working with the patient and their family. It basically covers all aspects of medicine. You have to be constantly thinking of options and navigate it with your patients and their families. [05:00] Types of Patients The majority of 30-50-year-olds are rare diagnoses but most of them present pretty similar cases. They come in and the doctor asks appropriate questions and they give an accurate history for the most part. This excludes people who are actively psychotic. In the older population, you have to expand your differential in what they say because a lot of things present differently. They have dampened immune systems. They have neuropathy and they don't feel pain in the same way. Until you spend a lot of time with your geriatric patients, it's hard to truly describe the extent of how different it is. You're essentially dealing with a variety of factors when you're trying to approach a problem. Then there are a lot more limitations on what the achievable goals are. So you have to reconcile those to arrive at a realistic outcome and that people can be comfortable with. [07:19] Traits that Lead to Being a Good Geriatrician Shannon says that having a healthy sense of humor is good. You have to be patient and not afraid to get into the thick of things. You never know what you're going to walk into half of the time. Don't take things too seriously otherwise you're going to end up missing what the patient really needs and that of their family. Being empathic and being comfortable with mortality are two other important traits of a good geriatrician. Shannon believes that if you're not someone who can stop doing things to people, you should not be a geriatrician. There's this mentality in medicine where doctors intervene when there's a problem and they're going to fix it. As patients get older, the only truth is we all die. There's always more we could do but you have to be able to step back. Think about the quality of life and prognosis for the patient if you did it. How would it look like not only after they recover but also in two years down the road? Essentially, you have to take it one patient at a time and take their goals and preferences at a time. Have your opinions but separate yourself from that. Moreover, there's a lot of misinformation even for geriatric patients and their families as to what's achievable in medicine. You have to get to know both the patient and their family. Be honest with them about what you think and whatever intervention they're considering. If it's a treatment situation, you have to be able to take their goals and translate what the realistic prognosis would be for them, knowing what their wishes are. That's not easy always because there's a lot of misinformation about what the medical community can achieve at a certain point." [11:00] A Typical Bread and Butter Day Shannon explains how geriatrics is struggling in terms of how they're under Medicare plans. But it's a cognitive field. It's not a procedure that they can always do and can rack up reimbursement for. Especially if you're in private practice, it's really hard to pay off your student loans and do it well. Unfortunately, there are very few private practice geriatricians anymore because it's tough and the pressures in the private practice world are hard. Not to mention that there are only a few great academic institutions that have great geriatric support programs. Shannon describes her typical day as being different from an academician. It's basically different depending on what realm you practice in. If you're in academic geriatrics, you're going to do a mixture of geriatric consult service at a hospital you're affiliated with. You will be on service with heavy clinic and lots of didactics. It's hard for academic institutions to do long-term care providing. It's a whole different set of private regulations that tend to be challenging in an academic setting. As a private practice geriatrician, your day is variable depending on whether you're clinic-based or when you're doing house-based care. When Shannon's new job starts, her practice will be in one geographic area with the goal to see 10 patients a day. Four will be in one assisted living facility and the other four from another assisted living facility, and then two independent homes within the same geographic region. Moreover, Shannon has done some expert witness and chart reviews. There is so much chat vomit in terms of what they're required to put in the medical records. So much of it is just completely useless information. [14:50] Doing House Calls Before Shannon moved to Denver, she used to do direct primary care house calls. She was fortunate in her geriatrics fellowship to get good exposure to it. The problem with geriatric fellowships is they're hugely variable. Some are more research-focused, some are more clinical. Shannon did it for a year but it was clinically focused on every level. While Shannon loved her fellowship training, she also saw how bad what you walk into could get. But part of why she loves doing this is that because of the patient population they serve. Just because you're Medicare age does not mean you need a geriatrician. It's really based on your physiology and the individual patients. Shannon explains that doing house calls could be best for the majority of the patients. This way, you also get to figure out what's going on with them. Whether it's physical debility or even a mile cognitive debility, getting them to the doctor is a huge deal. This also gives Shannon as their physician so much more information. Plus, the relationship you're able to build with them goes to another higher level. Being invited to their home, you kind of become part of their family. There is a much more intimate relationship with your patients. There is a lot more trust involved. Whereas just receiving patients in your clinic and you only have to go on the face with what they say that they're taking their medicines or they're eating. But it's different when you walk into their homes and see how they're taking their medications. So you get this unique perspective when you get to go to their home. [17:45] Work-Life Balance and Geriatrics Being a Low-Reimbursement Field Shannon says there's a potential to have a very good work-life balance as a geriatrician but it depends on how much money you need for your life balance. Again, it's a low-reimbursement field. So if you are one of those people that wants to take extravagant vacations, it is not for you. As a single mom and not having to be tied to an office, Shannon says this is really huge for her. When you're doing house calls or going to a long term care facility or nursing home, there's a timeframe. There's that flexibility of time that comes with having children but still being able to go out and do clinical work. The only challenge is the documentation requirements that put a lot of pressure on you so you end up taking more work home. Medicare sets the fees even for private insurances. So everything in medicine is all based on trying to figure out how much they're going to pay you and how many RVUs (relative value unit) you've got for a visit. The way the system works out is that time gets very few RVUs unless you do a ton of volume. But procedures get a ton. It's inherent that it's highly cognitive and diagnostic but it's not like you should be ordering tons of tests because usually, those tests are bad for the patients. People who do nursing home care sometimes do pretty well because they can do high volume as they're able to see a ton of people in one place. Also, the reimbursement system is different in nursing homes than in an assisted living or even in house calls. In nursing home care, how reimbursement works is that it's not just face-to-face visits but it works like at a hospital where it's billed for all the time you spent on the patient. If you're in an outpatient clinic or in a house call, your time is all face-to-face time with them. [21:35] The Training Path You can either do internal medicine or family practice to become a geriatrician. She was originally going to do internal medicine. Then she had great mentors in family medicine that told her that geriatrics is really an outpatient field and that if your patients are in the hospital, it's not good. Because of this, Shannon wanted to go to a field that emphasizes outpatient and she got a sense in medical school that family medicine did this. So she decided to do family medicine the last minute. After residency, you have to go through either a one or two-year fellowship thereafter. Whichever one you choose, you have to take both boards. Since she did family medicine, she would have to take a family medicine board every ten years and the geriatrics board. She also has to do a ton of things that family medicine requires that are focused on peds and women's health, which are not related to what she's currently doing. In terms of subspecialty, there really isn't that much. You can do geriatrics/psychiatry but you would have to also go into psychiatry residency. [24:04] Bias Against DOs There is apparently no bias against DOs. Geriatricians are badly needed. Unfortunately, there are people who do fellowships just for filler because they can but they don't really have intention of really practicing the specialty. [25:33] Working with Primary Care and Other Specialties Shannon wishes to say to internal medicine and family medicine physicians that geriatrics is a specialty. This has been her biggest frustration with some family doctors. There are some that think that they've got it all and they don't need help from geriatricians. But they are trained to recognize a lot of things that can help their patients out. Geriatricians are very good at recognizing and helping treat dementia, Alzheimer's, and most vascular dementias. They're actually better suited to treat it than neurologists because they are also generalists in the whole area. They're able to take a more big-picture approach. They can stay involved with the families and get them connected to the resources they need, more than just do a cognitive evaluation once a year and give them medicine. For family medicine or internal medicine physicians that have patients that are of the geriatric population or have geriatric syndromes such as Parkinson's disease and certain types of early-onset dementia, you would benefit from a geriatrician. Other specialties they work the closest with include cardiology, ophthalmology, and neurology, and gastroenterology. She also works with nephrology but not as much. They also work closely with trauma surgeons because so much of the geriatric trauma are related to unrecognized geriatric syndromes. Getting a geriatrician involved can medicate delirium and help the patients get on the right track. [30:30] Special Opportunities Outside of Clinical Medicine One opportunity is being an expert witness. Shannon only does defense. There's a lot of physicians, especially academic physicians that are on the plaintiff side. For instance, if a geriatric person had a fall in a nursing home and a bad outcome, the family goes and sues. So she does the defense and expert witness if she's asked to. [31:45] Most and Least Liked Things What Shannon wished she knew about the specialty that she knows now is that the system is not great for geriatric patients. And Shannon thinks it's even gotten a lot worse. If she had to do it all over again, she would still have gone into geriatrics. She just wished she had known how things would change in the system for the worse. For her, it would have been easier to accept things if she knew about it going in, sort of like an informed consent process. Just like when she didn't know she had to take the family medicine boards every ten years that doesn't even apply to geriatric patients. So she was really frustrated about it. And had she known it, it would have been a different story. There's a disconnect between the general population's understanding of how the medical system works and how the system actually works. What she likes the most about being a geriatrician is the patient population. It's fun to be dealing with people. You get to know them and their families. She likes how these people have a lot of wisdom. If you go into it with a sense of humor, you can have a lot of fun with it. On the flip side, what she likes the least about her specialty is the system. She really believes how detrimental the system is to the patient population. It's a growing population and it's costly. Eventually, she wants to get involved in advocacy for changing the system because she really doesn't think we can sustain the way we do things now. [37:08] Major Changes in the Field Shannon admits that she stopped subscribing to the Journal of American Geriatrics Society as she didn't see it necessary. She doesn't think there are major changes in the field but she hopes that there will be changes in terms of the system and Medicare. On a side note, Shannon also does hospice, which a lot of geriatricians do because of a similar mentality. And she really hopes politics will recognize the need for qualified geriatricians. [39:15] Final Words of Wisdom It's one of the most fascinating medical fields you can go into. You have to constantly use your mind and be an expert at pharmacology and psychiatry in some ways. The physiology is fascinating as well as the pathophysiology. So if you love to think and you love relationships, it's a great field for you. But be aware that everybody is different in terms of their student debt burden and the kind of support systems. That being said, it's not the field that's going to make you the most money the fastest. Links: Meded Media

Full show notes at the publisher