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99: What is Blood Bank and Transfusion Medicine? Jun 12, 2019

Show notes

Session 99

Today, Dr. Aaron Shmookler joins us who has an interestingly different type of specialty. He is a pathologist trained Blood Banking & Transfusion Medicine specialist. A year and a half out of training now, he serves in an academic setting in West Virginia.

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[01:48] Interest in Blood Banking and Transfusion Medicine

Aaron took a transitional year and started his residency in Neurology. But he realized something was missing – the lab. He went into pathology really enjoying the field.

Then he finished his Pathology residency and quickly realized he also missed taking care of patients on the bedside. So he subspecialized in Transfusion Medicine and Blood Banking that has the bedside aspect of care. Then he also gets to do the laboratory side where he works behind the scenes.

[04:14] Traits that Lead to Being a Good Blood Banking & Transfusion Medicine Specialist

In this specialty, you have to be detail-oriented, very specific, and concise. This is generally true in the field of pathology as well.

What got him initially interested in Neurology was when he began caring for patients with Alzheimer's disease. Specifically, he was interested in localizing lesions.

[06:35] Types of Patients

At the bedside, they perform a procedure called apheresis. He describes it as an "oil change" to patients. So if you have a patient with sickle cell disease, they can be chronically dependent on blood transfusions.

One of the ways they can be treated is by exchanging their abnormal red cells and transfusing them with normal red cells. The procedure can take a couple of hours.

When the problem is with the patient's plasma, they'd also take out the plasma and given them back new plasma.

Nevertheless, there's a whole slew of guidelines put out by the American Society for Apheresis. This would give you an idea of the kinds of conditions they would be treating and see what kinds of patients they encounter.

Aaron is also in charge of all the blood products dispensed in their hospital. This refers to whoever who needs blood such as emergency patients who come in with trauma or surgical patients in the OR. They also give blood to obstetric patients, basically, anyone who needs a blood product.

[08:55] The Role of a Physician in a Blood Bank

As someone in charge of the blood bank, a physician makes sure that all blood products that come out are going to be compatible with the patient who is going to receive the blood product.

One of the ways to do this is to make sure patients haven't developed any antibodies to some of the antigens in red cells. If they have, he makes sure he's able to find units of blood that would be negative for those antibodies.

Sometimes, they might not be able to work up with the patient's antigen status. As a result, they may need to release blood emergently. In this case, they caution physicians who require that blood that they haven't really completed all the testing they need to do to find the best-matched blood for that.

An example of this would be cases of patients bleeding significantly and they can't wait for any testing and they'd have to transfuse something. They're able to provide special blood for this, but they can't guarantee this wouldn't cause an adverse effect. So they have to be mindful of these particular conditions.

They also manage factors. Factor VIII, for instance, is used to treat patients with hemophilia. They also make sure the doses are appropriate.

[11:35] Typical Day, Procedures, & Taking Calls

For Aaron, a typical day would be coming to work and following up on any patients that may have come in at night that required a significant amount of blood.

Aaron also takes some time to teach residents and conduct research. Part of his training includes clinical pathology.

In terms of procedures, Aaron does apheresis. This involves the help of a nurse to run an apheresis machine and he oversees all of it as it's happening.

They also have standard operating procedures such as making sure that when they issue blood, the nurses are able to transfuse it in the right way. They also have to oversee procedures that their blood bank technologists are doing.

So while not directly hands-on, they're definitely overseeing a lot of the procedures that other people are doing.

Aaron takes about 6-8 weeks of call. A lot of the calls come from the blood bank. They can ask him about whatever questions they may have. They're mostly blood bank-related questions although it can be specimen-related questions.

[15:50] The Training Path

After medical school, you can do whatever you want for residency. Specifically, there are residencies that may tend themselves toward wanting to become a transfusion medicine physician such as pathology.

In fact, the board certification exam for Blood Banking and Transfusion Medicine is offered by the American Board of Pathology.

Physicians who are also training in Anesthesiology may be interested in Transfusion Medicine as well as Hematology Oncology and Emergency Medicine.

In terms of competitiveness, Transfusion Medicine is not as competitive. Looking at the 2019 residency match data, there were 924 applicants for 601 pathology positions. About 95% of them were filled. This is nearly 3 physicians for U.S. senior. So 93% of U.S. seniors who apply were matched.

[18:05] Subspecialty Opportunities

You can subspecialize in just about everything. You may like to subspecialize in another subspecialty that's a little bit closer to clinical pathology such as Microbiology or Clinical Chemistry.

[19:10] Working with DOs, Primary Care, and Other Specialties

Aaron explains that there's an increase of DOs that have been reported to going into Pathology. That said, he doesn't think there is any bias against DOs.

Other specialties they interact with include primary care physicians and general surgeons. They help select the most appropriate tests. They make sure that the resources are utilized in a cost-effective manner without harming the patient.

They want to make sure they're giving patients what they need. They also see to it that blood is being used appropriately. Often, they give blood unnecessarily.

There has been a lot of data to show that a restrictive transfusion strategy can be beneficial compared to a more liberal transfusion strategy. The less you can give somebody, the better it can actually be in certain clinical situations.

Studies have shown that a transfusion of blood is independently associated with increased mortality. Hence, this has to be utilized in the right setting. Aaron's job, therefore, is to make sure that the blood being distributed is used appropriately.

[22:30] Special Opportunities Outside of Clinical Medicine

Blood Banking and Transfusion Medicine Specialists can function as medical directors and other doctors of other blood donor centers. Teaching is another route they can take.

[24:15] What He Wished He Knew Going into this Specialty

Aaron actually took this subspecialty relatively late in the process so he wished he had known about this earlier. He also wished he knew about pathology earlier.

What he likes most about his specialty is both the patient side and the laboratory side of things.

On the flip side, what he likes the least is they're often undervalued or unnoticed by the administrators and even patients. That said, they lack the support, resources, and the basic facilities they need compared to more money-making surgical specialties,

Additionally, as a pathologist, the workload can get busy resulting in slower than expected turnaround times which can delay care. Otherwise, haste makes waste and that could result in a significant error that can seriously harm the patient.

[27:00] Community vs. Academic Setting

Being part of a donor center would mean being very much out in the community. As a pathology trained transfusion specialist, you would be a pathologist practicing in the community.

With additional training in blood banking, you'd be able to address a lot of calls. As a result, you could be put in charge of the community blood bank.

[28:08] Major Changes in the Future

Specifically, in blood banking and transfusion medicine, they're bringing back whole blood. They used to give whole blood in the military. They still do.

But since World War II, they've developed the ability to provide more component therapy. This means they're able to give only red cells if they only need red cells. Or give only plasma if they only need plasma, and so on.

This has a lot of benefits. But they also realized that in the trauma setting, whole blood actually has been very beneficial.

In the pathology side of things, they have a lot of emerging hot topics such as artificial intelligence, digital pathology, liquid biopsies, and next-generation sequencing. These are fancy technologies that supplement the microscope. The microscope has been used since the late 16th century and it will continue to be used for the foreseeable future.

On the negative side, there is a shortage of physicians in the U.S. and pathology is no exception.

In fact, Aaron read a 2013 article offering a predictive model examining some of the factors influencing pathology workforce supply in the U.S.

In the coming two decades, it's projected that there will be a decrease from 5.7 to 3.7 full-time equivalent pathologist for 100,000 population. They're actually looking at a deficit of more than 5,700 full-time equivalent pathologists.

Aaron believes that artificial intelligence would be an adjunct and it would never replace the pathologists. He doesn't anything could come close to replicating the human eye. But when AI can help in the digital pathology perspective, this could be very useful for them.

[33:05] Final Words of Wisdom

Aaron says that if he had to do it all over again, he would still have chosen the same specialty.

He encourages students to look into pathology. Out of all the medical disciplines, he thinks that pathology offers the most subspecialties. There's the clinical side of things and more!

Finally, he encourages medical students and physicians to take care of themselves. Think of medicine as this journey on the expressway. So enjoy the scenery and reflect on the vehicle you're riding.

Links:

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Guidelines - American Society for Apheresis

98: Community Breast Oncologist and Researcher Shares Her Career Jun 05, 2019

Show notes

Session 98 Dr. Stephanie Graff is a breast oncologist who has been out of training for 8 years. Today, she talks about her journey – what got her into the specialty, the training path, and the most and least liked things about her specialty. Meanwhile, please be sure to check out our whole host of podcasts on Meded Media as we seek to help premed students and medical students along their path towards becoming a physician. [01:38] Interest in Oncology Stephanie decided on oncology in the early rotations of medical school. One of her high school teachers used to tell them that whatever they decide to do in life, they have to read about. She now finds this as true advice, especially in medicine. And she just couldn't put down the book about oncology. When she moved to clinical rotations, everything just seemed to fit for her. With oncology, it allows physicians to connect with patients in a longitudinal way. You're going through something intense and emotional. Then you also get to see them into long-term survivorship. "Whatever you decide to do in life, you have to read about." In-patient oncology covers dying or very ill patients. But Stephanie clarifies this is just the minority of their patients. Most of her patients are working their full-time jobs on their chemo so they're not sick. It's not a depressing job. Of course, people die, but so do with heart failure and other kinds of diseases. That said, every field has those highs and lows. [04:02] Going Through Oncology Training Stephanie started doing lung cancer research, primarily because she got attached to her first mentor. But she ended up leaving her training program during the scope of her fellowship. The next mentor she attached herself to was the breast oncologist. So for the second half of her oncology fellowship, she was mentored by the fellowship program's breast oncologist. She found it as a good fit. "A lot of it is just finding your niche when you start your practice. There's no breast oncology sub-boards." For instance, sarcoma is an exceedingly rare tumor so you won't probably be going to be a full-time community sarcoma expert. But Stephanie is part of a large group of oncologists with 15 partners in her group. Stephanie exclusively sees breast while one of her partners does 90% GI. Two of her partners are heavily subspecialized in lungs. And one of her partners exclusively sees GU malignancies. They have a niched subgroup specialty across her practice. They also have clinical research sites where they're principal investigators on their disease types. [06:55] Traits That Lead to Becoming a Breast Oncologist "Oncology is definitely a communications-heavy field." Stephanie thinks that the lay public's understanding of cancer and cancer treatment is infantile in its development. So you really have to talk them away from the fear into the treatment, why the treatment, how to manage the side effects, etc. You have to do this concisely in the construct of the clinic appointment. You have to be resilient as there's still death and dying in oncology and you have to be optimistic by that nature. [08:33] Types of Patients Stephanie also runs their high-risk women's programs. So she sees a fair number of patients identified either by their primary care, GYN, or just the breast imaging center. They usually have a striking family history or other significant risk factors. They're being referred to her in their high-risk women's capacity to talk about risk production and genetic testing. So she gets patients this way. She has a great relationship with the breast surgeons, primary care, gynecologists in their study. She sees patients even before they're diagnosed with breast cancer. She would often be called to manage even the workup of a lump. Since the fear of having breast cancer already creeps in at this time. Breast surgeons are her number one referral source. She attends all of the breast cancer tumor boards at two different hospitals. She participates in conversations about optimal care. Stephanie is involved in clinical research so she gets referrals from all over the country for their open trials and patients connect to them. "The metastatic oncology patient community is very well-informed. They are very engaged and educated about their disease and their disease process." [10:55] Running Clinical Research Oncology is a bit different than a lot of other career tracks. In oncology, there are large academic groups and most of the research happening is sponsored by pharma. But some of them are also sponsored by the big cooperative groups like SWAG and Alliance. These are all government-funded research programs. There's a lot of oncology drug development happening that's entirely funded by pharma. They want networks that can put a lot of patients on trial, do it effectively and efficiently with good, high-level expertise and experience. "There are several nonacademic cancer research networks that are centralized cancer networks." Pharma typically contracts with non academic research networks. Their aim is to broaden the reach of their trial and improve accessibility for patients. However, they need to maintain that academic level of experience and expertise in the actual design and delivery of the trial. [13:30] Diagnosis vs. Treatment and Procedure Time The vast majority of her patients come to her with the diagnosis. She estimates 15% of patients coming to her without a diagnosis. The other 85% come to her with the cancer diagnosis. In terms of procedure, Stephanie doesn't do breast biopsies and the breast surgeons do this. She did love procedures as a medical student and resident but this is something that she really doesn't miss at all. She hasn't really done one since she graduated from her internal medicine residency. [15:05] Typical Day, Taking Calls, and Work-Life Balance Stephanie leaves her home at 7:30 am and she's at the hospital by 7:45 am. But her clinic doesn't technically start until 9 am. So she uses her 8-9 spot as his add-on spots for her nurses. When somebody calls with problems, she can take care of it. She then sees her patients in 15-minute spots. She normally sees 2-3 new patients a day while the rest are follow-ups. She keeps her lunch hour to close down her mind for a bit, follow up on emails, and eat. So she sees patients from 9 am to noon. Then resumes her clinic from 1-4 pm. Stephanie doesn't usually have a lot of in-patients. It's not unusual for her to have no patients in the hospital. Her inpatient rounds are super quick at about 30 minutes. The rest of the afternoon is spent on signing charts and running clinical trial meetings. And she'd be home by 6 pm. Being part of a large group, Stephanie is on call one week in a month. It's usually half-day. She's very much in control of her hours. She has three kids and family comes first. So she makes sure she sees her kid's soccer game first before doing rounds. Her weekend hours are normally 4-5 hours. She very rarely has any emergencies in the middle of the night. She can almost always handle everything through a phone call. All that being said, Stephanie feels like she has really good work and family balance. "Most oncologic emergencies aren't actually medical oncology emergencies. Their either radiation oncology or surgery emergencies." [19:20] Acting Like Primary Care A lot of people connect with their subspecialists as a primary care physician. This is because a lot of patients need regular follow-up and monitoring because of the nature of the diseases, the long-term risks, and the side effect profile of the medication. So they're scheduling 3 or 6-month follow-up appointments every time they leave the office. For healthy adults, they're not scheduling their annual follow-up or being seen every 3-6 months by their primary care doctor. So they just develop this longitudinal relationship with their subspecialists. This is one of the things she really loves about her career. But when a patient is admitted to a hospital with a totally unrelated disease, she often gets consulted. She loves this though and she's glad to cheer for her patients. [21:28] The Training Path and Competitiveness After medical school, you do an internal medicine residency. After your internal medicine residency, you do an oncology fellowship. Most fellowships are a combination of medical oncology and hematology. But there's a handful of training programs in the country that you can just medical oncology or just hematology. "In 2019, it's probably more employable to go through a training program for both medical oncology and hematology." Stephanie recommends taking both oncology and hematology, especially if you're still unsure about where your career path goes. You need to be able to see everything and help cover call for your group. A lot of weekend calls are about hematology stuff and a lot of hospitalized medical oncology. And hematology consults are thrombocytopenia, anemia, and a lot of blood stuff. So it's good to have that training. In internal medicine, cardiology and GI are the top two competitive specialties. And hematology is a close third probably. [24:00] Subspecialty Opportunities There are true, dedicated bone marrow transplant sub-fellowships. You can graduate and have another diploma and other board certification in bone marrow transplant. "In basically every organ system, you can subspecialize in." You can do neuro-oncology fellowships out of neurology. You can also do gynecology oncology, although there are medical oncologists that specialize and treat gynecologic malignancies. There are gynecologists that do gynecology oncology fellowships and manage GYN-Onc malignancies, both surgically and medically. Whereas with medical oncology, you would still need a surgeon to handle that surgical piece. Following down the academic path, there are GI oncologists, breast oncologists, sarcoma experts, lymphoma, multiple myeloma, acute leukemia, myelodysplastic syndrome. There are also breast, lung, genitourinary, etc. A lot of what subspecialty you choose depends on how rare the tumor is and the size of your practice. If you join a practice of three oncologists, it's going to be hard to be super specialized. If there's going to be more diversity in the caseload, you'll have to help your partners manage. But if you join a large group, there's a great opportunity to find a subset of patients you have a particular interest in. "An increasing percentage of private practice oncology physicians are in large groups." [26:35] Academic vs. Community Setting When Stephanie started looking at opportunities, she knew she wanted to stay in Kansas City for personal and family reasons. She interviewed out of several groups and the private practice group was just a great fit for her. Her internal medicine residency was split between two hospitals. One was a private for-profit hospital that had residents from the academic site in every single field rotating in that center. So it was an education-heavy environment in a private practice hospital. They also had a more traditional academic site. For internal medicine residency, they had two internal medicine chiefs. One was the chief of the private practice facility and the other was the chief of the university. Her current practice she joined felt home when she interviewed. She connected better with her now-partners. She liked the opportunities and growth developing at that time. [28:45] Bias Against DOs Stephanie doesn't really see any bias against DOs. There are several DOs that are very well-respected nationally in the field of Oncology without any particular bias. There are DOs in her group. Oncology has a really strong international medical graduate community. She doesn't feel there's any bias there either. [29:40] Working with Primary Care and Other Specialties If primary care physicians have questions about particular mutual patients but just oncology in general, Stephanie says that what they're here for. Other specialties they work the closest with are radiation oncologists, plastic surgery, pathology, and radiology, neurosurgeons, interventional radiology. "I work a lot with our neurosurgeons because a lot of breast cancers metastasize to the brain or the spine." Additionally, they have a really robust nurse navigator program. Nurse navigators help their patients move between their diagnostic imaging and their surgery as well as the systemic therapy for their cancer diagnosis and radiation oncology to help connect all the pieces. [33:18] Plastic Surgery Side of Things For the plastic surgery side of things, there are a lot of options for patients including breast reconstruction and mastectomy. With her mastectomy patients, they recommend that every patient talks to a plastic surgeon even if they want to stay flat. "Information is power. It's not going to hurt to talk to a plastic surgeon and find out what's available." They have patients that don't think it's for them and just come back and they're amazed by the way science has advanced the techniques. Patients look amazing after breast reconstruction. That being said, tons of her patients work with plastic surgery. Mastectomy and lumpectomy followed by radiation are roughly equivalent in terms of cure and survival. So very few patients need a mastectomy. Tumors that are very large sometimes are only candidates for mastectomy. But with neoadjuvant chemo, they can oftentimes shrink a large tumor and they're still a candidate for lumpectomy if they're highly motivated. They also consider mastectomy, even bilateral mastectomy in patients with genetic mutations, but this is only a minority of breast cancer patients. Only about 5-10% will have genetic mutation. The minority of her patients need a mastectomy but nationally, statistics tell that half of them choose a mastectomy. They try to educate patients that the outcomes are the same and that removing more breast tissue doesn't increase their likelihood of "beating it." However, there is just that inner voice that drives most of their patients to feel like they just really want a bilateral mastectomy. [36:20] Special Opportunities Outside of Clinical Medicine First, you can be an educator. At their hospital, there are lots of opportunities for education in terms of trainees. Especially in oncology, there are a lot of opportunities to educate the broader community about cancer. She does a lot of speaking events for cancer-related organizations. She does education events about what cancer looks like or what's happening in cancer. Second, you can do volunteering. Stephanie serves on the American Cancer Society Board for their region. She also volunteers with the American Society of Clinical Oncology, their large, national organization for medical oncology. You can also do international mission work in oncology-related fields. You can also do clinical research. All those being said, there are a lot of opportunities to do different work within the scope of oncology. You can do work on the governmental side for oncology. The NIH and FDA employ medical oncologists. "There's a pretty broad spectrum of oncology-related careers you can consider." [38:00] The Most and Least Liked Things About Being a Breast Oncologist Stephanie feels very happy with her specialty and she wouldn't choose anything different. As a trainee, she worried about how she was going to be a doctor and a mom. But she assures it just magically works itself. She had worried about some sense of emotional burnout but she had never felt that. It can be saddening to have sick and dying patien…

Full show notes at the publisher

97: What Does Academic PM&R Sports Medicine Look Like? May 29, 2019

Show notes

Session 97

Dr. Brandee Waite is a physical medicine and rehabilitation (PM&R) specialist who practices in an academic setting for almost 15 years now. She talks about her specialty, types of patients, and the things she likes the most and least about her practice.

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[01:30] Interest in PM&R

Brandee actually didn't even know PM&R existed until the summer after her second year in medical school. It was a relatively small specialty on the west coast.

She and her friends were reading about the different specialties they could possibly take. One of them told her that PM&R actually fit her personality. It actually talked about how the specialty involves patients and their functions in their day-to-day life. With a background in fitness and dance, she figured out it was a great fit for her.

They basically described PM&R as an intersection of neurology, orthopedics, neurosurgery, and psychiatry. She thought she highly liked most of those things.

[04:10] Traits that Lead to Becoming a Great PM&R Doctor

You have to like working with other people. The PM&R physician is the leader of the care team who works very closely with the physical therapists, occupational therapists, and nursing staff.

They work in an in-patient rehab setting to really address all of the rehabilitation needs for patients. These may include learning how to dress again or walk again.

Hence, you have to be able to work on a team that will have additional input with you as the guide. Some PM&R doctors do procedures, others don't.

Brandee further subspecialized into musculoskeletal as a PM&R doctor. Since she's very much into dance, fitness, and sports, she liked the aspect of taking care of athletes. Plus, she likes to do a lot of procedures so she found it as a really good fit for her.

[06:45] Other Specialties She Considered

Brandee initially wanted the OB/GYN route. But what really sold her into PM&R was when she did a rotation in PM&R.

The doctor she rotated with was an outpatient musculoskeletal specialist, who was double-boarded in Rheumatology and PM&R. He was prescribing pool therapy for people with back pain and lower extremity problems. And she had never seen any other physician who did such as a way to deal with those problems.

As a dancer and fitness instructor, Brandee used to teach water aerobics during summer time. She knew it just made so much sense.

Brandee doesn't like primary care and so she knew she was going to do a specialty and OB/GYN was the one she ended up liking the most. More so, she just didn't love her rotations in internal medicine.

She went into PM&R not even knowing that she wanted to do a sports medicine fellowship. It was basically just the overall function for general musculoskeletal care and the rehabilitative aspects for people with neurologic and orthopedic injuries.

And as she went more into it, she found that the subspecialty was even more exciting to her than the rest. Hence, she ended up doing it.

[11:52] The Roots of PM&R and Types of Patients

PM&R actually came about way back after World War II. A lot of people came back with disabilities and primary care physicians didn't know how to care for an amputee or one with a spinal cord injury.

Currently, Brandee sees a lot of people with knee arthritis and knee problems. She sees a range of people from professional athletes to a woman with cerebral palsy who has lived an ambulatory life.

They basically see any problem that is affecting a joint that's not part of the skull or the spine. Although there are PM&R doctors that do spine treatment. They have separate sports and spine clinics at their office, and she only works on the sports side.

Sometimes, she sees patients where they have to do "investigative" medicine. They take histories and listen for nuances. They do a strong physical exam combining elements of neurologic exam, orthopedic exam, and general exam.

Other times, some patients come to her already with a diagnosis from their primary care doctors. This would then be a different conversation.

[14:50] Taking Calls

In their group, they have a lot of subspecialists. They have some general PM&R doctors as well as some neuromuscular specialists and pediatric rehab specialists. They have a 20-bed inpatient acute rehabilitation hospital.

That being said, she takes calls about six times a year over the weekends. She is on call from home from 5pm-8am during the course of the week that she's on call.

On Saturdays and Sundays, they go in and make rounds to see all the patients while the other doctors have their weekends off.

[16:15] Choosing Academic Setting over Community Setting

Brandee chose the academic setting over the community route not for the money obviously. After ten years, all her students were paid. She owns a home, takes care of her family, and travels a lot.

She saw that in the community, there was not so much focus on keeping up with what's the latest thing that has come out recently. It was more of a struggle for them to get out and go to conferences and collaborate with other people in their field.

Additionally, she likes teaching. She feels that her presence in the residency program might mean more as a woman and an underrepresented minority in the field. Plus, she gets more time off to travel to attend conferences.

[18:42] Work/Life Balance

You figure out how to do the balance. She doesn't take that many calls. However, in sports medicine, she ends up spending more time covering games. This takes additional time to her regular call schedule.

She is married and has two kids. She's lucky to have support from her family. Ultimately, you just have to be efficient with your time and what's required of your documentation. Eventually, you will be able to figure this all out.

Brandee sees 15-22 patients a day. Her last patient is usually scheduled at 4:15-4:30 so she rarely stays in the office beyond 6 pm.

In addition, she's also a fellowship director, the director of their clinic, and the chief for sports medicine. Hence, she has other administrative and leadership responsibilities that she has to take care of.

Because of this, she doesn't necessarily have to see patients five days a week all day everyday due to her other responsibilities. So she could have half a day in the clinic and probably take a half day or full day for administrative time.

[21:30] Doing Procedures

Brandee does a lot of ultrasound-guided procedures. Some doctors use X-ray guidance while she does ultrasound.

PM&R has this interest in regenerative medicine which involves cells and biologic materials to treat diseases like stem cell injections or platelet-rich plasma injections. They don't do stem cell injection at their office but they do some plasma injections.

A lot of PM&R doctors do an interventional spine or a pain fellowship. They can then do epidural steroid injections for back pain or injections into the facet joints or the zygapophysial joints for back or neck pain.

Some doctors do EMG and nerve conduction study, which involves an electrical study of the extremities or face to measure different nerve functions.

[23:15] The Training Path

The PM&R residency takes four years. Some residencies have all four years at the same spot. While some have internships somewhere else and you just do 3 years of PM&R at the site.

You can do a one-year transitional internship or just a preliminary medicine year. Then you can do your three-year PM&R residency. Brandee took this route before doing a 1-year sports medicine fellowship after finishing residency.

Brandee thinks PM&R is getting more and more competitive. They've noticed that they're getting more and more applications each year. The board scores are getting higher and higher.

It's not as competitive as Dermatology or Neurology. But out of the medical subspecialties people can go into, PM&R is becoming more competitive. Although location plays a role too. East coast and west coast spots tend to be more selective or more competitive than those in the middle of the country.

[25:10] What Makes a Competitive Applicant

At Brandee's institution, they have a small residency program with only 3 residents per year. For their program, they want to make sure that people are very self-motivated and very collegial.

Having advanced clerkships in neurology, orthopedics, medicine, rehab, psychiatry, and those other subspecialties related to PM&R can be very helpful.

For people going into sports medicine, they look at whether they've done some volunteer work at local high schools or colleges. They look at any shadowing experience with a sports medicine doctor.

Have good letters of recommendation and show that you're a hard worker. Get those letters from fields that are close to PM&R.

If your institution doesn't have PM&R, you have to go out and look for places that do rotations. This was what Brandee did and she knew she had to do well at those places in order to get letters of recommendation.

[27:00] Bias Against DOs

Brandee says there are a lot of DOs in PM&R so she's not seeing any bias at all. That said, certain residencies may have a screening and selection process coming from different DO schools.

[28:25] Subspecialty Opportunities

Some people do a traumatic brain injury fellowship. Concussion is a very hot topic in medicine today.

Others go into 2-year pediatric rehabilitation. They would subspecialize in debilitating diseases that affect muscular dystrophy in children or cerebral palsy.

You can also do pain management fellowship or neuromuscular disease fellowship (offered at UC Davis).

[30:15] Working with Primary Care and Other Specialties

What Brandee wishes primary care doctors to know about PM&R is that you can't necessarily send a patient to a general PM&R doctor and expect him to do certain procedures. Understand that even within a practice, there is some breadth of expertise.

Also, physiatrists can be a very integral part of a sports medicine practice. Sometimes people think of orthopedics or internal medicine doing sports medicine. But PM&R is actually an incredibly good fit for sports medicine types of issue.

A lot of what they do is recommending how people can be more physically active, not just for the sake of sports. So use the PM&R doctors as a helper to help treat other chronic diseases by using exercise and physical activity.

Other specialties they work closely with include orthopedic surgery, neurology, and rheumatology.

[33:35] What She Knows Now That She Wished She Knew Going into Medicine

Brandee wished she had known more about the billing and argument issues. She's also big on self-confidence but she sees a lot of people struggling with this. So she wishes they knew they're smart enough to make a good contribution.

[35:15] The Most and Least Liked Things About PM&R

Aside from doing injections, what Brandee really likes about her specialty is educating patients about their disease so they're not reliant on their physicians for everything. She likes being able to help people make milestones and fully participate in them.

What she likes the least is arguing with insurance companies that don't want to pay for MRI or procedure that she really thinks would help her patients.

[39:45] Major Changes in the Future of PM&R

She doesn't see any major changes coming although she's seeing how PM&R is now being more and more accepted.

After you take your regular board exams for internal medicine or family medicine, and if you do a fellowship, you can sit for the nonoperative sports medicine boards. It was only 11 years ago that PM&R doctors were allowed to start sitting for that exam. There were not a lot of fellowships that allowed PM&R doctors to join them.

There are only 20 or less accredited PM&R sports medicine fellowships in the country and Brandee would love to see more of that.

That being said, it can be very competitive to get into a fellowship just because there aren't as many spots for PM&R doctors as there are for internal medicine or family medicine doctors.

[41:11] Final Words of Wisdom

If she had to do it all over again, Brandee would still have chosen the same specialty.

Finally, her last piece of advice to those interested in sports medicine through the PM&R path is that you have to do your primary residency first.

If you're so focused on what your subspecialty would be, sometimes you miss some of the learning opportunities that you can get along the way that will help you end up being a better physician overall.

Especially with sports medicine, if you're so focused on getting your fellowship that you don't do a good job in the other things you have to learn in order to get there, that will shoot you in the foot every time.

For people who really like musculoskeletal and body functions, Brandee thinks the pathway through PM&R is more interesting than going through family medicine or internal medicine. But if you love primary care, then the latter is definitely the way to go.

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96: A Look Into General Surgery With A Program Director May 22, 2019

Show notes

Session 96 Today, Dr. Brian Smith, a general surgery program director at UC Irvine, talks about his journey to becoming a surgeon and what he expects from applicants to be competitive in his program. Find out what you can do to be more competitive as an applicant and as a medical student. Please take a listen to all our other podcasts and get the resources you need. For medical students, we have the Board Rounds (with BoardVitals). For the premed students, come check out The Premed Years, OldPreMeds Podcast, and The MCAT Podcast. [01:30] Interest in General Surgery Brian's interest in general surgery started in his first year of medical school. When he started medical school, he wanted to be a family practitioner. He liked the idea of continuity and being able to take care of the whole patient. Very quickly after starting his rotations in the anatomy lab, he realized he had a tremendous love and passion for human anatomy. It was the first time he ever considered surgery. He knew that if he wanted to spend most of his career involved with human anatomy, then surgery would be a excellent way to do so. [03:00] Traits that Lead to Being a Good General Surgeon One of the basic traits of being a good proceduralist is that you like working with your hands as well as diagnosing or treating things. Do you like working with your hands or do you like working with your brain? Once you've answered that question and you've moved down to "working with hands" halfway, then you begin to figure out you're probably down the proceduralist path. Brian's inherent tendency is to enjoy fixing things. He used to enjoy working with his car. He likes tinkering with things. He has always had this inherent joy in taking a problem and giving it a definitive fix. Surgery initially became the clear choice for Brian. But general surgery became his choice when he was sure he needed the variety. He enjoyed the variety that comes with general surgery. [04:50] Risk of Running Out of Patients As Brian puts it, one of the beauties of general surgery is they take care of the whole patient. They take pride in the fact that they're really an internal medicine physician that operates. They're able to manage the entire patient and at the same time be able to operate and fix their derangements. There's a tremendous kinship with either family medicine or internal medicine who serves as the contractor for all of the patient's ailments and really manage them all. That being said, there's a drive or movement in the direction of increasing subspecialization of current trainees. This is a trend that's not going to dramatically change over the near future. But for those people with broad interests and really like to take care of the whole patient, general surgery has that to offer. Brian was concerned that subspecialization would narrow down his knowledge base. And he didn't want to give that up, hence, he chose general surgery. [07:00] The Bread and Butter for General Surgeons The bread and butter in 2019 is dictated by the community in which you serve. If you're a general surgeon in the midwest and there's not a lot of specialists in town, you're more likely to do more than the general surgeon in downtown Los Angeles. By and large, in the urban and suburban environments, the bread and butter for general surgeons is going to consist of gastrointestinal surgery, colons, gall bladders, hernias, endocrine surgery including thyroids, parathyroids, and adrenals. Occasionally, they deal with the liver, spleen, skin (melanoma and skin cancers), and extremity work (soft tissue tumors). [08:20] The Most and Least Liked Things About Being a General Surgeon Brian loves being able to take care of all the patient's needs. He's able to handle almost everything. From an operative perspective, he loves being able to travel all over the body. He rarely does two of the same operation in one day. He's constantly doing something different. And this forces him to keep up with the literature or current advancements in a specific area. It keeps him sharp and interested. And it never gets dull and boring. On the flip side, what Brian likes the least about his specialty is more on the administrative aspects that come with surgery in 2019. There's a lot of time spent charting on the electronic medical record. It's a wonderful thing, in and of itself. But it takes extra time that it becomes a distraction. Now he gets to have less time spent face-to-face with patients. It prevents him from having that human interaction and bonding that makes a good physician-patient relationship. [10:00] The Training Path and Career Trajectory The medical student basically applies for general surgery where they will match into a categorical internship followed by residency. In general surgery, they don't distinguish internship and residency because they're a single continuum. The first year is just the internship. There are six-year programs across the country where they will have one year of mandatory research. These are heavily focused on clinical outcomes research during the year of mandatory research. There are also seven-year programs where there will be two years of mandatory research, most of which is basic science research. The standard five-year programs are focused on training somebody to be clinically confident. A resident may or may not be expected to have some research productivity during that time. You can train in general surgery and go out to practice. Or you can do a one-year fellowship in minimally invasive surgery, bariatrics surgery, thoracic surgery, or spend several years doing cardiac surgery. You may also combine cardio thoracic fellowship. You can go do a year of colorectal fellowship. Or you can do additional training in plastic surgery or a year of breast surgery or endocrine surgery. You can stop after general surgery training and be the generalist, or you can still go down one of 10 or 12 different pathways now – some are ACGME-certified and a few are not. You can get specialized fellowship training in order to be better at a particular subsection of general surgery. Brian did general surgery but he also took one year fellowship in minimally invasive bariatrics surgery. That said, it's not the entire focus of what he does. He still gets to be a general surgeon but he has that specialized niche training which he enjoys several days of the week. [12:45] What They're Looking for in Applicants As previously mentioned, Brian is a program director for a general surgery residency. One of the first things they're looking for is somebody with a broad interest and is eager to learn. These are inherent traits that they need the applicants to bring with them. In terms of the more tangible level, they sort of move in this hierarchy of importance. First, applicants need to be academically qualified. Sadly, the best measure is still USMLE Step 1. Since not everybody has taken Step 2 by the time they apply, they can't use it as diligently as they do Step 1. So do well in Step 1. Ideally, they would then want to see somebody with a good, solid dean's letter. They also look at how they've done on their clinical clerkships, how many courses they've honored, and how they did in surgery. They also look at how the applicants did in their internal medicine rotation. Again, getting back to that kinship with internal medicine, somebody who's broadly interested really likes to take care of the whole patient. To him, this is an appealing characteristic. Then they look closely at letters of recommendation, research background, and personal characteristics, respectively. [14:40] Pass/No Pass for Step 1 Brian loves the idea of Pass/No Pass for Step 1 recognizing that students can have a bad day or they choke on the exam for some reason and they just don't achieve their potential. The magnitude of the high stakes Step 1 is a problem that needs to go away. But that being said, Brian's biggest concern is that we don't have another good surrogate. There's no other good, easily identifiable measure to help determine one's academic qualifications. Program directors need to look at an entire application and not just a Step 1 as a screening score, which many of them do. So he likes the concept of it not being a weeder or screener. But there should be a composite measure of one's academic qualifications. It doesn't mean that if one doesn't do well on the test, that they can't be a fantastic clinician. In fact, Brian says, some of the real gems that he found are not the people that completely knocked Step 1 out of the park. However, they also want to make sure that they did well enough on it so they won't struggle on their in-service exams or passing their written board exam. As a program director, one of his endpoints for students is for them to be able to easily get out and obtain their board certification. So while he likes the concept, he thinks additional surrogates are lacking which can serve as a good marker of academic qualifications. [17:10] Why the Need for Academic Qualifications A good residency program does a phenomenal job of developing clinical skills. But in your average five-year program, a resident who doesn't have a whole lot of book knowledge as a foundation can only continue to excel and do well until you get to the fourth year of residency. In the fourth year, there's so much clinical skill that now starts to rely on a solid foundation of knowledge. So you may be technically good in the operating room, but if you don't have the knowledge foundation to back up those clinical skills, that deficiency starts to get a spotlight on it right around the beginning of your fourth year. If that deficit in knowledge continues in the fifth year, it starts to be an anchor for a good resident. There's a tremendous knowledge base that backs up any clinical superstar. By academically qualified, it means being academically capable of sitting down and synthesizing and getting a tremendous knowledge base in their head. By doing so, they're able to back up their decision making and their instincts they've learned as residents. You should be able to establish that you have the study habits, the intellectual capacity, and capability to pack a lot of information into your brain about a particular specialty. Brian explains that you can train almost anybody as a surgeon. What is a tougher challenge is training a clinical superstar. [21:21] What Makes a Superstar Sub-I A superstar sub-I will oftentimes be almost seamless with an intern. A lot of time in the third year is spent on just learning how to function comfortably in the hospital environment. Then you begin to know how to accomplish patient care on a regular basis. A great sub-I is somebody who is functioning at the level of an intern. These are students that have a lot of charisma and are self-starters. They are able to figure out how to start a new rotation. They can quickly get up to speed with important details and facts. They're able to identify key interactions that need to occur and execute those efficiently. You have to master how to be efficient. A great sub-I reads about their patients and knows their patients backward and forward. A student will never have a better opportunity to solidify in their own mind all the details of the disease process as they will when they have a patient with that disease process. [24:19] What Medical Students Shouldn't Do Brian explains that the fastest way medical students shoot themselves in the foot is when they treat those beneath them with disdain. For instance, the medical student comes into the operating room and talks down to the circulating nurse or disrespectful to the ICU nurse. Nurses that do the same thing over and over for years know what they're doing very well. When medical students fail to recognize the knowledge and the expertise in the rest of the team involved in the patient's care, oftentimes, they shoot themselves in the foot. [25:55] Mistakes Medical Students Make with Their Application If your Step 1 is not a true reflection of what your knowledge and skills are, then study up and take Step 2. Let Step 2 prove that Step 1 was not an accurate reflection of what you're capable of. Somebody with average performance on a sub-I is somebody who's not going to do really well. Failing to recognize that the sub-I really is your audition and treating it as such is such a huge misstep. [27:40] How Important Are Elective Rotations An external rotation is a very easy way to get an interview at that institution. Especially for people with mediocre applications, they need to do external rotations to maximize the likelihood that they're going to perform at a really high level. This increases their chances of getting an interview. Brian encourages their students to do two external rotations and fill the rest of them in at their school of medicine. If your passion is simply based on one rotation you really like and go do general surgery, Brian hopes you have the maturity to recognize that it may mean there are a whole lot more rotations that you're going to go through that might grab you equally. [32:50] The Influence of Great Mentors Mentors have a lot of ability to sway or influence that "organic chemistry" with a specific specialty. If you really have a good mentor, then you'd naturally be drawn towards that specialty. And this is often how people end up deciding where they're going to apply for a residency. There is something very appealing with having really great mentors, particularly when you get the trainees actively involved. Brian pushes people to become content experts in general surgery early on in their residency. And this oftentimes naturally translates to falling in love with it. [34:30] Women in General Surgery Brian explains there are a lot of female general surgery mentors. Regardless of what lifestyle, you need to start with the specialty you love. There's no specialty within medicine that anybody is going to enjoy doing for 30 years if they're not passionate about that particular specialty. Once you have found something you love and enjoy, you can always find a career setting that allows you to balance work and life in a manner that works well for you. Brian has worked with amazing female clinicians who are even technically better than many of their male counterparts. Men and women have equal opportunities in general surgery. That being said, females may be more reluctant to choose a surgical career because they don't necessarily see people having as much of the balance they're looking for. Ultimately, find your passion and get trained in something you love. If doing it gives you the work-life balance that works for you. You will find that opportunity somewhere out there. Brian encourages female students to give general surgery a try. You can have it all. But having it all means doing something you love in the process. Then finally find the balance that works for you. Additionally, one of the beauties about being a specialist or proceduralist as a female is being able to work 2-3 days a week. But you still can make the same amount of money you would make 5 days a week as a primary care physician. This gives you financial liberty. It gives you more options to create the balance of work and life you're looking for. [38:25] Overcoming Bias Against DOs Brian thinks a lot of the bias is now starting to fall by the wayside. It's still important to take USMLE so it's easier for you to be compared to somebody else. Do those external rotations and sub-I's. Have competitive board scores. At the end of the day, a DO with a mediocre Step 1 but was an absolut…

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95: A Sports Medicine Physician Shares His Journey May 15, 2019

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Dr. Jonesco is an academic Sports Medicine physician at Ohio State. Today we discuss what drew him to the specialty, the patient base he sees, and why he loves it!

94: A Look Into Community Reproductive Psychiatry May 08, 2019

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Session 94 Today's guest is Dr. Carly Snyder, a reproductive psychiatrist, a specialty which is probably something a lot of people don't know about. In fact, she didn't know it existed until she was in her psychiatry residency. She talks about her journey, what she likes about it, and what she doesn't. Get a glimpse of what her world looks like. Maybe this is something you're interested in too. Also, please be sure to check out Meded Media for more podcasts as you're looking for resources to help you along this journey towards medical school and residency. [01:30] Interest in Reproductive Psychiatry Carly didn't know reproductive psychiatry existed when she started residency. As a psychiatry resident, she did 4-6 months of medicine and pediatrics. Throughout that period, she kept on questioning psychiatry as she didn't like inpatient psychiatry. She found it depressing and it wasn't how she imagined her career would be. While on the pediatrics floor, she met a 3-month-old boy who suffered from seizures since he was born. Having a baby boy at that time as well, she identified with the mom that she had a very strong drive to help her. The child eventually died but the mom was doing well for having a strong support network already in place. They then decided they were going to set up a program where every woman who's baby or child was dying was going to be connected with a counselor or therapist who will focus on the moms. This was an aha moment for her that she could actually affect change and help women. At that time, one of their senior residents' wives was doing reproductive psychiatry. Eventually, she took an elective at Cornell University where they had a women's mental health program. It had a perfect mix of women's mental health and medicine. You think about the baby and the family system. You also have to consider whether there was a medical issue going on. After residency, she was given the directorship of women's mental health program. "It's a huge transition in life. And to be able to support women through that process is incredibly rewarding." [06:45] Types of Patients She sees women throughout the reproductive lifespan. Her practice is limited to adult women. The vast majority of her patients come to see her for 4-5 times who have history in depression, anxiety, bipolar disorder, or some psychiatric illness. They may or may not be on medication but they're looking towards a planned pregnancy. They want to figure out how to optimize their mood and keeping them stable. At the same time, they strategize on how to minimize risk from either exposure to medication and/or exposure to untreated illness. You have to weigh both sides of it. "A fair number of my patients are in fertility treatment and they're all referred by reproductive endocrinologists." Moreover, some patients come to see her when they're pregnant because they're experiencing mood symptoms, and sometimes women in their postpartum. Carly finds is fun and rewarding to see women's families grow and see their lives unfold. She also has a group of patients with severe PMS called PMDD where they come to see her every month for a variable number of days. Their mood changes to a degree that their ability to function has been impacted. [10:05] Traits that Lead to Being a Good Reproductive Psychiatrist "One needs to have empathy in any specialty." Empathy tops Carly's list. Think about your patients' lives, not from a standpoint of that specific medication and that's it. But you think about it from a standpoint of their family structure. Think about their future plans and their past. Think about the big picture. That being said, you also have to consider multiple factors. Make sure there's no underlying medical illness going on that's masking or feeding into a psychiatric illness. Additionally, you can't be dictatorial where the way you think is the way it should be. You, as a physician, may have a very rational approach to why you'd recommend xyz. Their anxiety means they're being completely irrational and that's okay. Work with them to get to where they want to go, not where you think they should be. People have anxiety all throughout different phases – planning pregnancy, fertility treatment, pregnancy, post-partum. This is normal to some degree but it shouldn't negatively impact your ability to function and enjoy life. Take everything you're hearing and assimilate it into a picture to get a sense of what is going on that is actually appropriate versus what's excessive. Determine it quickly because women don't want to wait and see for a while. "It's a time of huge flux and change. Our job is to support them through that process in whatever way, but support them in real-time." [14:41] Why Psychiatry? Carly initially planned on doing plastic surgery but when she got to medical school, she had written off all but medicine. When she was in 3rd-year medical school, she came across a patient with fevers of unknown origin that had been cynical. He was admitted to the floor reserved for patients with TB. He got discharged eventually since they weren't able to figure out what was wrong. But his liver function tests came back really high. She then went in and was drawing multiple vials of blood but the patient took the butterfly out and blood was just going everywhere. She then tried to put the needle back on his arm. But the patient took the needle out of his hand and jabbed it into hers. It turned out that the patient had Hep B, Hep C, and HIV-2. So Carly obviously had to be on a really nasty cocktail of medicines for three months. She was on a gazillion meds. That prompted her to not go into medicine. She didn't want to have anything to do with the specialty at all. Her next rotation was surgery and loved it. She also married a neurosurgeon during her third year at medical school. As she finished medical school and having spent her fourth year doing plastic surgery rotations, she was about to have a baby. She planned on taking a year off between medical school and residency because her husband did a fellowship in Toronto. Still not wanting to do medicine, she ultimately took psychiatry (Her dad was a psychiatrist too.) But she found inpatient psychiatry difficult. Then she eventually found her footing in psychiatry in general and found her niche within it. [20:28] Typical Day Carly's third kid was born a preemie, so she had a very first year of life medically. At that point, her dad encouraged her to join his practice. Her dad also convinced her not to work full-time so she can focus on her kid at the same time. "Psychiatry has an amazing amount of flexibility depending on how you structure your practice." Currently, she spends time in her office two days a week from 8am-8pm. She has back-to-back patients throughout the day. She sees patients for their 15-minute medication follow up, which tends to be extended at times. She sees the vast majority of her patients for 45 minutes. She not only talks with them about how they're feeling but also how they feel about treatment. She answers questions they have about the risk, benefits, alternative, and dosing. She becomes a safe place for women to come and talk about parenthood or fertility treatments, or their frustrations with the whole fertility process. They could talk about marital issues as it relates to the fertility process. In pregnancy, they struggle when people give them all this advice. It's not just a question of pharmacology, but how she can be supportive as someone who understands all the facets in their life. Carly says she can be a place where patients can come and talk through what you're experiencing. Second, she can realize when it's appropriate. Lastly, she'd take a step back and then push on later. This never happens in 15 minutes of course. Carly runs her radio shows on Wednesdays so she preps by doing at lof writing. She writes a fair amount of parenting-related stuff. [24:45] Taking Calls She's the only reproductive psychiatrist in their team and everyone does child, adolescent, and adult. So she takes calls 24/7. But she can just do it at home even when she's on call. But she rarely gets SOS calls. "I educated people in advance so there isn't time to question mark about what to do?" [26:08] Training Path There are a few fellowships available. You can find your own path. Find a mentor. As an attending at Cornell now, they have a rotation for residents. Some people go through Consultation Liaison. Or you can just have a mentor that supports you through the process. There are also conferences where you can learn more from. Reproductive psychiatry is not a big field. It's even pretty rare that she has never heard of someone doing what she does. But they do all other things as well. Carly used to be on the board for Postpartum Support International (PSI) and now she's on the President's Advisory Committee. PSI is the leading resource for women and their families suffering from various perinatal mood disorders. "We're still a small field and unfortunately, a lot of people don't know that we exist, which is unfortunate for people who are suffering and unsure where to turn." [29:15] Subspecialty Opportunities There are people who focus more on PMDD and do more research on it. Others are interested in Postpartum Psychosis, which is very research-driven. A third of her practice is fertility-focused although she doesn't think this is the norm. But you can subspecialize in this too. Additionally, some focus on perimenopause-related mood disturbances. [30:45] Bias Towards DOs and Working with Primary Care Carly doesn't think there is bias towards DOs in their field. In terms of working with primary care, she has a sound referral network at this point. She's also lucky to have a group of colleagues and friends that encompass various specialties that support women in the same phases she sees. It's very easy to collaborate together. But as she was still starting out, she would go to different conferences. She'd walk up and introduce herself. She also got into the PSI board early on in her career so she had that connection. "When I meet a pediatrician, my goal is for them to appreciate that I'm available for their patients." She helps in creating an online course for Postpartum Support International for primary care providers. It's a two-day course that can be done online. It's specifically for frontline providers so they can feel more empowered and understand perinatal mood disorders more. And so they can treat accordingly. They also have a consulting service through PSI. But at the end of the day, what she wants primary care providers to know about them is that reproductive psychiatrists exist as a resource. They specialize in treating women throughout their reproductive life cycle. If a woman said "I'm pregnant," people would say stop your medication. Save for a few medicines, there is really a risk-benefit discussion to be had between the risk of untreated illness and the benefits of medication. Stopping the medication can even be more dangerous and can present more risk than remaining on medication. That being said, just realize they exist as a resource. And seek them out if you have questions rather than advising the patient to stop medication. Sometimes, they should. But this is not the go-to answer in general. "Pregnancy is a very dynamic time physiologically and you have to keep up with the physiologic changes that occur in order to get people stable." [37:00] Working With Other Specialties Reproductive psychiatrists work closely with pediatricians. Carly mentions there is now a push for check-in visit between that 0-6 week mark with an OB/GYN. But this can be done on the phone. Whereas the pediatrician becomes the single frontline provider because they're seeing both the mom and the baby. Other specialties they work closely with are rheumatologists, internists, and other psychiatrists. [38:16] Special Opportunities Outside of Clinical Medicine You can actually do research. Carly does a lot of writing. She says that you can pretty much do whatever you want to do actually and create your own path. As a side gig, she has a business with acupuncturists where they're developing a nutritional bar line food for women. You can really find lots of different ways to use your practice. "You make your own path." [40:00] Most and Least Liked Things Carly advises that as a reproductive psychiatrist, you have to listen to what she thinks, what she wants, and where she's at, before presenting options. It's not your body, it's hers. It's not your future baby, it's hers. "Approach each woman as the unique individual she is rather than thinking about purely from which a standpoint of which medication is best." Present all the information that's available now and allow her to make an informed decision. Ultimately, it's her job is to enforce that and not have anyone feel like it's being taken away. What Carly loves about her specialty is when her patients get better. When they do, they find joy in motherhood. Being able to help a woman enjoy being a mom and enjoying her life is simply rewarding. "Parenting is a magical thing. It's so sad when someone isn't seeing that magic, where they really just feel pain in the whole process." On the flip side, what she likes the least, not specific to her specialty, is the paperwork. Also, when one of her patients get really sick, it's scary. She would have nights where she's worried and anxious for her patients. [44:45] Major Changes in the Field Carly thinks the field is growing and expanding with more and more data and research available and supporting what they do. It has been very important both for mom and her baby – both from emotional and physical standpoints. There's also recent medication that is soon to be released which is the IV formulation for the treatment of postpartum depression. There will also be an oral formulation for this. "There are new treatments that are being offered which will let us help women get better that much faster." There will be an understanding of the different subtypes of antepartum and postpartum depression and anxiety, the different causes, and treatment. They can hone in on various symptoms when they know the underlying mechanisms. And they're getting great data about this. [46:25] Final Words of Wisdom If she had to do it all over again, she would still pick the same specialty. Finally, she wishes to tell students who might be interested in this specialty is to find someone to shadow. It's one thing to read about, but it's another thing to do it. Find them and check out what they do in person. Ultimately, you have to really like working with moms and women who are going to be moms, and who are anxious. Have an open mind and be ready and see what pulls you. Links: Meded Media

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93: Academic Pediatric Hospitalist Shares His Career May 01, 2019

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Session 93

Dr. Potisek is an academic Pediatric Hospitalist. Today, he discusses the reasons he chose pediatrics, the different facets of his job, and the types of patients he sees.

Also, please check out all our other episodes on MedEd Media Network.

[01:10] Interest in Pediatric Hospitalist Medicine

Dr. Potisek has always enjoyed being around kids. But it was during the third year of medical school that he realized there were so many things about pediatrics that he really loved. So by the end of that year, he was choosing between internal medicine and pediatrics. Ultimately, what drew him to pediatrics is the resiliency of kids. He also likes the incorporation of families as you also take care of, not just the child, but the family members as well.

Before Dr. Potisek decided to go to medical school, his dad got very sick. He saw that the kind of communication a physician has with the loved ones, not only makes a difference for that individual but for the entire family as well. Additionally, Dr. Potisek describes himself as a good communicator. And so this was something he was looking forward to going into this career.

[04:45] Traits that Lead to Being a Good Pediatric Hospitalist

Pediatric hospitalists either work in a community hospital or in an academic setting. Oftentimes, you have to work well in a team. You have to be able to work well with your colleagues and be able to communicate well with patients and their families. Teaching is also an important skill, not only for learners but also for patients and their families so they can understand what's going on.

[06:15] Hospitalist vs Outpatient Pediatrician

What drew Dr. Potisek more to being a hospitalist over being an outpatient pediatrician is the acuity of care, which he likes more. He likes dealing with "sicker" children and some of the medical mysteries he deals with. He also likes working with numerous subspecialists as they try to figure out the problem. Hence, the two big things he likes about being a hospitalist is the acuity of care and the complexity of diseases he encounters.

[07:30] Typical Patients

During Fall through Winter, Dr. Potisek deals with a ton of respiratory conditions, with bronchiolitis as a heavy-hitter. He also deals with pneumonia (viral or bacterial) and other respiratory-related diseases that are more seasonal-dependent. He also takes care of neonates, infants 30 days or less. Other common cases would be skin and soft tissue, bone infections. They're also taking care more and more of medically complex children who are technology-dependent.

[08:55] Typical Week

Half of his time is geared towards pediatric hospitalist medicine while the other half is dedicated to teaching medical students and residents. He works seven days in a row. Mondays thru Fridays would typically start from 7am to 5:30 to 6pm. On weekends, he works for those same hours in the hospital and he'd just take calls from home for new admissions. He also works at night although this is not the majority of what he does. This only happens about 2-3 weeks of the year. When not doing patient care, he'd usually do curriculum development and other teaching activities.

[10:19] Doing Procedures

Dr. Potisek found that a lot of procedures are already done in the emergency department And if they aren't, they'd typically do a lumbar puncture. There are also pediatric hospitalists across the country that are trained in sedation, which they could incorporate into their practice.

[11:12] Training Path

After medical school, you would typically do a three-year pediatric residency. Then you can do a fellowship for 2-3 years. There are different options you can take such as additional master training, research, etc. So from the completion of medical, it takes around 5 years in total. That being said, Dr. Potisek has friends who are more outpatient-predominant.

Currently, people are being grandfathered in. Because of the many pediatric hospitalists and the lack of fellowships, they see this as an opportunity. People can have a certain amount of hours leading into the board exam.

[14:00] Subspecialty Opportunities and Bias Against DOs

A lot of fellowships are actually allowing opportunities for pediatric hospitalists. As with bias against DOs in the field, Dr. Potisek hasn't really seen this. At their hospital, they have a number of residents who are DO-trained.

[15:44] Working with Primary Care and Outside of Clinical Medicine

Dr. Potisek wishes to tell primary care physicians that they reach out earlier to them. Moreover, there are special opportunities outside of clinical medicine that pediatric hospitalists can do such as outpatient opportunities.

[18:10] Most and Least Like Things About Pediatric Hospitalist Medicine

What Dr. Potisek likes most about his specialty is working with learners – students, residents, pharmacists, and nursing staff. On the flip side, what he likes the least about his specialty is that sometimes you don't necessarily think that a child needs to be hospitalized all the time. But at the same time, he respects his emergency department colleagues. But at the end of the day, if this brings peace of mind to the family, he'd just have to honor the initial decision of his colleagues. That being said, he still finds that sometimes it's unnecessary.

"Sometimes, I don't necessarily think that it needs to be hospitalized but that seed has already been planted for them."

[21:55] Major Changes in the Field and Final Words of Wisdom

It would be interesting to see more fellowships popping up and so Dr. Potisek is excited to see a more developed curriculum. Ultimately, if he had to do it all over again, he would still have chosen the same field. He wishes to impart to students that whatever it is you want to do, just remember why you decided to get into medicine in the first place. Remember what you love about it and where can you maximize the things that you love. It can be challenging at times so having that understanding at the forefront of your mind is helpful.

"Just remember the joy and the love you have about the things that you do."

Links:

MedEd Media Network

92: A Community Allergist and Immunologist Shares Her Specialty Apr 24, 2019

Show notes

Session 92

Dr. Neeta Ogden is an allergist and immunologist. She has been out of training for about 13 years and she talks about her career as an allergist in a community setting. She shares some tips and tricks for you as you're going through the process to hopefully become an allergist if this is something you're interested in.

[01:16] An Interest in Allergy

There are two paths to Allergy fellowship – internal medicine residency and peds residency. Neeta took the internal medicine route. She remembers being in one rotation and the patient was very sick. He needed penicillin desensitization. And she found this very interesting that it was so specific. She describes the field as being precise, systematic, and specialized, which simply drew her to it. Then she did some HIV research at the hospital she was training at.

Although she comes from a family of doctors, she never really came across Allergy until her residency. She also liked Dermatology at that time because there was an overlap between the two, but she hasn't really thought about doing anything other than Allergy. Otherwise, she would have just really chosen internal medicine.

She thought Allergy was also a great lifestyle specialty. She didn't want to be taking crazy calls at the hospital so this was part of her thought process in choosing the specialty too.

[06:24] Types of Patients

With the huge rise of food and environmental allergies today, her day-to-day practice is mostly private practice. She sees a variety of both children and adult patients. She manages a lot of skin allergy. She also sees children with food allergies, allergic rhinitis, and asthma. She doesn't see a lot of complicated immunology although it could come up once in a while.

"There's a ton of rashes and hives and allergic skin reactions more than I probably would have thought I would see."

Allergy is driven by immunology and the immune system, the TH2 arm of our immune system specifically. But there's also a specific discipline of immunology like DBID. But she really doesn't see as much. That being said, immunology and allergy are both driven by the same pathophysiology.

Immunology is rare and is a discipline that highly evolves in academic centers. In fact, Neeta would 100% defer to academic medical centers for immunology or complicated immunology.

[10:16] Community vs. Academic

Although Neeta still sees patients at the hospital, it's not the same thing as being in an academic setting which she also misses. Nevertheless, this decision was driven by a lifestyle choice. She joined her family of doctors, a multispecialty private practice, which gave her incredible flexibility of time and overhead. Being a mother, she also thought she'd be more successful in treating patients if she had this level of flexibility.

[11:11] Diagnostics

Neeta does diagnostics for almost every single patient. Patients are referred to her to find out what they're allergic to. 95% of patients end up getting bloodwork or allergy test in her office.

[11:45] A Typical Day

A typical day for Neeta would be walking into the office, rotating between three exam rooms. She does a variety of procedures – skin testing, patch testing, pulmonary function testing. Patients end up staying in the exam room for a considerable length of time. So what she does is bringing them on different days for specific testing.

[13:05] Procedure Work

Procedures done may vary from doctor to doctor. Neeta says procedures can be delegated to staff provided they're trained well. She does scratch testing, pulmonary function testing, and patch testing, application, and removal. They could also do variations of nasal endoscopy.

[13:50] Taking Calls and LIfe Outside of Work

Neeta takes calls at the hospital but it's not that often. She can get called for desensitization for patients who need it. Other issues she would usually encounter include endroedema and complicated asthma. But then again, it's not that often.

"Internists, general doctors, and ER docs know how to get patients to a safe place and then discharge them with an instruction to see an allergist.

Neeta describes this specialty as being one of the nicest specialties. You can have a rigorous work life but you can still spend time with your family.

[15:50] The Training Path

You obviously go through medical school for four years and then followed by a residency either in pediatrics or internal medicine. Around 3rd to 4th year, you will be applying for an Allergy Fellowship. At her time, the specialty was pretty competitive. The fellowship is really for everybody including peds and adults. Then when you ultimately go out, you treat both.

To be competitive to match, try to find the chief of Allergy/Immunology at the hospital and get involved with research to show your interest.

"Show some sincere interest and truly research. Dedicated work never hurts."

[18:30] Subspecialty Opportunities and Bias Towards DOs

There are medial centers that have a Food Allergy fellowship as well as other subsets where you may be able to go deeper.

As for any negative biases towards DOs, Neeta hasn't really seen anything at all. There are just so many DOs everywhere and they're great doctors.

[19:50] Working with Primary Care and Other Specialties

Neeta wishes that primary care physicians wouldn't just test a battery food allergy test because people may leave the office thinking they're allergic to all these things and they need to stop. When in reality, we all have antibodies circulating in our bodies. So there isn't really any clinical relevance without a history of a reaction. So it's important for them to know how to interpret those tests or just leave it to the allergist.

She also hopes they don't lead people to believe it's an immunology when it's actually an intolerance. She has seen a lot of primary care physicians though that know the updated food guidelines in terms of allergy that all infants should be started on. Hopefully, this is going to turn around peanut allergy cases that have been rising in the last two decades.

Asthma is another one that she commonly hears where a primary care physician says they don't have asthma because they're not wheezing. But nocturnal hop especially in children is equivalent to wheezing. So she wishes she wouldn't hear as much of this as this makes the parents of patients doubt you.

Other specialties she works the closest with include Dermatology, GI, ENT, Pulmonology, etc. She says asthma is either taken care of by pulmonologist or an allergist. But an allergist can probably help more since much of asthma is driven by allergy.

"So much of asthma is driven by allergy and an allergist can do a bit more to help."

Neeta further shares an advice to aspiring primary care doctors who would be consideirng whether to send their patients to an allergist or a pulmonologist. If the asthma is triggered, pulmonary may be the better route. But the medications they're going to use are just the same anyway. That being said, you can't go wrong.

[24:50] Special Opportunities Outside of Clinical Medicine

A big part of her life is doing work in the media. Neeta has done a lot of TV and educational media around the issue of allergy, which has become a hot topic. You could also write or have a podcast.

[25:50] Most and Least Liked Things About Allergy

What she wished she knew that she knows now going into the field is that the field requires a bit of being business savvy. What she likes most about the field is the ability to make people feel better.

"Even though so many allergy medications are over the counter, I don't think people know how to use them efficiently."

What she likes the least, on the other hand, are chronic issues that can make people feel miserable. In many cases, they don't respond to therapies. Treating the chronic asthmatic isn't also fun.

[27:44] Major Changes in the Future

Neeta has read about allergists fighting against an FDA regulation that allergists can no longer make shots for their patients. This would be problematic since this is a huge source of income if you're administering shots.

Moreover, there's the automization of skin tests and the interpretation can take the allergists out of the picture. But that being said, you may think people may no longer need allergists. But people need that expertise.

[28:31] Final Words of Wisdom

If she had to do it all over again, Neeta would have chosen the same specialty. She simply loves it! She loves the "detective" aspect of it. One of the biggest medical mystery allergy-related cases she had seen was the drug reaction with eosinophilic systemic syndrome.

Finally, Neeta wishes to imparts to medical students and premeds that allergists are needed. You have to be willing to make time for people. Empathy is also needed. Keep in mind how valuable you are. Realize how much difference your words and your education can make in the lives of patients.

"It's a specialty that continues to be incredibly relevant because allergies are only going to get worse."

Links:

NeetaOgden.com

MedEd Media Network

91: Community Dermatologist Shares Her Specialty Apr 17, 2019

Show notes

Dr. Reid is a community Dermatologist who joins me today to discuss why Dermatology, her clinic days, and the number of patients she sees daily!

90: What Does Academic Infectious Disease Look Like? Apr 10, 2019

Show notes

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

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Session 99

[01:48] Interest in Blood Banking and Transfusion Medicine

[04:14] Traits that Lead to Being a Good Blood Banking & Transfusion Medicine Specialist

[06:35] Types of Patients

[08:55] The Role of a Physician in a Blood Bank

[11:35] Typical Day, Procedures, & Taking Calls

[15:50] The Training Path

[18:05] Subspecialty Opportunities

[19:10] Working with DOs, Primary Care, and Other Specialties

[22:30] Special Opportunities Outside of Clinical Medicine

[24:15] What He Wished He Knew Going into this Specialty

[27:00] Community vs. Academic Setting

[28:08] Major Changes in the Future

[33:05] Final Words of Wisdom

Links:

Session 97

[01:30] Interest in PM&R

[04:10] Traits that Lead to Becoming a Great PM&R Doctor

[06:45] Other Specialties She Considered

[11:52] The Roots of PM&R and Types of Patients

[14:50] Taking Calls

[16:15] Choosing Academic Setting over Community Setting

[18:42] Work/Life Balance

[21:30] Doing Procedures

[23:15] The Training Path

[25:10] What Makes a Competitive Applicant

[27:00] Bias Against DOs

[28:25] Subspecialty Opportunities

[30:15] Working with Primary Care and Other Specialties

[33:35] What She Knows Now That She Wished She Knew Going into Medicine

[35:15] The Most and Least Liked Things About PM&R

[39:45] Major Changes in the Future of PM&R

[41:11] Final Words of Wisdom

Links:

Session 93

[01:10] Interest in Pediatric Hospitalist Medicine

[04:45] Traits that Lead to Being a Good Pediatric Hospitalist

[06:15] Hospitalist vs Outpatient Pediatrician

[07:30] Typical Patients

[08:55] Typical Week

[10:19] Doing Procedures

[11:12] Training Path

[14:00] Subspecialty Opportunities and Bias Against DOs

[15:44] Working with Primary Care and Outside of Clinical Medicine

[18:10] Most and Least Like Things About Pediatric Hospitalist Medicine

[21:55] Major Changes in the Field and Final Words of Wisdom

Links:

Session 92

[01:16] An Interest in Allergy

[06:24] Types of Patients

[10:16] Community vs. Academic

[11:11] Diagnostics

[11:45] A Typical Day

[13:05] Procedure Work

[13:50] Taking Calls and LIfe Outside of Work

[15:50] The Training Path

[18:30] Subspecialty Opportunities and Bias Towards DOs

[19:50] Working with Primary Care and Other Specialties

[24:50] Special Opportunities Outside of Clinical Medicine

[25:50] Most and Least Liked Things About Allergy

[27:44] Major Changes in the Future

[28:31] Final Words of Wisdom

Links:

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