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**Specialty Stories**

Specialty Stories is a podcast to help premed and medical students choose a career. What would you do if you started your career and realized that it wasn’t what you expected? Specialty Stories will talk to physicians and residency program directors from every specialty to help you make the most informed decision possible. Check out our others shows at MededMedia.com

Latest Episodes:

58: What Does a Movement Disorder Specialist Do? Jan 16, 2018

Show notes

Session 58

Dr. Kathrin LaFaver is an academic Neurologist who specializes in Movement Disorders. We talk all about her job and what you need to know if you're interested.

Check out all our other podcasts on MedEdMedia Network. And don't forget to subscribe on whatever medium you have.

Going back to today's discussion is a movement disorder specialist who has now been four years out of training. She talks about why she chose her career, what it takes to become one, and so much more!

[01:54] Her Interest in Movement Disorder

Kathrin was a neurology resident and she got to shadow or do an elective in movement disorders. She found a great mentor and she was just fascinated by it, including the personal connections they formed. So from day one she knew it's what she wanted to do.

The great thing about movement disorders, Kathrin says, is that you see the problem in front of you. So you can often make a diagnosis as they come into the room. On the other hand, there are people with too much movements and you can describe and see what's wrong. Then you can make your own conclusions from just observing the patient.

"It's a really interesting specialty, a lot of treatments available, and the opportunity to follow people long term."

Ultimately, she enjoys the connection with movement disorder patients. Treatment-wise, the medication for Parkinson's disease that was discovered way back in the 1960's, it still remains as the mainstay treatment for Parkinson's disease.

[05:15] Traits that Lead to Being a Good Movement Disorder Specialist

Kathrin says you have to have good observation skills - seeing them, finding the pattern, and fitting them into the right category. Over time that you've done it for a while, it becomes natural to see those specific disorders, which may not be so obvious for someone who's not specifically trained in it. Other skills include being able to enjoy logic thinking and fitting clues together, which are actually things common to neurologists.

[06:40] Types of Patients and Cases

Parkinson's Disease is the mainstay for most people in this practice. Unfortunately, this disease has been on the rise. In fact, one in 37 patients is expected to have Parkinson's Disease.

"One in 37 patients is expected to have Parkinson's disease so it's actually a very common disease. Whether you do neurology or not, you're going to see people with Parkinson's disease."

Parkinson's disease affect people, young and old, and there are different treatments, both medication and non medical treatments. It also affects not only the motor system, but also sleep, mood, and other symptoms. So Kathrin says this is an interesting area to be active. There are a lot of things to be researched on and discovered.

Most common disorders spans the whole spectrum from age ranges such as dystonia, tourette's syndrome that often affects children and teenagers. Tremor can also be present in younger adults. Others would be genetic forms of movement disorders often presented in midlife. They also encounter other forms of dystonia as well as tremors.

Kathrin explains that many are still diagnosed although essential tremor and Parkinson's disease are so common. She says it's easy to tell them apart, but not everyone behaves like a textbook. So it's not always as easy.

"Surprisingly often, they're misdiagnosed either by a primary care physician or a neurologist who might not be very well-trained in movement disorders per se."

Being at a tertiary academic center, Kathrin says they do get patients where they have to dig deeper to look for the missing clues to get to the diagnosis. That said, she has challenging cases every week where they have to be thorough with their history and examination to get to the diagnosis.

[10:55] Academic versus Community versus Private Practice

Kathrin has always been interested in human psychology, and movement disorder was just so interesting for her. Although they're called movement disorders, they are so much more. All these disorders like Parkinson's disease and Huntington's disease have behavioral manifestations as well. Depression and anxiety for example, are common in Parkinson's disease. Anger and depression are very common in Huntington's disease, too.

"We're still just at the beginning of understanding all these diseases and finding better treatments and cure for them."

This said, Kathrin knew she wanted to be in a place where she can continue exploring and help contribute to gaining new knowledge about diseases.

[12:40] A Typical Day - The Parkinson Buddy Program

Being the director of the Parkinson's Disease and Movement Disorders Clinic at the University of Louisville, she spends 50% of her time in research. She's involved in several medication studies for Parkinson's and Huntington's. These are studies run in multiple sites across the US and Europe. This gives patients an opportunity to try new treatments or be involved in new treatment efforts.They're currently looking for treatment for anxiety affected by Parkinson's. So she doesn't see clinic patients. Rather, she's involved in teaching medical students as well as community outreach.

Three years ago, they started the Parkinson's Buddy Program where they team up first year medical students with Parkinson's patients in the community, This is an opportunity for these students to experience how someone with Parkinson's lives and what challenges they face in their lives.

So when they get paired with a patient, they get some mentoring sessions with her. But the goal of the program is to let them meet with the patient in social settings so they can explore and experience it. Kathrin is involved in other teaching community activities, fundraising, etc.

And the other half of her time, she does patients in the office.

Kathrin sees 100% movement disorder patients in the outpatient setting. All neurologists in their group the alternate call as well. One week every 2-3 months, she spends a week in the inpatient general neurology service. At this time, she'd supervise residents and see all patients with general neurology conditions like epilepsy, multiple sclerosis, etc. While all of his outpatient time is spent with movement disorder patients.

[15:50] Work-Life Balance and the Residency Path

Kathrin is married with two kids, ages 2 and 4. And her work is fairly busy. She explains her time outside of the hospital is spent with her family.

In terms of the path to being a movement disorder specialist, Kathrin outlines the process. First, you do the neurology residency which is usually a year of internships, one year of internal medicine, and three years of neurology.

"Movement disorder fellowship is actually not an accredited fellowship so the pathways are a little bit more flexible."

There are also fellowships that are one year, mostly clinical. And many are two years - one clinical and one research year. As well, there are some additional opportunities to get intensive training in deep brain stimulation surgery. This is a surgical treatment for mostly Parkinson's disease and essential tremors. Kathrin describes it as a teamwork where the neurosurgeon does the procedure and then the neurologist or movement specialist would do the programing and follow-up care for the patient. For Kathrin, she did one year of clinical fellowship in Boston. Then spent two years of research fellowship.

In terms of the competitiveness, Kathrin points out the shortage of neurologists. Some programs are more competitive than others. But if you're flexible with your location or willing to go, it's not really extremely competitive to get into a fellowship.

One of the challenges in the movement disorder sphere right now is the epidemic of Parkinson's disease coming upon us in the next 20-30 years. The trends she sees coming in the future is telemedicine, especially in rural areas, in the hope of meeting the demand for movement specialists.

[19:36] Negative Bias Against DOs and Special Opportunities

Kathrin doesn't really see any bias going on against DOs. Moreover, if you're interested in surgical treatment options like deep brain stimulation surgery, it requires special training.

[20:38] How Deep Brain Stimulation Surgery Works

The patient essentially gets a pacemaker for the brain. Electrodes get placed in targeted areas and in order to make sure this is done correctly, the procedure is done while the patient is on an anesthesia. Then the electrode is advanced and the patient wakes while a mapping is being done. Then they actually listen to the cells as the electrode is advanced. And this is how the actual training plays in.

"Cells and the different parts of the basal ganglia have all characteristic sounds."

Imaging plays an important role but most centers still do the microelectrode recording as additional means of finding the right location for these electrodes. Doing this procedure is a team effort - they have the neurosurgeon, the neuro electrode physiologist. Then a neurologist helps with listening to the cells and doing testing on the patient. If they're in the right spot, they turn the stimulation briefly on. Then they look on where the tremor gets better. So they're able to see immediate effect in the O.R. as it confirms that the space is the correct spot where the electrode is placed. Although results are not guaranteed, but there have been many cases where the tremor has really stopped. For many patients, it's a really miracle surgery.

[23:58] Working with Primary Care and Other Specialities

Kathrin's message to primary care physicians is to not be afraid of referring a patient to a neurologist or movement specialist. Because Parkinson's and essential tremor are so common, sometimes the internist or the primary care physicians become the main providers treating patients. And often, it works out just fine. But it's important for people without special training to realize the limitations and first-end treatment does not go so well. So if patient still experience the tremor, then they should not hesitate referring them.

In many cases, we really have very effective treatments which can make a huge difference and even for people in more advanced stages, treatments like the Deep Brain Stimulation Surgery may be an option.

"Don't hesitate asking for help for someone with Parkinson's disease or tremor and we can often make a big difference."

Other specialties they work the closest with are Psychology, physical therapy, speech therapy, and occupational therapy. Many centers, in fact, run special multidisciplinary clinics, where they have a monthly clinic for Parkinson's or Huntington's disease. People can see multiple specialists at the same time. This is very helpful in facilitating care for the patient as they try to streamline care. It also helps to get input from multiple specialties as to how to serve the patient best and work all together.

They also work with social workers in their clinic. Kathrin stresses the importance of understanding how movement disorder affects someone's work or social life in, especially in later stages.

Special opportunities outside of clinical medicine include research. Some have actually pursued a full time research career. Other options are private practice or working in academia. She adds your career can actually change multiple times throughout your life.

"Just being in medicine in general and being a physician, getting expert knowledge, you can really forge your own path and find your niche."

[27:55] What She Wished She Knew and Major Changes in the Field

Kathrin explains there are many changes in medicine. They can be burdensome and taking too much time. But as a medical student, you don't really see that side. Nobody will tell you that in the anatomy class. And in the real world, you spend a lot of time on the phone as you try to get your patient's medication approved due to insurance issues. And this is a hidden truth.

"That's a hidden truth right now that our physicians are maybe not as autonomous as we would like to be... oftentimes, insurances mandate the medications we can prescribe."

That said, Kathrin saw really no surprises from the neurologic side of things. Rather, it's about how you deal with the whole business side of medicine.

What she likes most about her job is working in a setting where she gets to see the patients, doing interactive trainings and teachings as well as research. There can be lots of challenging times but in the end, Kathrin says it's all worth it. Having success in one area can sometimes compensate for another disappointment so it balances things out.

Alternatively, what she likes the least are the regulatory burdens and dealing with insurances. She's hopeful though that this gets resolved in the coming years and physicians will gain a little bit of autonomy.

Major changes she sees in the field are developments in multiple areas. One is the Deep Brain Stimulation Surgery that has already been mentioned and that these could be more individualized soon. Another interesting area is genetics. They can now do a whole genome sequencing for $5,000 which was years ago, was unthinkable to do that. So there's more discoveries and insights to come in the future.

Additionally, Kathrin wants people to understand the interplay of environment and genetic factors and how that impacts complex disorders like Parkinson's disease and other movement disorders. Hopefully, we can learn more about how to intervene and really make differences.

Lastly, Kathrin says that if she had to do it all over again, she would still have chosen the same subspecialty.

[33:55] Last Words of Wisdom

Kathrin encourages students to do an elective in neurology. That said, there are lots of opportunities to get engaged in research. She has students working with her during the summer break. And this is a good opportunity to have a good hands-on experience. Also do a little research project like see someone in their day to day or get some patient contact. See if this is something that interests you.

Links:

Parkinson's Disease and Movement Disorders Clinic

MedEd Media

57: What Does a Pulm Critical Care Medicine Doc Do? Jan 09, 2018

Show notes

Session 57

Dr. Tom Bice is an academic Pulm Critical Care physician in North Carolina. We talk about his specialty and what you should be doing if you're interested in it. Tom has been out of fellowship for four years now.

By the way, check out all our other podcasts on the MedEd Media Network.

[01:03] His Interest in Critical Care Medicine

Not being able to decide on one topic, Tom knew he wanted to do a little bit of everything. And he has mild to moderate ADD. He also considered Emergency Medicine early on but he found he didn't enjoy people showing up at 3 am with significantly non-emergent problems.

So when he focused more on internal medicine, he was doing his rotations in surgery and medicine. Then he realized that all of the patients and disease processes that were cool ended up in the ICU. What cemented his decision was his OB rotation with a young 26-year-old lade with sickle cell anemia came in at 29 weeks and went to the emergency section. She ended up in the unit for several days and intubated, septic shock. He was a third year medical student at that time and he was the one from their team surrounding the patient. And he realized he loved every minute of it. In fact, the attending OB was one of those who wrote letters for his residency. Since then, he got hooked.

"I was hooked. Right away, I just love the excitement of the physiology and meeting a broad swath of knowledge about the various systems."

In short, it was the acuity that actually drew him towards what he's doing now. He had this notion that patients are going to need you when they come see you. But that's not always the case in the emergency medicine.

[04:55] Types of Patients

Being part of a large academic medical center, they have different ICUs for all the different patient types. As with Tom, he works predominantly in the medical ICU. But they also have the cardiac ICU, neuro ICU, surgical ICU, and cardiothoracic ICU (where he spent the first two years out of fellowship).

At medical ICU, they see patients with sepsis and septic shock of some kind. You also have those with liver failure, drug overdoses, and problems which you can't figure out what's wrong but they look real bad. What identifies all those patients is the need for fixing a deranged physiology.

Neuro intensivists tend to go through neurology or emergency medicine and then do neuro critical care. The cardiothoracic ICU uses a bit of everyone including anesthesia and critical care. Cardiac ICU does cardiology and pulmonary critical care too.

Tom explains that you get training during fellowship because your'e required to do so many months of ICU, that you can go and work in any kind of ICU necessary. Having done a lot of moonlighting during fellowship, and he saw that at the bigger community-based academic programs, intensivists rounds on all those ICU patients providing critical care.

[09:15] Typical Week

When Tom is o service, his typical week would be nighttime covered by the different intensivists where he is on from 7am to 7pm for seven days. And for the weekends, the ICUs have to have two attendings on so they split it between the two of them every other day.

Tom tries to keep his rounds short. And there's a lot of work that need to be done, procedures, consults, and activities for patients. Then before he leaves for the day, he ensures he has followed up everything and whatever action plans that needed to happen should have happened.

[10:35] Is It Procedure-Heavy?

Tom says it's a lot of procedures, with a caveat. To some extent, you can do as many or as few procedures as you want depending on how hands-on you want to be. But if you don't like procedures then it's not the specialty for you. Especially for the pulmonary side of things, they do thoracentesis and chest tubes as well as intubation, lumbar punctures, etc.

If you really don't like procedures, then it's probably not the specialty for you."

[12:00] Work-Life Balance

Tom says he has a lot of work-life balance, and this is the reason he chose academic over private practice. He probably would have enjoyed private practice critical care for 2-3 years. But he enjoys about 12 weeks of ICU time a year. And the rest of his time is non-clinical, doing research. His focus is clinical research so it's still patient-focused. But the 24/7 grind is not constant.

Nevertheless, when he's home, then he's really home. He likes the advantage of shift work. In fact, most of critical care is moving that direction around the country. In their state, what he notices is very much a day group and a night group. You're on when you're on and you're not when you're not. So it's easy to maintain balance that way.

"There is generally recognized shortage of people that are critical care trained and most of the hospital quality folks would prefer that there was a critical care trained person in the hospital 24/7."

[13:45] The Training Path

Tom cites a few options available now. When he started his fellowship, he knew he was going to keep doing research and stay in academics, he did his three-year internal medicine residency and then a two-year critical care fellowship only.

Another options is for one extra year, you do pulmonary. This is mostly determined on whether you like clinic or not. People who do critical care only, tend not to have clinic obviously because there's no ICU followup per se. But if you want some of that longitudinal relationship with patients then you get to a little bit of both. That's why Tom also has a pulmonary clinic. This is three year after internal medicine residency, totaling to 6 years after medical school.

"There is no particular disadvantage to hiring a critical care fellowship only."

In terms of competition, Tom thinks it's getting more competitive, but it's not cardiology, or GI, or oncology. They get very competitive applicants every year at their program. He describes it as being competitive enough that requires some degree of forethought. He also thinks you have to have some research exposure if you go to an academic-type program.

[17:24] Negative Bias Towards DO Physicians and Special Opportunities

Tom has not seen any bias against DO doctors. In fact, a couple of his absolute famous attendings from residency were DOs that did pulmonary critical care. They've interviewed plenty of DOs. To them, it seems another way of getting the same training.

There are further subspecialization both in the pulmonary care side and the critical care side. Under pulmonary, there's interventional pulmonology which is more procedure-based. There are no formal NRMP matching programs for lung transplants but there are a few places that offer fellowship and subspecialty training in that. There are not set training programs, but they are niches within pulmonary medicine.

"As with everything, subspecialization continues to involve. There aren't formal training programs but emphasis or subspecialization has developed in recent years."

[20:10] Working with Primary Care and Other Specialties

Tom explains they do have interaction with primary care doctors in the pulmonary side. One of the balances they often run with primary care is the shortness of breath consultations, which cardiology and pulmonary like to point the finger at the other direction. His advice to primary care is to accept that both are probably wrong. And it's probably a little both of the lungs and the heart causing the shortness of breath.

Other specialties he works with include Nephrology. One-third of patients through the ICU require dialysis at some point. Tom also underlines the importance of having a good relationship with critical care trained surgeons, which are different from your general surgeons. Sometimes, it's knowing when not to take the patient to the operating room. And sometimes, it's knowing that you need to take a patient to the operating room, no matter what. He may also work with GI/Hepatology.

"In the medical world, having good relationship with your critical care trained surgeons makes a big difference."

Outside of critical care, there are other opportunities that are available. Pulmonary gets involved with high altitude medicine which also includes diving (low altitude medicine). Personally, he has had some experience traveling and training in resource-poor environments. Knowing how to provide critical care in those environments can be very handy.

You can also do research. Critical care is relatively a new specialty. So there's still a ton that we don't know about how to do things right, according to Tom. You can also do quality and leadership initiatives through that.

[23:40] What He Wished He Knew that He Knows Now

The one thing he didn't know as much early on about critical care is how much time spent with families of dying patients. He's glad though that it's something he enjoys having those conversations about end of life care and the expectations of what is going to happen.

"Most of our medical training leading up to, and including in residency and fellowship, is find the problem, fix the problem. There's just so much of the time where we just can't."

Tom stresses that unlike what they're taught during training to find the problem and fix it, there are times they just can't. And being able to have that conversation with patients or their families is really important.

This is a good message he wishes to send out to primary care doctors as well is to have those conversations in clinic early. But recognize that they're flexible and people change right up until the last minute.

[25:20] What He Likes Most and the Least and Major Changes in the Future

What Tom likes the most about critical care is that there's always something to do. It's always a busy specialty. There's always going to be sick patients. And the acuity never stops because if you're going to get one patient better. And there's going to be three waiting in line.

"Flu is one of the diseases that they know most of the symptoms of it, but they can just do anything later on and affect almost any organ system."

On the flip side, what he likes the least is that the ICU never closes. So you have to know that you're going to work in the ICU on Christmas and all the other holidays at some point. Know that going in.

Although this has been growing over the last several years, you still see the inclusion of advanced practice providers like PAs and NPs in the ICU. This is primarily because of the shortage of critical care providers. It's a numbers problem that a number solution can help with.

Ultimately, if he had to do it all over again, he still would have chosen the same specialty. Tom wishes to tell students who might be interested to explore this field that they'd love to have you. Contact your local critical care doctor for rotation. It's a good time even if it's busy.

[29:30] Personal Takeaways

Most students that love a little bit of everything go to emergency medicine. Yet, there's also this subsection of students who love the high acuity stuff.

Go back and listen to Episode 2 of Specialty Stories where I interviewed an emergency medicine doctor where he revealed that the high acuity stuff only comprises a small percentage of an emergency physician's job. So if you like the high acuity stuff, and you like a little bit of everything, pulm critical care might be the specialty for you.

If you have a physician you want to be interviewed here on the podcast, shoot me an email at ryan@medicalschoolhq.net.

Links:

MedEd Media Network

ryan@medicalschoolhq.net

Episode 2 of Specialty Stories

56: How Hard is the Neurosurgery Match? A Look at the Data. Jan 02, 2018

Show notes

Session 56

Neurosurgery follows the rules of economics. There are very few spots, so it is really competitive to get into. We covered the NRMP Match data for Neurosurgery.

Neurosurgery is one of those residencies that are super hard to get into. Ryan has had an academic neurosurgeon previously on Episode 20 of this podcast.

Please subscribe to this podcast. We're on Spotify now! Check us out there as well as on any Android phone, or on Stitcher and Google. Nevertheless, the podcast app on the iOS is the best way to subscribe on an iPhone or iPad. You will also find all our episodes on the MedEd Media Network.

Let's dive into today's data...

All information here are based on the NRMP Main Residency Match 2017, Charting the Outcomes 2016, Medscape Lifestyle Report 2017, and Medscape Compensation Report 2017. Ryan walks you through the data along with some commentaries. So you will know what it means and what it looks like and what you should be thinking about if you're interested in Neurosurgery.

[02:30] Match Summary for 2017

Looking at Table 1 of NRMP Main Residency Match 2017 Summary, Neurological Surgery is how they list it. For this field, they have 0 unfilled programs. This means lots of people are applying for neurosurgery and they're getting filled. There are 107 programs. Comparing this to other fields, Emergency Medicine has 191 programs and Anesthesiology with 124 programs.

So for neurosurgery there are 107 programs and 218 positions. It's just over two spots per program. Comparing this to Anesthesiology, it has 124 programs and 1202 positions. This is almost 10 spots per program.

This said, there are not a ton of spots and programs for neurosurgery, but every program is super small on average. As you think about your journey, and you're dead set on being a neurosurgeon, all this data shows that you need to well.

"If you're dead set on being a neurosurgeon, you better buckle down for medical school...to make sure you have great board scores, great grades."

So for U.S. Seniors there are 212. Again, U.S. Seniors here means that it's somebody who's an allopathic/MD still a senior in school. So this doesn't include U.S. Grads who are now taking a gap year, doing research, or doing something else who have graduated.

There are 311 total applicants for those 218 spots. Through this episode, Ryan will discuss where these other 99 students are coming from. And out of those U.S. Seniors, 183 matched. So it's 83.9% U.S. Seniors matching in an allopathic medical school. This tells you that they're favoring students at allopathic medical schools.

[06:45] Summary of Students: U.S. Seniors, U.S. Grads, IMGs, Osteopaths

Table 2 shows where these students are coming from. Again, 83.9% of those that matched are U.S. Seniors. And 15% of those students are U.S. Grads. This means they probably took a year off or they didn't match their first time around so they did research or whatever. There are 2 osteopathic students and 4 U.S. citizen international medical graduates matched into neurosurgery.

Looking at this data, is going to a Caribbean school better than going to an osteopathic school? Thinking this alone is wrong. You can't draw these conclusions as to why the numbers say so. If all four of those students when to a DO school, they might have still matched because of who they are, not the letters after their name.

"You can't draw conclusions that says going to Caribbean school, Australia, or Ireland better than going to a DO school if you want to match into neurosurgery."

Non-U.S. citizens international medical graduates are 14 of those that matched. They are obviously strong students who crushed their boards that they were able to match almost as many students as U.S. graduates.

[09:22] Yearly Trends

Table 3 shows the yearly trend showing a slow, steady incline every year for the number of positions from 204 to 218 over the last five years. It's a 0.8% increase every year from 2013 to 2017.

Looking at Table 8 shows the number of positions offered and the percent filled by U.S. Seniors versus all applicants.

For 2017, 83.9% were U.S. Seniors and the numbers are pretty high every year. In fact, this is the lowest year since 2013. It's 92.6% in 2016, 89.5% in 2015, 91.7% in 2014, and 93.1% in 2013.

This tells you a couple of things. That for 2017, less U.S. Seniors matched percentage-wise for the total number of positions offered. This tells you that either there were less qualified students applying this year or there are more qualified non-U.S. Seniors applying this year.

Table 9 gives you scope of how big a specialty is. For neurosurgery only 0.8% of all applicants matched into neurosurgery. There are a total of 27,688 students and 100% of those students are matching. Another surgical subspecialty that is low is ENT with 1.1%. Not a ton higher but still higher.

"Out of the 27,688, only 0.8% of those are matching into neurosurgery. So it's a very, very small specialty."

[12:35] Unmatched U.S. Seniors and Independent Applicants, SOAP

Looking at Figure 6, Neurosurgery has an unmatched percentage of 20.6% so one out of every five students is not matching into neurosurgery. 55.4% of the independent applicants go unmatched. So it's a large percentage of that are non U.S. Seniors. Only 10.4% of U.S. Seniors are unmatched.

Comparing this with other specialties, plastic surgery is 16.3% for U.S. Seniors, Dermatology is at 13.8%. This is a high percentage but not the highest.

Table 18 shows the SOAP (Supplemental Offer and Acceptance Program). Neurosurgery had 0 unfilled programs so no neurosurgery programs needed to participate in SOAP.

[14:00] Charting the Outcomes 2016

Digging into the Charting the Outcomes 2016, looking at percent match by preferred specialty, Chart 3 shows that 76% of U.S. allopathic seniors matched into it. This the third lowest. Vascular surgery is 71%, Orthopedic surgery is 75%. This tells you that it's one of the most competitive specialties out there, at least for U.S. Seniors.

Table 2 talks about the mean USMLE score for Step 1 and Step 2 CK (Clinical Knowledge) versus CS (Clinical Skills). The mean USMLE Step 1 score for all specialties combined for those that matched was 233 and 230 for those that did not match. Keep these numbers in mind.

"To match, you have to rank a lot of programs. The more programs you rank, the higher the chance that you will match."

Chart 4 shows that in Neurosurgery, the median number of contiguous ranks is at 16 while those that did not match only had a median number of 11. So you need to rank enough programs to match. If you want to match, you cannot be very picky. Are these people not ranking programs because of location? Or prestige? Or are they not ranking programs because they just didn't interview there and decided not to rank them. So there are many questions there.

Again, the data is just data. You can't draw conclusions based on this data. We can only make some inferences and discuss what is behind these numbers. But there is no way of knowing specifically why the numbers are what they are.

[17:23] Ranking by Specialty and Step 1, Step 2 Scores

Ryan always tells students that if you want to be a physician, don't have a plan B of being a PA. Don't have a Plan B of being an NP. Don't have a plan B of using your Biology degree or something else. If you want to be a physician, figure out how to get there.

"Don't have a plan B of being a PA... If you want to be a physician, figure out how to get there."

Chart 5 talks about the mean number of different specialties ranked by U.S. Allopathic Seniors. This tells you that those who have a plan B did not match at a much higher percentage in most instances than those that didn't have a plan B. Looking at Neurosurgery, the mean number of different specialties ranked was 1.1. This means a large majority of students only ranked neurosurgery on their rank list. The mean number of those that did not match was 1.4. It means there are more of those students putting in different, most likely, surgical specialties. If you're applying for neurosurgery, that means you like the operating room. This probably means you're applying for maybe general surgery as a backup. And that back up might hurt you. Psychologically, it might hurt you. And the data shows it leans that way.

Chart 6 looks at Step 1 scores. The mean Step 1 score for all specialties was 233. For neurosurgery, the mean Step 1 for those that matched was 249. Those that did not match was closer to 238. So you need to have great board scores to match into neurosurgery on average. The same thing for Step 2 scores. The mean Step 2 scores for all specialties was 244.8. For those that matched into neurosurgery, the number was upward to 251-252. For those did not match, it's closer to 242.

"You need to have great board scores, if you're planning on being competitive for neurosurgery."

[20:21] Scores, Research, Publications, AOA

Table NS-1 shows that Mean USMLE Step 1 Score is 249 for those that matched and 238 for those that did not. Step 2 Score is 251 for those that matched and 241 for those that did not match. Research experience is 4.8 versus 4.2. Number of abstracts, presentations, and publications for neurosurgery is 13.4 for those that matched versus 8.4 for those that did not. This tells us that research is very important for neurosurgery.

"Research is very important for neurosurgery."

The number of students that are AOA (the medical student honor society) based on grades, almost 33% of those that matched were AOA versus only 11.5%. It's not just about having the AOA label, but having the grades that made you competitive and that led you to AOA. It means having the grades to give you the knowledge to do well in the boards. So you can look at this thinking you have to be AOA but you have to have a solid foundation of scientific knowledge of all those courses you've taken in medical school. And this leads to AOA. But it also leads to great board scores. So it's not just AOA.

So 9.5% of those that matched have a PhD degree versus 7% who did not. Mean number of contiguous ranks is 15.7% of those that matched versus 10.2% for those that did not match. Again, you need to rank a lot of programs to increase your chances of matching.

[22:27] Burnout Rates and Compensation

Moving on to the data of Medscape Lifestyle Report 2017, Neurosurgery is not on the list since there are only a few number of them. And looking at Medscape Compensation Report 2017, it's the same thing, Neurosurgery did not have enough representation to be in this list.

Anecdotally, Neurosurgery is one of the highest paid specialties out there. If this is something that's motivating you, which shouldn't be, neurosurgery is up there. Based on the NRMP Match Data, it's very hard to get into neurosurgery. But if this is what you want to do, start now. Make sure you have a solid foundation of your classwork. Get AOA as much as possible and get great board scores. Get those connections to neurosurgery programs. Make a great impression as you go through this process.

Links:

MedEd Media Network

Specialty Stories Podcast Episode 20

NRMP Main Residency Match 2017

Medscape Lifestyle Report 2017

Medscape Compensation Report 2017

Charting the Outcomes 2016

The Premed Years Podcast

55: What Does Rural Pediatrics Look Like? Dec 26, 2017

Show notes

Dr. Ekta Escovar is a general Pediatrician in rural Texas. We talked about her desire to work in a rural setting and the benefits and challenges it presents.

54: Academic OB/GYN Discusses Her Journey to the Specialty Dec 19, 2017

Show notes

Session 54

Dr. Esther Koai is an academic general OB/GYN. Listen to what drew her to OB/GYN, what she recommends you do if you're interested in it and so much more.

She talks about her role, why she chose the specialty, and what you should be thinking about if you're interested in getting into OB/GYN.

Also, check out all our podcasts on MedEd Media. For suggestions of physicians you want interviewed here on the Specialty Stories, shoot Ryan an email at ryan@medicalschoolhq.net.

[01:07] An Interest in OB/GYN

Esther says she likes working with women as well as the comprehensive care OB/GYN's provide. She also loves surgery. Specifically, she loves working with women and women's issues, women's health, and women's sexual health. She does a lot of contraceptive counseling in the office. She finds a lot of women who may not feel comfortable of talking to their friends or mothers/family, or even a male provider about certain aspects of their sexual health. And they'll open up to a gynecologist or open up to someone listening specifically for certain things.

"It's a good mix of both the patient side, the continuity of care, and the surgical aspect of care."

She realized this was the path for her during her four year of medical school. She finished her OB/GYN rotation on the third year. It was towards the end of her third year that she applied to all of her neuro electives as she was going into neurology. Then her last rotation of third year was Pediatrics and she realized in the middle of that rotation that she was much more interested in the maternal fetal aspect of things. She missed the labor floor since she had so much fun at her OB rotation. So she ended up canceling all of her fourth year electives and reapplying for OB/GYN.

[03:47] Traits that Lead to Becoming a Good OB/GYN

Esther thinks that in order to be a good OB/GYN, you have to be a good clinician and have that clinical acuity. You also have to be able to act fast. Similar to emergency medicine where you have to be able to respond fast. You have to be able to recognize that this is an emergency and you've got to call your team in and all that.

Additionally, you have to be able to be flexible and be able to go between your OB and GYN patients. That means you have to switch back and forth from doing prenatal care to doing a paps smear and all of that.

As an OB/GYN, she can decide whether she wants to focus on GYN over the other and vice versa. She explains it depends on your department but you can say you can focus more on GYN and do more teaching. There are people who refer their hysterectomies to her.

"In order to be a good OB/GYN, you have to be a good clinician and have that clinical acuity."

[05:18] Academic vs. Community Setting

Part of the reason she chose to go into academic medicine versus going out in the community is her love of teaching. She loves teaching both her patients and residents and medical students, which you can only get in the academic setting.

They do a lot of grand analysis and statistics and a lot of academic activities sprinkled in throughout her week. And she enjoys those.

She did interview at a couple private practices but she found they just weren't for her. Part of it too is the thrill of just being in a high, action-packed, high risk academic center. Because you can see all the cool, crazy stuff out there. You get all the referrals for the intricate medical puzzles.

[06:37] Types of Patients, Typical Day, and Taking Calls

Being at a big academic center, Esther is seeing a wide range of patients. They're an accreta center so they see a lot of placenta accretas. They do hysterectomies. They have a Level 1 NICU. So they're able to deliver very premature infant. Their MFM (Maternal Fetal Medicine) team is well-developed so they have a larger referral base.

A typical day for Esther would be Mondays, she would have a morning off for paperwork. Monday afternoons, she precepts the residents in clinic. Tuesday mornings, they have their academic days - stats, rounds, etc. And they usually have their own panel in the morning and then in the afternoon, she precepts again and do continuity clinic. By panel, she means her own patients. So Wed-Thurs, she sees her own patients.

Usually, two Wednesday nights per month, she'd be on call. So she would be post call on two Thursdays. And then Fridays, she's in the hospital either doing labor and delivery cases and OR cases.

It's her personal preference to have clinics just by herself on days and with residents other days. She chose to be a clinic preceptor and she enjoys teaching and seeing patients with the residents.

Esther takes three overnight calls a month. One is a 24-hour shift on a weekend and the other two are 15-hour shifts. It's an in-house call where she's there with the residents. They see all the patients, triage them, and present them to her. Then she will go and reevaluate and go over things they may have missed or they may have not thought about.

"It can get pretty busy to where I get no sleep at all. And it can also be every once in a while, very chill and laid back."

[09:45] Percentage of Patients in the OR

For Esther, the percentage of patients that come from her clinic ending up in the OR is higher. During Wednesdays and Thursdays, she's at a site where she's the GYN consult. So all the patients she sees have already been screened by a family medicine or internal medicine provider. They refer them to her because they need additional workup of they're a little bit more complicated. So she only sees GYN patients that are more complicated on those days.

She thinks she has a disproportionately high number of GYN patients that she ends up doing procedures on. She estimates it would be a third to a half, she ends up looking for cases. Everything else is either medical management or routine.

[10:44] Work-Life Balance

Esther feels like she never has enough time for family. For her the work-life balance is what you make of. Like when you're able to utilize your vacations well. She has one weekend of call a month so she gets to spend time with family for most weekends. And she thinks this is better than if she were in private practice.

"Work-life balance is what you make of."

[11:25] The Training Path to Become an OB/GYN and Competitiveness

After medical school, you have four years of residency. Then if you want to specialize, they have two to three year fellowships including Family Planning, GYN Oncology, Maternal Fetal Medicine, Urogynecology, Minimally Invasive Surgery, Reproductive Endocrinology, and Infertility. Family Planning Fellowship involves contraceptive counseling, IUD placements, dilation curettage, dilation evacuations, terminations, etc.

Esther doesn't think it's one of the more competitive residencies. Rather, it depends on the program so she'd describe it as mid-range, much like Emergency Medicine. What they're looking for in applicants are those who are willing to put a lot of time and effort into the residency. It does suck up a lot of your time. As far as research and things go, they're not really a huge research center so applicants can do academic research at their program. But it's not the program that turns out into academic literature. But they're looking for people who are able to see a high volume patients and are willing to deal with patients with high morbidity and who are obese. They're able to deal with patients with multiple medical problems. They're looking for people who are ultimately going to be happy.

For someone doing an elective rotation as a medical student, it can be hard to look for these qualities. But part of it is just the general feel. The residents are pretty clear about whom they click with. So her first move is to usually ask the residents what they think of the applicant or the sub-I. She'd find out whether they seem interested or engaged or they just checked out in the corner.

"People always put their best face forward, or at least, should be putting their best face forward."

Esther explains that the mark of a good sub-I is someone who is just very much part of the team, very self-motivated, and somebody you would rely on just as much as your own intern.

[14:35] Bias Towards DOs and Working with Primary Care and Other Specialties

Esther hasn't seen a lot of negative biases towards DOs. And part of that is because one of their MFM's at their program who is highly respected and he ended up being the director of the department at their site, is a DO. That said, they haven't had any DO residents so she hasn't really encountered any other DO OB/GYNs. Alternately, she does see a lot of DOs in Anesthesiology and they're doing just fine.

What she wished primary care providers knew about OB/GYN to better serve their patients is that they knew more about contraceptive counseling for one. And in general, she wished more people felt more comfortable talking about and dealing with female anatomy. It's a daunting idea to people who don't routinely work in that field so it's something that people tend to shy away from. But there's nothing scary about it, Esther says. Other specialties she works the closest with include Urology, Emergency Medicine, Family Medicine, and Surgery.

"There are a lot of misinformed statements floating around out there about contraceptives."

[17:02] Special Opportunities Outside Clinical Medicine, What She Wished She Knew, and the Most and Least Liked Things

Special opportunities outside the clinical world for OB/GYN may include work in patient safety. They have so many obstetric emergency situations. So there are opportunities in patient safety in QI.

What she wished knew that she knows that you've got to really work really hard. But it's all going to be worth it in the end. The amount of knowledge that you gain and the amount of surgical prowess you gain are just unbelievable. It's so rewarding to be able to apply that on a day to day basis.

What she likes most about the job is the patient counseling. She likes having that sit-down conversation with them where she's able to connect with them and they understand things about their own health they may not have understood before. She adds it's an aha moment for every patient when they find out something they've never known before. She finds this very rewarding. And for selfish reasons, she says she loves doing surgery and for her, it's an immediate gratification.

What she likes the least on the flip side is chronic pelvic pain in terms of the types of patients and treating them and all the stuff that goes with it. She finds it cumbersome and difficult to treat. She thinks it's very multifactorial and patients usually get bounced around from place to place. Then they come to you very frustrated because they've tried everything.

[19:20] Major Changes in the Field of OB/GYN and the Future of Residencies

She thinks there's a lot of tracking going on and in other fields as well. Especially in OB/GYN where they're two very separate fields meshed together into one. And this is reflected a lot in the way that the entire field is moving both in the academic and in the private world. Before, you'd see more generalist doing both OB and GYN, but now you're seeing people doing OB only as laborists or GYN only in the clinic. And it's becoming more of a divisive field, Esther puts it. So this is the general trend of things and a lot of academic centers are doing it.

"You have your OB side and then you have your Gynecological side. If you weren't dealing with the same organs, they'd be almost totally separate fields."

Although she's not yet seeing this as of the moment, but potentially down the line, there is that possibility of students applying to OB-specific residencies and GYN-specific residencies. Esther says that if she had to do it all over again, she would still have chosen the same. She loves the people and the patients. She thinks it's a great field and it's fast-paced and can be very intense. But you can also make it very calm and inviting. So it's a very versatile field.

Lastly, she leaves the premed students with an advice to do it. Be enthusiastic. Be curious and ask questions. Seek out the puzzles and really dive right in. There's no better way to experience something other than just committing 100%. It's so rewarding to be able to talk to a patient and have them really hear what you're saying and have them light up.

Links:

MedEd Media

53: An Academic MS Specialist Discusses The Specialty Dec 12, 2017

Show notes

Session 53 Dr. Jacqueline Bernard is an academic Neurologist who specializes in treating patients with multiple sclerosis. She is a physician at OHSU (Oregon Health and Science University). We talk about the specialty and so much more. Tune in every week to hear different stories of specialists even if you're interested in going into primary care. One of the questions I ask them is what they wish primary care doctors knew about their specialty. Also, check out all our other podcasts on MedEd Media. This week, I interview Jacqueline who has been in practice now and out of her training for many years now. She has been in the community-based setting and is now back in an academic setting. I was diagnosed with MS about three and a half years ago so this episode hits home for me. So we chat about her career as an MS specialist, what drew her to it, what keeps her happy, things she didn't like about it, and her advice to you if this is something you're interested in. [02:04] What Do Her to Becoming an MS Specialist Jacqueline says her interest grew in her. As a woman, her practice was getting referred a lot of female patients with neurological disease. And a large percentage of them were patients with MS. She realized very early on how this was a very compelling group of people. They were trying to educate themselves as much as they could about this disease process and what treatments are out there. This grabbed her pretty quickly once she was in the region of the country where it was disproportionately highly prevalent compared to other places. Minnesota for instance, has a lot of MS cases. So it was the volume of patients she was seeing that grew quickly. Within a couple of years from moving to the state, this impacted her. "MS is a very tricky disease. You have to be able to detect it. That's also true about Neurology in general." Jacqueline explains how MS is a tricky disease and you would have to be able to detect it to figure out what's going on because it can relapse and remits. So you'd have to look at the circumstantial evidence. It might involve various parts of the nervous system such as optic nerve, spinal cord, or the brain. So you get to see the impact of the inflammation in a lot of different ways. The most compelling part for her is how people are able to manage it and how they bounce back and continue to really live with the disease. Another piece about it is that people with MS can have really severe attacks. Jacqueline says you can help them get through that and bounce back. Ans this is something that inspires her to help patients. [05:45] Traits that Lead to Being a Good MS Specialist Jacqueline says you have to be curious about the path of MS and having interest in all the different ways you can suppress inflammation. If you're interested in neuro immunology, Jacqueline things it's one of them most interesting parts of clinical medicine today. "It's really an interesting disease to watch over the last 20 years because in the process of trying figure out ways to stop inflammation, a lot of science is being uncovered." Jacqueline was initially drawn to Epilepsy seeing how it has interesting science and mechanisms. In fact, it's more interesting now that there are certain antibodies found to be associated with refractory epilepsy. She was also interested in moving disorders, having had some of the country's best moving disorder specialties in their school. They actively engaged them into going rounds and invited them to hang out. They taught all the perils along with their fascination and passion about moving disorders. She specifically cited one of the editors of Handbook of Neurology who was their teacher - a big supporter of medical students. In fact, 10% of each class went into Neurology because of his teaching. Teachers have a huge impact in the way they bring the top of the live and how that inspires students. Anyway, she ended up doing MS which for her was workable for someone trying to raise a family. "MS was more amenable to trying to have a career and a family." [09:23] Patient Types and Over Diagnosis of MS Classic patient demographics are those between the ages of 20 and 40, women to men ratio of 3:1. However, they're now seeing much more pediatric MS. These are cases of children down to age 10. They're also seeing first time diagnosis for people in their 50's and even in their 70's going to their clinic. "It means that something about the way we live. Not for ascertainment but probably the prevalence is increasing. It also means people are living longer with MS." That said, they have a huge age range of patients at the MS clinic across the country. And by ascertainment, we're not just getting better at testing and finding MS. Instead, there's more people developing MS. And now that we have an MRI machine in every corner, it's much easier. In fact, people are over diagnosing MS. This was at a recent meetings at European Clinical Trials MS Meeting in October saying this. Spots on an MRI does not equal MS. So it's important we make sure we're following criteria and that we're able to sit with a little bit of ambiguity until we collect all the appropriate data before we tell people they definitely have MS. Three years ago, I was diagnosed with MS and it was a question of whether I have MS or was it something else. It's interesting to hear that there's a lot of over diagnosis. It seems pretty simple. It's not a test but a clinical diagnosis through the McDonald Criteria for MS. Jacqueline explains that the good thing about this criteria is we could now incorporate MRI neurological information into out decision-making. Then use that to help us proof of dissemination and space and time. Those criteria are actually being decided upon for possible revision. She adds the need to be able to have clear evidence of dissemination in space and time. Otherwise, we're going to see more people having lumbar punctures to try to find evidence of abnormalities to help substantiate this. This being said, more corroboration will be needed. There are the clinically isolated syndrome but even before that, people talk about radiologically isolated syndrome, which are spots on the MRI obtained for other reasons. And this is probably the most common reason people are having an MRI. [13:55] Percentage of Patients Already Having a Diagnosis of MS and Typical Day Jacqueline sees patients in the MS clinic as well as some general neurology patients. Most of the patients in the MS clinic have been given a diagnosis. They're asking for second opinion on the diagnosis or regarding some new treatments that may be out. "75-80% of the patients they see in the MS center already have a diagnosis. 20% wonder if they have it or are worried they might have it. But most likely, they don't have it." In the general neurology clinic, they get a lot of questions about numbness and abnormal MRIs. Some of them turn out to be MS but not all numbness equals MS and not all abnormal MRIs equal MS. A typical MS day for Jacqueline may include having a medical assistant in the clinic with them. They have an MS-certified nurse and three fellows and several MS faculty. They get people roomed. They also have two city coordinators in the clinic, who see who could be patients appropriate for studies. They have 12-14 desktops in their workroom so they can pull the MRI results there and get a lot of discussions. So Jacqueline sees 50-50 percentage of her time spent on MS versus general neurology. She also has another administrative role being the Vice Chair for Clinical Operations in her Department. She does a lot of work around access in the state of Oregon. She sees patients and learns about how they get referred in.So she's still trying to understand referral patterns, access, and improving it in every way they can. [18:06] Taking Calls in an Academic Setting vs. Private Practice In academic medicine, Jacqueline their calls to be a little different. A couple of weeks may be spent on the teaching service. Their residents are taking the call for the general neurology ward as well as the stroke service. When they're covering the neurology ward, they're not covering the stroke service. But for at least the first week of their two-week stint, they're covering the transfer service. Any doctor in the state of Oregon, and sometimes the state of Washington, Idaho, or Montana can call into HSU if they have a neurology question. Or if they have a potential transfer. They take those calls. She describes the transfer center as very organized and data-driven that they call it command control. They monitor all calls that come in. Everything's recorded. They give advice and they may follow the patient. Or if it's a critical patient, they suggest they transfer the patient and their transfer center makes it happen if there's a bed available. "Bed availability of course, is a problem at academic medical centers around the country." Moreover, they partner with other community hospitals. Some of the less acute neurology transfers might go to one of their community partners rather than all the way into the university hospital. Her calls are intermittent during the day and at night for the first week of her two weeks. They also cover 24/7. Jacqueline differentiates this from taking calls in private practice, which she did for a number of years. That would be you're on call 24/7 for a full week and you're taking primary call, mostly people you see in consultation on the same day or next. Or you get call from the ER for acute stroke or a huge hemorrhage. As a neurologist, they're consultative when they're working in private practice. At academic institutions, they typically have a neurology ward where they do their teaching. So it's a little bit different. Typically, when neurologists go out of private practice, they're strictly consultative. They're not running a ward. [21:44] Work-Life Balance Her decision to leave private practice and go back into academics was that because her kids were getting bigger, she can spend more time running papers and grants. "A neurologist spends, on average, five hours more per week outside of work doing computer back up work, five hours more per week than other specialties." Jacqueline thinks there is a demand of time that is difficult to balance with having a family. It takes resources to raise a family. So it made more sense for her to cut back when her children were younger and then when they're older, she's now able to dedicate more bandwidth to her work. At this point in her life, she considers herself busier than most people by choice considering the opportunity to take her leadership position. But she believes it's hard to achieve a balance when your children are younger. [23:55] The Training Path Typically, you can take a one-year or two-year fellowship after four years of general neurology. These are not yet funded in the same way a stroke fellowship would be funded for instance. So it's not ACGME-funded at this time. Most of their MS fellows find their funding either through pharma and other national MS society funders. They often go out and write their own application to entities that do fund. Jacqueline advises to plan this ahead of time. "Essentially for any fellowship, you've got to be ready by about PGY-2 to start thinking about it for sure." Talk to some people and places and so some electives. See if that's really what you want to do. Start to get your applications going. The training is pretty popular as Jacqueline would describe. They would receive plenty of applications for their one or two spots they take each year. She thinks the MS prevalence has increased and the number of things they can do has increased. MS was also the place where they talk about neuro immunology which has grown so much. In fact, at the American Academy of Neurology, there's not just an MS section but they now have an neuro immunology section. They call their fellowship MS under immunology but it may by at some be split off and it will be either/or. A lot of these disorders are associated with unusual antibodies. So there are different ways to think about your fellowship. [26:42] How to Be Competitive for Fellowship If you're a resident interested in MS fellowship, during your PGY-2 when you're trying to get exposed to everything, set up some electives. This way, you can spend more time to expose yourself. Second reasons is to get people to know you and like you and write letters for you. If you have a research interest which is hard to do in your PGY-2 year, but if you can think of something where you can do over your residency in that field, go ahead. Have at least some project you can submit as a poster or write a paper, a review or part of the chapter with your MS faculty. Inquire early as to what they're working on and where can you fit in. "Get to know the faculty where you are so that they can tell you what you need to do, maybe get to like you, and try to help you stay there or write letters for you." Another important thing is to try to present at meetings to help you get to see what other people are doing. Get inspired by them and that will help you determine whether you want to do the fellowship. [28:27] Bias Towards DO and Working with Primary Care and Other Specialties and Special Opportunities Outside of Clinical Medicine Jacqueline has not seen any bias towards DOs. She has worked with fellow who had osteopath training. They fit in absolutely with the other fellows. What she wished primary care providers knew is that not everything that is white spots equals MS and that not everything that is none is MS. It's important to look for other entities and exclude other entities who are writing out e-consult guidelines to help our primary care doctors. At least, they do something to work up before sending patients over to them so they can help them know and also become more efficient and appropriate with their time and who they see in clinic. "If somebody has numbness, do a good neurological exam." That's why neurology is so important in medical student education so people can start to put together all this random cranial nerves and motor reflexes. Learn that so that you can do these exams. Maybe it's a peripheral neuropathy and it's not MS. Or maybe it's a migraine and not MS. So try to get a good neuro exam to get good history if you can. Other specialties she works the closest with include ophthalmology, rheumatology, and hematology oncology. Special opportunities outside of Clinical Medicine for MS specialists include pharma aspects. People can work in the lab and direct a drug development or in clinical trial design for potential drug candidates. Then those people putting drugs to the FDA. There are people who zoomed into pharma early in the career and they get an intensive experience getting a drug through the FDA. It's a 24/7 stuff where you have your SWAT team. Others who have worked in the MS centers for many years can get scooped up and get offers to go to different pharma companies to run their different clinical development program. [33:55] What She Knew Now, Women in Neurology, and Major Changes in the Field Jacqueline says there are no guidelines being a woman and having kids. But if she had known it's going to work out then it would have been good. But she had no choice otherwise. "As I look at women today, many women are choosing to have their children in residency and somehow that all works out just fine." It's common to see women in neurology now that more than 50% of medical school classes are women. I…

Full show notes at the publisher

52: A Look at Pathology Match Data, and Lifestyle Reports Dec 05, 2017

Show notes

Session 52

This week, we're diving into the match data and cover Pathology. Interestingly, Pathology is a small field that seems to be losing interest among graduating U.S. seniors according to the data.

I'm digging into the results of the NRMP Residency Match Data 2017. As you're going through the process, you can understand what this data is telling you and what you should know to help you better plot a path.

[02:40] General Overview

Table 1 shows the match summary. Let me clarify first that the U.S. Seniors for the NRMP match data means U.S. students in an allopathic/MD program who are still in school. So a student could have graduated from an allopathic program and now applying to residency. Maybe they didn't get in the first time or took a gap year for some reason.

Caribbean students and international medical grads, foreign and U.S. citizen international medical grads are not counted as U.S. Seniors. DO students are not counted as U.S. Seniors.

Back to the data, there are 159 programs in Pathology with 601 spots. It's a very small specialty. Just to give you a comparison, Anesthesiology has 1,202 positions with 124 programs. So it has less programs but double the spots. This said, Anesthesiology has much bigger residency programs than Pathology.

Unfilled programs for Pathology is 33. It ranks up there with a lot of other programs that go unfilled. It's interesting to know why this is.

U.S. Seniors who applied are 232 out of 601 spots. Let's say out of 150+ medical schools in total, only one and a half students per medical school are applying to Pathology. So it's not a lot of senior medical students are applying to Pathology.

There are 876 total applicants for those 601 spots. Even though there were more applicants than positions, they still went unfilled. Out of the students who filled Pathology, only 36% were U.S. Seniors and 91% of all the spots were filled. Pathology does not have PGY-2 positions and it doesn't have any physician positions here.

"It's a good number of programs, but very small programs."

[06:25] Matches by Specialty and Applicant Type and Trends

Table 2 of the NRMP Match Data 2017 shows the matches by specialty and the applicant types.

Out of 601 spots in Pathology, only 545 were filled. This data is only pre-SOAP. Let's see if they filled the programs after the SOAP.

Out of the 545 filled, there were 216 U.S. Seniors who were accepted. There were 25 U.S. graduates, 32 osteopathic students, no Canadians, 57 U.S. international medical graduates, 215 non-U.S. citizen international medical graduates, and 56 unfilled spots.

Table 3 shows how many spots are available each year from 2012 through 2017. Every year, it goes up by 2.1% or 2.2%. So it's a slow steady rise in the number of spots available.

Table 8 shows us the number of positions offered and the percent filled by U.S. Seniors and all applicants from 2013 to 2017. There was a dip from 2015 to 2016. The number of U.S. Seniors that filled those spots went from 45.1% in 2013 to 42.9% in 2014, then 46.6% in 2015 and down to 42.8% in 2016, and further down to 35.9% in 2017. There's been a pretty sharp decline of U.S. Seniors filling up those spots.

"There are less U.S. Seniors who seem to be interested in going into Pathology."

Table 9 shows the number of all applicants that matched by specialty from 2013 to 2017. 2% of all students that matched, matched into Pathology. Anesthesiology is 4.1%, Emergency Medicine is 7.4%, Family Medicine is 11.6%, and Internal Medicine is 25.6%. Orthopedic Surgery is 2.6%. It's the only one that's close to compare Pathology with. Neurology is 1.7% and Medicine-Pediatrics is 1.3%.

[10:42] U.S. Seniors, Osteopathic Students, Foreign-Trained Physicians

Table 10 shows U.S. Seniors that matched by specialty. 1.2% of U.S. Seniors matched into Pathology. This is less than last year of 1.5% and less than a year before at 1.7%.

Table 11 shows osteopathic students that matched. 2.1% of all osteopathic students matched into Pathology in 2016. While it was only 1.1% in 2017. There were 51 in 2016 and 42 this year, 2017. It was 44 in 2015 (1.9%) and 51 (2.4%) in 2014, and 2.4% in 2013. So it's going down dramatically over the years.

"If you're an osteopath and you're interested in Pathology, there's another sharp decline in Pathology for osteopathic students."

Table 12 shows the foreign-trained physicians that matched by Specialty. There were 272 foreign-trained physicians who matched into a PGY-1 spot for Pathology. It went up to 4.1% in 2017 from 3.3% in 2016. But the number of U.S. trained physicians is going down.

[12:20] Unmatched U.S. Seniors and Independent Applicants Who Ranked Pathology as Their Only Choice

Figure 6 shows the percentage of unmatched U.S. Seniors and Independent applicants who ranked their specialty as their only choice.

Pathology is high up on the list for total unmatched applicants at 23.3%. That's because there's a large contingent of non U.S.citizen foreign medical graduates applying to pathology. Hence, the large percentage of unmatched total applicants. 33.5% of those are unmatched independent applicants, which are anybody other than U.S. Seniors. Only 5% unmatched U.S. Seniors.

Looking back at Table 1, there are a lot of spots for a little number of U.S. Seniors applying and yet 5% of them still were unmatched.

There could be a number of reasons why they didn't match. It could be that they didn't apply to enough programs. Or it could be their board scores were terrible. It could be that they didn't have enough research experience. It could be that they didn't have enough exposure to Pathology when asked why they wanted to be a pathologist.

That's what residency is all about. So you can ask yourself whether you can work with this person for 80 hours a week for the next four or five years.

"It's all about getting to know that person who's sitting from you on the table during the interview."

[14:40] SOAP

There were 31 Pathology programs that participated in the SOAP for 54 positions. If you look at Table 1, there were 56 positions that went unfilled. So two positions magically disappeared.

After the SOAP, there were only 22 programs that went filled and 45 spots were filled as shown in Table 18 of the NRMP Match Data. So even after the SOAP, there were 9 positions still available. In 2016, there were 14 programs for 24 spots and all of those spots were filled.

"It's telling me there are not a lot of qualified candidates for Pathology out there if these programs are going unfilled."

[15:55] Charting the Outcomes 2016

Let's go to the Charting the Outcomes for U.S. Allopathic Seniors 2016.

Looking at Table PTH-1, the mean number of contiguous ranks means how many students ranked before leaving a blank spot in their rank list.

Those who matched had 9.9 contiguous ranks. Those who did not match only had 5.1. This shows that you have to rank enough programs if you want to match. If you're restricted by geography or some other reason, you need to be aware there's a good chance you won't match because of that.

"You need to rank enough programs if you want to match."

The mean USMLE Step 1 score is 233 for those who matched and 210 for those who didn't. There's a very low Step score for those who didn't match versus those who did. Mean Step 2 score is 243 for those who matched and 225 for those who didn't. The mean number of research experiences is 2.8 for those who matched and 2.4 for those who didn't.

Mean number of abstracts, presentations, and publications is 5.9 for those that matched and 7.6 for those that didn't. Maybe they spent too much time writing abstracts and not enough time studying for the boards.

Percentage of AOA members is 13.3% for those that matched and 0% for those who went unmatched.

The percentage who graduated from one of the 40 U.S. medical schools with the highest NIH funding is 37.6% for those that matched and 12.5% for those who went unmatched.

Those who have PhD degrees have 22.4% for those that matched and only 20% for those that did not match.

[19:20] Medscape Lifestyle and Compensation Reports 2017

In the Medscape Lifestyle Report for 2017, Slide 2 shows the physicians who are the most burned out. Pathology is near the bottom at 43%. Psychiatry and mental health are the lowest at 42%.

Slide 3 shows how severe is the burnout and Pathology is near the top at 4.4. It's a random 1-7 scale and all of them are between 3.9 and 4.6.

Slide 18 shows which physicians are the happiest at work and outside of work. Pathology is pretty low for at work at 36% and 66% outside of work.

In the Medscape Physician Compensation Report 2017, Slide 4 shows the average annual physician compensation. Pathology is in the middle of the pack at $293K a year. Pediatrics is the lowest at 202K and Orthopedics is the highest at 489K.

Slide 5 shows who's up and who's down year over year. Pathology is higher up at 10% increase along with Orthopedics. Pediatrics is the only one that went down year over year.

Pathologists feel fairly compensated at 62% as shown in Slide 18. Emergency Medicine is the highest at 68%. Slide 38 shows only 76% of pathologists said they would choose medicine again. 83% is the highest with Rheumatology and the lowest is Neurology at 71%. And for those who would choose the same specialty (Slide 39), Pathology is at 85%.

Links:

NRMP Match Data 2017

Charting the Outcomes for U.S. Allopathic Seniors 2016

Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

51: What is Neuro-Ophthalmology? How Do You Become One? Nov 28, 2017

Show notes

Session 51

Dr. Bryan Pham is a community based neuro-ophthalmologist who is fresh out of training. He discuses the field and what drew him to it and so much more.

First off, please check out all our other podcasts on MedEd Media.

[01:30] Interest in Neuro-Ophthalmology

Bryan recalls having a difficult time in his neurology residency that got him disenfranchised.It was the end of his first year in neurology, which was the beginning of his second year that he had a very busy workload without a real break.

And the next rotation coming up was neuro-ophthalmology. And for him, that rejuvenated his love for medicine and for neurology.

He likes the wide variety of disease being able to see all different areas in neurology represented within neuro-ophthalmology. There are strokes that affect vision and there are movement disorders of the eyes.

My wife, Allison, is also a neurologist and I remember in her first year of neurology is her second year of postgraduate training. And then your junior of neurology, she was destroyed that year. So this is not an uncommon thing. So expect this if you're going into Neurology.

"The first year of Neurology, the PGY-2 year, tends to be the most difficult for everybody."

[03:07] Traits that Lead to Being a Good Neuro-Ophthalmologist

Bryan says that to be a good neuro-ophthalmologist, you have to take the time to think over the patient. It's a cerebral field. Not too much in terms of procedures, but he likes the mystery of patients and trying to figure that out.

Being a neuro-ophthalmologist, you're not actually operating on patients or conditions. Bryan explains that there are also neuro-ophthalmologists that do additional training in occulo-plastics.

Other specialties in the running for fellowship training, Bryan also considered neuro-intensive care. But he realized he doesn't really like terribly sick patients and the intensity of it.

[04:42] Types of Patients and Neuro-Ophtho versus Ophthalmology

Bryan describes that one-third of the brain volume is dedicated to vision. We see essentially everything that can affect vision that doesn't come from the eye itself. These could be strokes affecting areas of the brain causing vision loss as well as different abnormalities.

"Anything that affects the brain can and often does affect vision."

Bryan explains their bread and butter diagnosis is a condition called idiopathic intracranial hypertension or pseudotumor cerebri. It is where the pressure in the brain builds up that it can lead to vision loss when it puts pressure on the optic nerves causing them to swell. Nothing in the eye itself is abnormal, the problem is further. So any conditions where the eyeball itself is normal but the vision is affected would be appropriate for a neuro-ophthalmologist.

Bryan says he often gets referrals from his colleagues in ophthalmology but he also gets a few from primary care physicians.

[06:17] The Residency Path

There are two ways going to residency. One is the neurology residency and the other is an ophthalmology residency. Because it's a non-surgical subspecialty, it is an option through neurology. You do the typical neurology or ophthalmology residency and then followed by a year of fellowship in the neuro-ophthalmology. But it's a nonsurgical fellowship.

The joke in Neurology is finding the lesion and knowing the location, or localizing the lesion. But then not being able to do anything about it. In Neuro-Optho, there are also common jokes related to this.

But Bryan clarifies that there are some things that they're able to treat and cure. One example is benign paroxysmal positional vertigo.

Nevertheless, Bryan admits their subspecialty is the "diagnose and adios!"

[07:50] Typical Week and Community versus Academics

Currently, Bryan deals with 80% general neurology and 20% neuro-ophthalmology. There are neuro-ophthalmologists that do it full-time but they generally consist of essentially a full day of clinic.

There are consults they need to do in the hospital depending on the setting. In academic centers, you have more inpatient consultations.

"The nature of their subspecialty lends itself better to an academic setting just because there are a lot of ancillary testing available."

What really drew him to community versus academic setting is the absence of research. Bryan doesn't like the need to be constantly churning out research as well as the politics of climbing the academic ladder.

Bryan's typical week involves 100% clinic for neuro-ophthalmology. In his practice, the inpatient consultations are handled by the general ophthalmologist on call. And if they have any issues, they will refer them to him to be seen in the clinic.

[09:30] Taking Calls and Work-Life Balance

In terms of taking calls, during his fellowship, Bryan served through phone call. He remembers having done it twice in the middle of the month during his fellowship so it was very manageable.

The residents would call him whenever an issue came in. A typical emergency is a condition called temporal arteritis, characterized by an inflammation in the blood vessels on the side of the head. This can present vision loss or impending vision loss. This is one instance they have to act quickly to get the appropriate treatment started.

Bryan describes having a great work-life balance, more so now that he's out of training than he was in training since you'd have to be 24/7. Nevertheless, he has always thought he'd do things around the city and not have to worry.

[10:55] Neuro-Ophtho Fellowship Programs

Bryan describes there is generally one fellow a year at an institution, although some may have two. But only one program has three fellows a year. So it's a very small community. If you go to a fellowship and you're the only one, you are really are 24/7 for that year.

Bryan describes this can get better over the course of the year. Through the middle and end of the year, the residents are well-seasoned so they tend to wait until the morning to call rather than 2 am.

In terms of competitiveness, Bryan says it varies by the year. During his year, they had most of the spots filled. The following year, which is this year, they have a lot of open spots available.

"It fluctuates but certainly not difficult to land a spot."

If this is something you're interested in, Bryan's advice to become competitive is to make it to their national conference called NANOS (North American Neuro-Ophthalmology Society). Because it's a small community, everybody knows each other and so get your face out and meet the other neuro-ophthalmologists out there. Bryan thinks this is the best way to get ingrained in the field. It's all about networking, which I'm a huge believer of.

[12:45] Bias Towards DOs and Special Subspecialty Opportunities

Bryan says a lot of the leaders in NANOS come from osteopathic medical schools.

Moreover, Bryan mentions other opportunities out there to further subspecialize. Johns Hopkins, for instance, does the neuro-otology fellowship where they focus on dizziness. He further jokes that it has its own punishment. Other groups have their own niche as well such as those specialized in the people. Others focus on eye movement abnormalities and eye movement recordings. There are also those that scale in for more vision loss disorders.

[14:30] Working with Primary Care and Other Specialties

What Bryan wants primary care doctors to know is that examining people with your own eyes is important. There are things that can wait in neuro-ophthalmology so his advice to primary care docs is to not be shy about reaching out to them whenever they're concerned about any issues. If it's not appropriate for neuro-ophthalmology, they will direct your otherwise. But they're always willing and open to answering any questions.

"Examining people with your own eyes is important, no pun intended."

Just like general neurology where there is the need for the primary care physicians to know a good neuro exam, you need to know how to look at an eye or the retina. You need to get some sort of differential going. Bryan recommends resources like the online database called NOVEL (Neuro-Ophthalmology Virtual Education Library). They have examples of all the things you need to read about going to medical school.

Other specialties they work the closest with are neuro-surgery, neurology, and ENT. Special opportunities he sees outside of clinical medicine would be clinical trials. You can look into treatments for some of these neuro-ophthalmic diseases. It's mostly clinical practice as the end game.

[18:50] What He Wished He Knew and What He Likes Best About the Field

Although he is still relatively new to this, there is an end game. During his fellowship where he'd like to call it quits, he was glad he didn't at this point.

What he likes about being a neuro-ophthalmologist is the variety of cases. There's a little bit of different areas in neurology in neuro-ophthalmology. So everyday, there is something new to learn, specifically the continuity of patients. What he likes the least, on the flip side, is the charting.

In terms of any major changes that he sees in the field, it's still a relatively new subspecialty. So he feels there are two peaks for the neuro-ophthalmologists practicing out there. The first generation is starting to get through their retirement now. And there's this newer generation that's coming through. This said, there will be a lot of turnover in terms of the field. They will be losing a lot of their mentors. Nonetheless, he doesn't think this will change the practice of neuro-ophthalmology.

"There will be a lot of turnover in terms of the field. We will be losing a lot of the mentors that we had."

If he had to do it all over again, Bryan would still choose the same specialty. Finally, Bryan leaves with some words of wisdom.

He recommends students to come to a neuro-ophthalmology clinic and check it out. He never thought about it before his rotation. And here he is now!

[18:40] Last Thoughts

I actually didn't know that the majority of neuro-ophthalmologists out there were diagnostic physicians. They don't operate. When I think of ophthalmology, I think of a surgical subspecialty. But when you add that neuro on the front of it, then you lose the surgical part of it and you don't get that training.

Finally, please share this podcast in your Facebook group for your class (if you have any) or if you have some sort of email list or email group. Please let them know about this podcast.

If you know anybody who is a physician and should be on this podcast, shoot me an email at ryan@medicalshoolhq.net and we will make it happen.

Links:

NANOS (North American Neuro-Ophthalmology Society)

NOVEL (Neuro-Ophthalmology Virtual Education Library)

ryan@medicalshoolhq.net

MedEd Media

50: How Can Breastfeeding Medicine Fit Into Your Practice? Nov 21, 2017

Show notes

Session 50

Dr. Kristina Lehman is a Med-Peds doc who specializes in Breastfeeding Medicine, helping new moms and new babies through the struggles of breastfeeding.

Check out all our other podcasts on MedEd Media. If you're a med student and you want to be prepared for what's coming, we have a boards podcast coming up for Step 1 and probably Step 2 in the future.

Back to today's episode, Breastfeeding Medicine is one of those fields that really gets down into a "super" niche which is pretty awesome. Kristina is a Med-Peds doc who has taken some further specialty training being a breastfeeding physician.

While the breastfeeding side of her practice only comprises about 25%, still this is worthwhile to talk about as a stand alone podcast. This will give you the information you need if this is something you're interested in. Out of training now for about ten years, Kristina is practicing in an academic setting.

[02:13] Her Initial Interest in Breastfeeding

Kristina's interest in breastfeeding sparked when she had her first child. She always knew she would breastfeed and when she had her baby, she thought she had no idea what she was doing.

So she began researching until she just grew more passionate about it. But the turning point for her was when she discovered the Dr.MILK group, a breastfeeding group. MILK stands for Mothers Interested in Lactation Knowledge. She realized there were people out there who actually are pediatricians and lactation consultants.

Before this, her training focus was in internal medicine and pediatrics. She did a med-peds residency. Coming out of it, she wanted to do primary care and she started in an academic setting. She joined the faculty at where she trained to do Med-Peds Primary Care.

[04:00] Lack of Coverage on Breastfeeding During Pediatric Rotations

Kristina explains that a lot of times, experiential learning comes down from our attendings. Because doctors don't do a great job at breastfeeding, they're not likely to advise their patients well, too. To add to that, there is a lot of formula marketing in pediatric residency. A lot of the AAP stuff is sponsored by these companies.

"We know that doctors don't necessarily do a great job breastfeeding themselves. And that when they don't do a great job, they don't advise their patients very well."

That said, AAP now has a curriculum where they recommend breastfeeding but still it's not widespread. Also, there are a lot of issues with breastfeeding in terms of other specialties telling that infectious disease antibiotics are not compatible with breastfeeding. So when a mom has a complication, she has to stop breastfeeding or pump and dump. Kristina thinks doctors should just really go back to medical school.

[05:40] Traits that Lead to Being a Good Breastfeeding Medicine Doc

Kristina cites the primary things to be a good breastfeeding doc are wanting continuity of care, being a good listener, and wanting to know what's going on. Kristina says the need to integrate and see what's happening to both the baby and the mom. Think about what's going to be best for both of them.

"You can sit there and talk about what's really important for the baby but then that can lead mom to the wayside."

Kristina adds having good problem solving skills is helpful. More importantly, you have to be interested in women and women's health. You shouldn't be afraid of breasts since the breasts are a big part of the practice. She admits there are people that are actually scared of that a lot of times.

Kristina says that are male lactation consultants. It's obviously a female-dominated field. But if you're a guy and you're super interested in helping women then it's like male OB/GYNs. There are a lot of women that see male OB/GYN and they have a good reputation.

[07:37] Other Specialties that Caught Her Interest

Before going to Med-Peds, Kristina was interested in OB/GYN. She loved prenatal visits and all the outpatient stuff that goes with it. She hated surgery and being up at night. So she realized quickly that it wasn't the right specialty for her. That said, she has always been interested in the women's health aspect of things.

Within primary care, she was happy just to do straight up primary care. She loves the variety of seeing both kids and adults. And when she found Breastfeeding Medicine, she was happy she had the opportunity to focus on the academics. She was happy she could get to work on it with medical students and residents. She had the opportunity to work on curriculum development.

[08:30] Types of Patients and Taking Calls

On a daily basis, she deals with regular breastfeeding stuff. She's able to give more evidence-based information and more support for the day-to-day latch and milk supply. When she has a more specialized referral, she gets varied cases. For example, a baby that hasn't latched since birth. Or it could be a baby that was in the NICU so he/she was formula-fed so they have a hard time getting back to the breasts.

Sometimes too, moms are having a hard time with milk supply so she helps them troubleshoot how to make this better. Although there are really moms that have insufficient glandular tissue which never developed from puberty so there isn't enough milk supply. She also deals with other issues like cracked and bleeding nipples or mastitis.

"Most of the stuff is just the day-to-day maintenance of breastfeeding that moms just need a lot of support."

Kristina doesn't do any of the inpatient stuff such as taking calls. But she wishes sometimes though that there was somebody on call. They recently had a mom that had a wound infection. She was in the hospital and got switched around in antibiotics, specifically Cipro. The doctors on the service talked to the pharmacist and the pharmacist said it wasn't okay to breastfeed with it. They told the mom that she had to pump and dump. And so for ten days, she had to pump and dump. Then the mom came to her a bit later. But they would have been able to take care of that early on. She didn't actually need to pump and dump since there was no indication for that.

Moreover, mastitis would be an urgent thing but not necessarily too urgent for you to really drive to the hospital just to see it.

[11:10] Erring on the Side of Safety

Kristina explains there's a lot of stuff that says benefits outweighs risks. But very few places actually consider a mom's plasma level and what level gets into the breastmilk. Therefore, how much is the baby ingesting and how much of that ingested amount would the baby absorb into their bloodstream?

There is the infinite risk center run by a pharmacologist that has gone through all this. But doctors prefer to err on the side of safety. But Kristina points out there is more risk of clogged ducts and mastitis if you're pumping. Throwing milk away is just heartbreaking too. There is also the risk of that formula to the baby if the baby is formula-fed.

"Basically, nobody feels comfortable with the information that is out there saying it's okay to breastfeed."

[12:37] Work-Life Balance

Kristina describes having a good work-life balance. Her husband is also a hospitalist in internal medicine. So financially, they're in a good spot but they're also busy. They have two kids. She started full-time and as they're having kids, she has worked herself down to 50%. Currently, she's working herself back up with some nursery work. Nevertheless, this has allowed her to have some good work-life balance.

Similar to primary care, you're not on call and you're not going to the hospital necessarily. It's mostly an office-based work.

[13:24] What It Takes to Become an IBCLC

Kristina notes that to become an International Board Certified Lactation Consultant (IBCLC), there is an international exam that anyone can take. But there are different pathways depending on your background. The nurse or a doctor has a different pathway than a lay person off the street that wants to get it.

It requires some health and science background classes. As a doctor. you have to do 90 hours of lactation coursework. And you have to have a thousand clinical hours. Fortunately, those aren't supervised. So if a OB/GYN wants to become an IBCLC, they can use the time they talked for prenatal and postnatal counseling. Their hospital rounds can count too if they took care of mastitis or if they've worked with support groups. All those hours can add up.

Once you have those hours, you take the exam and then you're given this gold standard of certification. You're reputable and the community is having that level of knowledge and experience.

Another program is the Healthy Children Project, the certified lactation counselor. And this is how Kristina actually got her start. She did a 40-hour course. You do an exam and then do a little certification.

"Technically, anybody can do it. It's just having that evidence-based information. Make sure you're learning the right stuff."

There's also the Academy of Breastfeeding Medicine that has the fellowship track where you get an FABM designation. They're also working on a more clinical-based fellowship in the future.

Kristina also adds getting knowledge from mentorship and working other people and getting those other certifications.When it comes to billing, Kristina bills not as a lactation consultant but as a physician.

[16:20] Working with Primary Care and Other Specialties

Again, Kristina recommends making sure that what you know is evidence-based. See if there's somebody in your area that is more specialized. See if they're listed on the Academy of Breastfeeding Medicine's website or there's a doctor in town that's IBCLC. This way, you know who to refer to if you're having issues. Secondly, it's nice to reach out to them and talk about it especially if you have any questions.

"Search out that extra bit of training so you can be the best resource for your patients possible."

Other specialties she's working with are ENT and Peds in Dentistry. Kristina says it's nice being trained both in internal medicine and pediatrics since she's self-sustaining. She can take care of the mom and the baby.

But if you're a pediatrician and doing breastfeeding medicine, you'd probably be working with internal medicine or OB counterpart to help you with some of the mom stuff. Conversely if you're an OB/GYN, you'd have to work closely with pediatricians to take care of the peds stuff.

Other special opportunities outside of clinical medicine would be academia and research. They sponsored fourth year medical students to do some pre-residency lactation work. She also worked on the curriculum development for the interns in the pediatric residency. She does nursery rounds so she does teaching there.

Research-wise, there are a lot of opportunities in terms of curriculum and teaching development and the biochemical science behind breastfeeding.

[18:55] The Most and Least Liked Things About Breastfeeding Medicine

Kristina has been so enriched with the experience personally that bringing it on to other moms is helpful. She likes the fourth trimester concept when they help moms realize that those first couple of months of motherhood are really overwhelming and exhausting. So being able to support moms through that is enriching for her. She likes watching those kids grow and develop and the parents become parents and learning the parenting kinds of things.

"For me, the biggest things is helping those moms meet their goals and raise cool kids."

On the flip side, she finds it frustrating how little other people understand about the field. When people do or say things along with their lack of knowledge can affect how they take care of patients.

[20:17] Major Changes in Breastfeeding Medicine

Kristina hopes they can get a more dedicated fellowship or clinical track for this niche. We are in the day and time when breastfeeding is becoming more than the norm. So moms are initiating a lot more and are being more successful. Along with that, we see more moms struggling or having issues that need the support. Unfortunately, Kristina admits the lack of infrastructure for them at this point in time.

Things have definitely been a lot better. But she hopes to continue to see more changes with that like paternity leave for instance.

[21:20] Breastfeeding versus Formula-Feeding

Kristina points out that it's important to let moms know that there are going to be challenges and they need that support system. So find that support system and make sure you know what your resources are. She often tells parents to never give up on their worst days. Reach out for help when you need it.

"I often tell parents too, never give up on your worst day. You're going to have bad days. You're going to have bad moments."

Breastfeeding also has a lot of health benefits for moms that we don't usually look at. It actually reduces the risk of breast cancer, diabetes, heart disease, hypertension, multiple sclerosis, etc. So there are lots of benefits for moms as well. So there should also be a focus not just on the baby but also on moms.

[22:35] Final Words of Wisdom

If this is something you're interested in, Kristina recommends checking out the Academy of Breastfeeding Medicine. They have a great website with a lot of great protocols there which are evidence-based.

If you're a woman and interested in this, look up Dr.MILK group. They have over 10,000 members on Facebook. They welcome even those who are not breastfeeding but just want to learn more about breastfeeding.

Lastly, be open to the fact that you may not get a lot of training about this but it's super important and there are opportunities out there to learn more.

Do you have any ideas for specialties or if you know any physician whom you think would be great guest on this podcast, shoot me an email at ryan@medicalschoolhq.net.

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Specialty Stories

Session 58

[01:54] Her Interest in Movement Disorder

[05:15] Traits that Lead to Being a Good Movement Disorder Specialist

[06:40] Types of Patients and Cases

[10:55] Academic versus Community versus Private Practice

[12:40] A Typical Day - The Parkinson Buddy Program

[15:50] Work-Life Balance and the Residency Path

[19:36] Negative Bias Against DOs and Special Opportunities

[20:38] How Deep Brain Stimulation Surgery Works

[23:58] Working with Primary Care and Other Specialities

[27:55] What She Wished She Knew and Major Changes in the Field

[33:55] Last Words of Wisdom

Links:

Session 57

[01:03] His Interest in Critical Care Medicine

[04:55] Types of Patients

[09:15] Typical Week

[10:35] Is It Procedure-Heavy?

[12:00] Work-Life Balance

[13:45] The Training Path

[17:24] Negative Bias Towards DO Physicians and Special Opportunities

[20:10] Working with Primary Care and Other Specialties

[23:40] What He Wished He Knew that He Knows Now

[25:20] What He Likes Most and the Least and Major Changes in the Future

[29:30] Personal Takeaways

Links:

Session 56

[02:30] Match Summary for 2017

[06:45] Summary of Students: U.S. Seniors, U.S. Grads, IMGs, Osteopaths

[09:22] Yearly Trends

[12:35] Unmatched U.S. Seniors and Independent Applicants, SOAP

[14:00] Charting the Outcomes 2016

[17:23] Ranking by Specialty and Step 1, Step 2 Scores

[20:21] Scores, Research, Publications, AOA

[22:27] Burnout Rates and Compensation

Links:

Session 54

[01:07] An Interest in OB/GYN

[03:47] Traits that Lead to Becoming a Good OB/GYN

[05:18] Academic vs. Community Setting

[06:37] Types of Patients, Typical Day, and Taking Calls

[09:45] Percentage of Patients in the OR

[10:44] Work-Life Balance

[11:25] The Training Path to Become an OB/GYN and Competitiveness

[14:35] Bias Towards DOs and Working with Primary Care and Other Specialties

[17:02] Special Opportunities Outside Clinical Medicine, What She Wished She Knew, and the Most and Least Liked Things

[19:20] Major Changes in the Field of OB/GYN and the Future of Residencies

Links:

Session 52

[02:40] General Overview

[06:25] Matches by Specialty and Applicant Type and Trends

[10:42] U.S. Seniors, Osteopathic Students, Foreign-Trained Physicians

[12:20] Unmatched U.S. Seniors and Independent Applicants Who Ranked Pathology as Their Only Choice

[14:40] SOAP

[15:55] Charting the Outcomes 2016

[19:20] Medscape Lifestyle and Compensation Reports 2017

Links:

Session 51

[01:30] Interest in Neuro-Ophthalmology

[03:07] Traits that Lead to Being a Good Neuro-Ophthalmologist

[04:42] Types of Patients and Neuro-Ophtho versus Ophthalmology

[06:17] The Residency Path

[07:50] Typical Week and Community versus Academics

[09:30] Taking Calls and Work-Life Balance

[10:55] Neuro-Ophtho Fellowship Programs

[12:45] Bias Towards DOs and Special Subspecialty Opportunities

[14:30] Working with Primary Care and Other Specialties

[18:50] What He Wished He Knew and What He Likes Best About the Field

[18:40] Last Thoughts

Links:

Session 50

[02:13] Her Initial Interest in Breastfeeding

[04:00] Lack of Coverage on Breastfeeding During Pediatric Rotations

[05:40] Traits that Lead to Being a Good Breastfeeding Medicine Doc

[07:37] Other Specialties that Caught Her Interest

[08:30] Types of Patients and Taking Calls