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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:

48: What Does the Pediatric Residency Match Data Look Like? Nov 07, 2017

Show notes

Session 48

Pediatrics is a primary care specialty. Usually, primary care spots are easy to match into. Does pediatrics keep up the trend? We’ll dig into their data.

The reason for this episode is to give you an idea as to how hard or easy it is to match into a specific specialty. I'm getting all of this data from the NRMP Match Results and Data for 2017.

An overview: When you're in medical school, you apply to match into residency in the U.S., through an algorithm-based system. The three people who created this algorithm won a Nobel Prize for it.

It's not a usual job application where you apply to 40 places, get interviewed in all of them. Then whoever wants you offer you something you say yes or no. With residency matching, you rank based on what programs you like. And the programs will also rank based on who they like. And the magic happens.

[02:47] General Summary of the NRMP Match Results and Data for 2017

Table 1 of the NRMP Match Results and Data for 2017 shows the general summary. Pediatrics for categorical slots have 204 programs and there are 2,738 different positions available.

"Categorical means you are going for all three years to that program."

They have a pediatrics preliminary (PGY-1) slots. So maybe for those who didn't match into a categorical, you can apply for a preliminary slot to make sure you're going somewhere. In this episode, we're covering mostly categorical.That means you're applying to one program for all three years for your pediatric residency.

Comparing it with other specialties, Family Medicine has 520, Internal Medicine has 467, Psychiatry is 236. So there are more psychiatry programs than there are pediatric programs. Surgery is 267.

Number of unfilled programs based on Pre-SOAP. SOAP is the Supplemental Offer and Acceptance Program. The students who match in SOAP are not counted in this chart here. There were 13 programs that went unfilled in the 2017 match. That means they have at least one spot left.

Out of 2,738 positions offered, there were only 2,056 U.S. Seniors applying for those programs. So almost 700 spots available for U.S. Seniors assuming your qualified for the spot. This does not count the number of DO students applying for these programs or the number of international medical graduates. The total number of applicants is 3,763 so there are a thousand more applicants than there are spots available and about 700 less Seniors. This implies that there are a lot of international graduates likely applying for the spots.

"This is an MD data. The U.S. Seniors in this chart means students at an allopathic medical school."

Of those that matched, there were 1,849 U.S. Seniors. There are still 200 U.S. Seniors that applied and did not match. Why? There could be several different reasons for that. Their board scores were terrible. Pediatrics is not a board-heavy specialty but it doesn't mean you can bomb your boards and match. Or maybe they're a bad interviewer or didn't apply to enough programs.

Again, 700 fewer U.S. Seniors were applying for the spots but a thousand more total applicants than there were spots available.

[08:50] Table 2: Matches by Specialty and Applicant Type

Table 2 of the NRMP Match Results and Data for 2017, out of 2,738 positions, number filled 2,693. That's 45 spots that went unfilled. U.S, Seniors that matched were 1,849. So there were 889 left for other applicants. 24 went to U.S. Grads.

Again for this data, U.S. Seniors are students who are currently at an allopathic medical school. A U.S. grad is somebody that's already graduated from an MD-granting medical school. These could be students who didn't know what they wanted to do so they did more shadowing or research. Or these could be former students who didn't get in previously.

Moving on, there were 361 allopathic students that got into a Pediatrics (Categorical) residency and two students were Canadian. It doesn't mean a Canadian at a U.S. school means a Canadian graduate. When you look at the overall numbers, only 7 total Canadian graduates got into a PGY-1 position and two of them went into Pediatrics.

There were 204 U.S. IMGs (International Medical Graduates). This is somebody who's a U.S. citizen who went to an overseas school - the Caribbean, Israel, Australia, Scotland, or wherever that may be. And 253 were non-U.S. citizen international medical graduates. Lastly, there were 45 spots that went unfilled for the Pediatrics (Categorical) rotation.

"Good for allopathic and U.S. IMGs since there's still a big opportunity for you to go into Pediatrics."

[12:13] Trends in the Match Program (2013-2017): Growth, PGY-1, Osteopathic Students

Pediatrics is growing pretty substantially to about 10% every year from 2013 to 2017. 2013 started off at 2,616 and there were 2,738 in 2017. It's between 9.5% and 10% growth year after year.

Figure 5 of the NRMP Match Results and Data for 2017 shows just how big Pediatrics is. Internal Medicine has the most positions offered followed by Family Medicine and Pediatrics is third at 2,821 and 2,775 of those were filled, and 1,880 were filled by U.S. Allopathic Seniors.

Table 8 shows the Percent Filled by U.S. Students and All Applicants. In 2017, 67.5% were filled bu U.S. Seniors. And in 2013, 70.2% were filled. It has gone down a little bit for the last couple of years. It's not a huge shift but it's showing you that it's roughly the same every year.

"When you look at the average total PGY-1 slots being filled by U.S. Seniors, 60.6% is the average based on all of them."

Table 9 shows that 9.7% of all applicants matching into a PGY-1 specialty are categorical Pediatrics. Just for comparison, Family Medicine is 11.6%, Internal Medicine is 25.6%, OB/GYN is 4.7%.

Table 11 shows that 12.3% of all osteopathic students an allopathic PGY-1 position program match into Pediatrics. Family Medicine is 19.6%. 23.5% of osteopathic students match into Internal Medicine.

[16:37] % of Unmatched U.S. Seniors and Independent Applicants and SOAP

For this data, independent applicants refer to IMGs and osteopathic students. For Pediatrics, the total unmatched is 12.4%. The unmatched independent applicants is 30.5%. It's very heavy with independent applicants. Unmatched U.S. Seniors is only 2.3%.

In comparison with other specialties, Internal Medicine/Pediatrics shows 0.5% of U.S. Seniors are unmatched. Surgery (Prelim) is 1.3%. Surgery-General is 9.6%. Neurosurgery at 10.4%; Orthopedics at 15.1% for unmatched U.S. Seniors. So pediatrics is relatively low as you would expect.

Table 18 shows the programs and positions filled in the SOAP program. SOAP (Supplemental Offer and Acceptance Program) is for students who didn't match in the first go round. This used to be called Scramble.

There were 12 programs in Pediatrics that did not fill and participated in the SOAP program. 44 positions were available and all spots were filled through the SOAP program.

"In Table 2, it looks like there's unfilled spots. But that doesn't count the SOAP and filling those spots through the SOAP."

[18:44] Charting the Outcomes in the Match 2017: Apply Broadly

Now, we dig into the Charting the Outcomes in the Match for U.S. Allopathic Seniors in 2016. It displays the information a little bit different so it's very interesting to look at.

Chart 4 shows the Median Number of Contiguous Ranks for U.S. Allopathic Numbers. For Pediatrics, students who did not match only have 3 programs contiguously ranked. While those that matched ranked 12 programs.

"This is going to be the theme of matching or not matching for every specialty. You need to rank enough programs to match."

This being said, you cannot be super selective with programs where you're applying to match. You have to apply broadly. Just like medical school where the average number for the AMCAS applications is 14-15 as well as for DO schools. The same goes for your rank list when applying for residencies. The biggest mistake you can make is not ranking enough programs.

Chart 8 looks at the Mean Number of Research Experiences for U.S. Allopathic Seniors that matched and did not match. The numbers are almost identical - 2.4 for those who did not match and 2.5 for those that matched.

Chart 12 shows the percentage of U.S. Allopathic Seniors who are members of the AOA. In pediatrics, 16% of the Seniors that matched are members of AOA (Alpha Omega Alpha), the U.S. MD Premed Honor Society for Medical Students. In comparison with other specialties, Dermatology is 53%, Plastic Surgery at 52%, and ENT at 45%.

"AOA is very much tied to the more competitive specialties."

[22:44] Mean Number of Contiguous Ranks, USMLE Step 1 and Step 2 Scores

Still looking into the Charting the Outcomes in the Match for U.S. Allopathic Seniors in 2016, PD-1 (Page 159 of 211) shows the summary statistics on U.S. Allopathic Seniors for Pediatrics.

The mean number of contiguous ranks for those that matched is 11.9 and for those that did not match is 4.0. Again, you have to rank enough programs.

Mean USMLE Step 1 Score is 230 for those that matched and 207 for those that did not. Mean Step 2 Score is 244 for those that matched and 224 for those that did not match.

Graph PD-1 (page 161 of 211) shows the curve of the probability of matching which is around 64% if you only ranked one program. 70% for two programs. Roughly 75% for three programs. 83-84% for four programs. The more programs you rank, the better your chance will be, even up to a 100% of matching at around 13 programs ranked.

[24:14] Medscape Lifestyle and Physician Compensation Reports 2017

The Medscape Lifestyle Report 2017 looks at which physicians are most burnt out. Slide 2 shows that Pediatrics is right above the halfway point at 51% with Emergency Medicine as the highest at 59%.

As to how sever the burnout is, Slide 3 shows that Pediatrics is on the lower end at 4 on a scale between 1 as the lowest and 7 as the highest. Which physicians are the happiest? Slide 18 shows Pediatrics is higher up at 36% happiest at work and 70% happiest outside of work.

Based on the Medscape Physician Compensation Report 2017, Slide 2 shows that overall, Specialties earn $316k while Primary Care (where Pediatrics is a part of) is $217k. Who has the highest average annual physician compensation? Slide 4 shows that Orthopedics is at $489k and Pediatrics is the lowest at $202k.

If you've listened to our previous episodes where we talked to pediatric specialists, on average, they say they're always paid less than their adult counterparts. It's still a great salary though.

"On average, they all say that pediatric specialties are always, always, always paid less than their adult counterparts."

Slide 5 shows Who's Up, Who's Down and Pediatrics is the only one that went down by 1%. Interestingly, even though Pediatrics is the lowest paid specialty, more than half of the physicians feel compensated at 52% as presented in Slide 18. In Emergency Medicine, 68% of them feel fairly compensated while Nephrology is the lowest at 41%.

Would you choose medicine again? Slide 38 of the Medscape Physician Compensation Report 2017 shows that the highest is Rheumatology at 83% and the lowest is Neurology at 71%. Pediatrics is at 78%, right in the middle of the pack with everybody else.

Slide 39 shows who would choose the same specialty again. Dermatology is the highest at 96% where they say they would choose the same again and Internal Medicine is at the lowest at 64%. For Pediatrics, 81% of them say they would choose the same specialty again.

[27:44] Final Thoughts

If you're interested in going into Pediatrics, these are great information to figure out what you want to do with your career moving forward.

Additionally, if you know a physician that you want me to talk to, shoot me an email at ryan@medicalschoolhq.net. I'm always looking for a guest for this podcast. If know someone on Facebook or Instagram, reach out to them and let them know about me. Put us in contact.

Links:

NRMP Match Results and Data for 2017

Charting the Outcomes in the Match for U.S. Allopathic Seniors in 2016

Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

ryan@medicalschoolhq.net

47: What Does Vascular Surgery at an Academic Setting Look Like? Oct 31, 2017

Show notes

Session 47 Dr. Westley Ohman is an academic Vascular Surgeon in the St. Louis area. We discuss why he chose academics, what makes a good vascular surgeon and more. Good news to all premeds out there! We have a new podcast called Ask Dr. Gray Premed Q&A. Or if you know someone who's a premed, point them to the podcast as well as all our shows on MedEd Media. [01:54] Interest in Vascular Surgery Westley had exposure to vascular surgery from an engineering standpoint as an undergrad. But it wasn't until late in his third year and going into his fourth year with his sub-I's that he had world-class mentors from the cardiac and vascular side of things. He was fortunate enough to be guided in his decision making. They supported him going into vascular seeing that's where his interest and his skill set lie more than on the cardiac side. He likes the interventional approach where you can treat aneurysm in one room with two small needle pokes in the femoral arteries and then patients go home the next day. Then in the next room, you can be doing an open aneurysm and the patients can stay for a week. You're deciding which patient benefits from which and really try to master both open and endovascular surgery. Westley is fortunate enough to where his mentors would let him manipulate the wires when it was safe to do so even as a medical student. So his appetite only went from there. Other specialties in the running as he was going through his sub-I's were cardiac surgery and cardiac interventions which he found interesting. But he can't explain but the technical aspects of doing a fenestrated aneurysm appealed more to how he approaches problems and think about things. He also thought about neurosurgery more on the endometrial neurosurgery as opposed to true neurosurgery. [04:50] Traits that Lead to Becoming a Great Vascular Surgeon Westley sees spatial reasoning more so than any other surgical discipline. They do open surgery anywhere in the body. So you have to understand not just where the blood vessel runs but where's the nearest muscle insertion or origin. Understand how you're going to be able to tunnel your bypass graft or how you're going to get exposure to that artery. And in the belly, understand where the important organs live as well as be able to manipulate the space in terms of where you're going to run your bypass. "I really demand for technical precision. Vascular surgery has a way of humbling you." In short, you have to know every inch of the body to be able to successfully operate on somebody. He even jokes in medical school that he's a practical radiologist. They know the anatomy from looking at pictures, but this is his practice on a daily basis. [07:00] Types of Patients and His Decision to Stay in the Academic Setting A big portion of the patients they're treating are the end stage renal patients. They do access creation or maintaining functional access through dialysis or revisions. They also treat peripheral arterial disease that comes along with the disease brought about by end stage renal disease. Your average VA patient encapsulates a lot of vascular surgery from a general standpoint. They're the smokers, the diabetics, the ones that don't necessarily take the best care of their body. So they get peripheral arterial disease or aneurysm. But from an academic standpoint, he also gets a lot of the referrals for infected endografts, aneurysms, in and of themselves. As to his thought process behind choosing academic versus community setting, he looked at jobs for both academic and community settings. One of the things that made him stay in the academics was a job available for him. When you're going through looking for a job, the academic jobs are always posted about 4-5 months after the private practice jobs. "No one truly knows when an academic job is going to pop up because of the difference in funding cycles." The complex endo interventions entail pushing the limits of what they can do from an interventional approach or minimally invasive approach while still doing right to a patient. It's very easy to do something to a patient but determining if it's the right way to do it. They also have to consider limiting the physiologic stress on aortic surgery patients. And this is what kept him in the academics. Moreover, he has always wanted to be a big aortic surgeon having found the disease processes in terms of aneurysm and dissections fascinating. And a lot of the smaller hospitals and mid-sized hospitals just don't have the resources to support the very sick and very challenging patient population. Westley clarifies it's not the fault of the hospital. It's just not their mission or their buildup. And it takes a very specific type of place to do it which he always saw himself doing as a surgeon. [11:10] Percentage of Patients, Typical Day, and Taking Calls Westley says two-thirds of his patients come in already diagnosed with a caveat. If he'd do thoracic outlet syndrome, they have one of the biggest, if not the biggest, thoracic outlet syndrome referrals in the country. Nearly 100% of those patients come in with a diagnosis in the ballpark. But for the remainder of his patients, he will get referrals from the hematologists or the rheumatologists. Once you get outside of the pure simple cases, you see patients in end stage renal disease and they need access or they've been smoking and they have peripheral arterial disease. So there are a lot of esoteric diagnoses they made in an interdisciplinary process. "There are days in my clinic where the diagnosis is made for the patient before they get there." This said, 25%-33% of his patients are usually an interplay between himself and another consulting physician where they bounce ideas off each other. But a lot of his diagnosis are not made from subtle physical exam findings. They're important but they're a more imaging-driven specialty. Westley can't say there is a typical day for him, which has been a selling point for him. But if he's on call at a major center, he could get a ruptured and aortic aneurysm and go do that. While he could also deal with a gunshot wound to an extreme median having to figure out how to reconstruct or what conduit to use. But it's very easy to start your day with one procedure and then going to a different procedure. And then you bounce back upstairs to either do bypass or belly revascularization. Outside of clinic days, he doesn't really know what comes his way. Because even if he's not on call, if they happen to get swamped and being pulled into other cases. So being able to be flexible and offer the full toolkit really allows his day to be as variable as the hospital needs him to be or as he wants it to be. He takes one and a half days of clinic per week so he basically spends more time in the OR or the cath lab or the interventional suite. Westley describes being one of those rare groups with ten partners, nine of which will take call. So it ends up being a one in eight or so calls. He'd be on call a weekday, usually every other week. Then he'd have a weekend call every other month. For him, this is better than it was when he was in training. Outside of those large groups, it's easy to be in a Q3, Q4 call. That said, he's in a major referral center so although it's an infrequent call, it's still a very busy call. Half of his calls, he's operating most of the night, if not all of it, and still running the full day the next day. And the other half, he's interacting with the referral line or fielding inpatient consults that don't necessarily need to go to the operating room. But students should expect that there are going to be emergencies going into vascular surgery. Not a lot of their cases is that when something goes wrong can be sit on until the next morning. "Going into vascular surgery, there should be the expectation that there are going to be emergencies." [16:52] Work-Life Balance Westley still finds having life outside of the hospital. He's married to a fourth year general surgery resident. They have a toddler and two dogs. It's tough. But since he's finished training, their life has gotten significantly better. Regardless of what his wife is doing, he has time for what he wants to do in terms of family and career. It's about finding that right balance and for them, that right balance is a wonderful nanny who helps them out. This allows them to stay in the hospital late on a rare night that you need to. [18:03] The Training Path to Vascular Surgery Westley explains that there are two routes. One is the traditional two-year fellowship after a five-year general surgery program, known as the 5+2. There's also the 0+5, which is 5 years of some amount of general surgery and a lot more vascular surgery. His program did it half and half for the first three years and the last two were only vascular, This allows you board certification only in vascular surgery. From this, you can go on to do fellowships in cardiology or critical care to augment what you can offer. Westley comes from a 0+5 program where he could whatever he wanted anywhere in the body that he needed to be. I don't think either pathway is the right way. I don't think there's a wrong way to go. He noticed that his co-fellow who came from general surgery training when he started his fourth year, was more comfortable in the belly. But by the end of it, they were roughly equivalent. And he felt he had stronger interventional or endovascular skills. That because he didn't learn laparoscopy whereas he did. "It really takes some soul searching from the student as to which pathway they think is best for them." According to Westley, all of his friends who have done general surgery and the vascular don't touch a laparoscope. And in fact, he's more likely to touch one than they are just by accident. Regardless of the setting, Westley stresses the importance of the quality of the training program. There are 5+2 programs that will prepare you for a very successful private practice. And there are some 0+5 that will prepare you for a very successful academic, doing the big cases and vice versa. He thinks that each program has its own individual strengths. When he sat down six years ago to make his rank list, his first three were integrated programs and his fourth was general surgery. He would recommend students to figure out what you want from there and what you want your life to look like. They may not know that and think 5+2 is the way to go since they have their general surgery to fall back on. It's not a bad decision. But it's a mindset that a lot of vascular surgery is moving more towards 95%-100% vascular surgery. This is because of what they can do and how they can do it expanding every year. In terms of competitiveness, Westley describes it as fairly competitive. He thinks there are slightly more applicants than there are spots. And in terms of the 0+5, when he applied, it was more competitive than dermatology. They still have 80 programs per one spot per year and they interview about 20-25 of them. And for the fellowship, the numbers are a little smaller. A big debate going on is that a lot of the 0+5 programs were born out of the big academic centers. Michigan was the first to have it as well as Pitt and Dartmouth, which are big names in vascular surgery. At WashU, they keep both pathways open. They're committed to matching one for each pathway per year. Part of that is having complementary learning that makes for a better learning environment. Then there's always the big academic centers that don't have the 0+5. And the biggest leaders in vascular surgery right now say they will hopefully never have a 0+5 at their program. So even though it's been out for almost a decade now, it's still a very polarizing topic for some of the very senior people in the discipline. [23:50] Advice to Students to Become Competitive Just like for everything else, Westley says it comes down to having a reasonable Step 1 score. It's going to be a very easy, quick, and dirty screening outlet. Another thing is that vascular surgery being a small field, doing a sub-I is absolutely critical. This allows you to get your name in the door in different places. And if you can, you get letters and phone calls fro not only your home institution, but other institutions as well. So this goes a long way towards building a competitive application. Especially at 0+5 level, it shows exploration and an interest. There are also people falling out of the pathway and having an empty spot for the next x number of years where you're supposed to be training. Being able to show you know what you're getting into goes a long way. This is something they look for when they're interviewing applicants. "Vascular surgery is a very small field and I think more so than general surgery...doing a sub-I is absolutely critical." [25:30] Bias Against DOs and Subspecialty Opportunities Westley doesn't see any overt bias against DOs. They've interviewed some DOs in the last couple of years. It's just that a lot of the big programs for vascular surgery aren't associated with an osteopathic school. This is an extra hurdle the student has to go through. They have to show they're investigated and they have the commitment. And if they can show that, then they could go further than the allopathic student who comes from a program that might have a great reputation for vascular surgery but didn't necessarily show as much interest or build a competitive application packet. In term subspecialty opportunities within vascular surgery, there are several ways to make your niche. There isn't any formal ACGME fellowships. But as he said, what comes into anyone's mind is there is advance aortic endografting fellowships. Cleveland Clinic has one as the Mayo Clinic, which they've rolled out as a complex aortic reconstruction fellowship. UT Houston also has it, which is where he went to medical school. These are big aortic referral centers so they attract the aortic "super" fellows to learn those techniques. Moreover, Westley says it's very easy to build a very heavy thoracic outlet syndrome practice if that's where you want to make your mark. Because if you can do it well and show consistent outcomes, those are patients that will come to you. And the referrals will come to you as well fairly easily. A lot of people in the community end up either specializing or treatments for venous reflux. Those are disease process that he thinks they've undersold as a society or medical profession. There's always one guy in town who's that carotid surgeon just like the thyroid surgeon that get good outcomes with your carotid procedures. Referrals will also continue to come as well. But in terms of established training pathways, there aren't any besides the aortic surgery. "Beyond the general training, it's just kind of how you want to market yourself." [28:50] Working with Primary Care and Other Specialties Westley wishes to thank primary care physicians which he considers as his very best friends.A lot of the medical management of vascular patients is driven by the primary care physician. Whether in terms of following the JNC guidelines and the AHA guidelines in terms of the best medical management. About a third of his clinic patients, he ends up getting or giving a phone call to the primary care physician to pick their brain about it. He thinks it's underrecognized. In a large portion of society, everyone thinks about carotid disease and stroke but lower extremity and peripher…

Full show notes at the publisher

46: What Does a Private-Practice Based Neuroradiologist Do? Oct 24, 2017

Show notes

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

Full show notes at the publisher

45: What is a Cardiac Anesthesiologist? Oct 17, 2017

Show notes

Session 45

Dr. Maninder Singh is an academic Cardiac Anesthesiologist. He's been out of his fellowship now for four and a half years. And he's in a large academic medical center in Cleveland, Ohio. In our conversation, we talk about everything that you need to know about the field.

Check out The Premed Years Podcast Episode 256 where I interviewed the dean of the brand new medical school, Carle Illinois College of Medicine. Also check out all our other podcasts on MedEd Media.

[01:35] Why He Chose Cardiac Anesthesiology

Being the medical student that loves everything, he was interested in every rotation he was on. And he found that anesthesiology was the perfect mixture of everything. So it was more of a decision of exclusion where after he excluded everything else, the only one left was anesthesia.

What really drove him to the specialty was being close to the fire, and it gets ugly really quickly, then you get to control things and everything gets back to normal.

Cardiac was fun for him too. He always had that interest in cardiology because of the physiology. So it's the level of understanding and the impact you can have on the patient in an acute setting. Not to mention the outcomes you get to see right away were the things he was attracted to cardiology.

What really drew him to anesthesiology over emergency medicine is because the days are a little more regimen from a standpoint that he was able to have more control over his schedule. It made more sense to him back them.

[05:15] Traits that Lead to Becoming a Good Cardiac Anesthesiologist

"Being a team leader, regardless of the setting is the most important trait."

Maninder cites the traits that lead to becoming a good anesthesiologist such as being a good leader and a good communicator. Also, you have to be confident in your skills. He best describes it as being closest to the fire without being inside the fire. He also mentions that cardiography has become huge in the last five to ten years.

[07:10] Why Anesthesiology Subspecialty is Important

Maninder explains having a subspecialty gives you different options within the field. And from the patient population standpoint, it's different when you're putting a four-old-baby to sleep versus a 30-year-old athlete with an ACL tear to sleep. And versus a 90-year-old person with another severe condition to sleep. So it depends based on the type of surgery, the comorbidities of the patient, etc.

"You need a certain group of people that get advanced training in that particular field to provide the best care for the patient."

The field is changing dramatically with all the procedures they have available. So it's nice to be an expert for that exact procedure and that exact population.

[09:10] Types of Cases

Maninder cites cardiovascular as the number cause of death. From a cardiac standpoint, cases they deal with are bypass surgery, issues with valves. Moreover, congenital cardiac patients are living longer now so they see them in their adult lives.

From a heart failure standpoint, there is a huge shortage for heart transplant organs. As a result, lots of people are placed on assist devices until an organ is available.

50% of their cases are cardio-thoracic which includes lung surgery as well. And some cardiac surgery which is half bypass operation and half of which are valve replacements or valve repairs.

[11:06] Community versus Academic and Taking Calls

There are lots of community-based programs that are busy and have a huge demand for cardiac anesthesia. It used to be that after the surgeon does the surgery and comes for bypass, and now you call the cardiologist to the operating room to take a look at the valves. So you bring another physician provider into the room. Now, you've taken cardiology out of the operating room.

Maninder says this is one of the reasons to be in academic is that the acuity of patients you see are a lot sicker. The operations you're doing are much sicker.

"You get to teach residents which also would keep you on your toes and keep your skills up to speed."

In terms of taking calls, they take one weekend day call per month which is about 24 hour-in house on a weekend. They they'll do anywhere from one to two weekend days, which is usually a sixteen-hour call. You go at 3pm and stay until 7am. A cardiac call ends up being a home call. There are 25 of them so they end up having to do it one weekend a month for calls, which is a big academic practice.

[13:20] Work-Life Balance

Maninder says it's one of the main benefits of being in anesthesiology is that you get to live a more structured life. Cardiac is one of the busiest subspecialties out of all subspecialties in anesthesiology. But it's pretty well-balanced.

"One of the benefits of being in anesthesia, your life is a little it more structured."

It's also center-specific. So they would do one case a day and they're done by 2-3 pm. By that time, they finish their paperwork and then be home by 4-5pm. And probably go to the hospital by 7am. So he still gets to have dinner with his family and take care of his kid.

[14:25] The Path to Residency and Fellowship

Out of medical school, you will apply for an anesthesia residency. It used to be advanced which is some sort of general training. And a transition year from general surgery to medicine. And then you have three years of dedicated anesthesia training. Then the cardiac fellowship is one additional year where you deal with high intensity programs. You basically do multiple cases a day while getting good at providing anesthesia for patients in terms of anesthetic management. Then you try to become sufficient and be certified in doing cardiography. So it's five years in total.

Maninder describes matching to not as terribly competitive in general. Chronic pain and cardiac are the most competitive. Pediatric is getting more competitive as well. But certainly, it's much easier to get into cardiac anesthesiology that it is to get into anesthesiology.

For students interested in doing cardiac anesthesiology to stand out, Maninder recommends to learn the residency program you're in. Shadow a cardiac anesthesiologist to see what they're doing. Understand the intensity to see if this is the right field for you. If you have the intensity and the dedication and the desire, Maninder says you will succeed no matter what. You can do research or anything that's going to help you in your anesthesia residency. This shows that you're really interested in the field.

"There's understanding the intensity that goes with it and seeing if this the right field for you."

[17:10] Bias Against Osteopaths and Working with Primary Care and Other Specialties

Maninder sees no roadblocks for osteopaths who are looking into taking this path. He has met multiple cardiac anesthesiologists that are DOs and he finds them phenomenal and even better. He has trained with DOs and he has trained DOs. At least on the East Coast where he did his training, he didn't see any bias against DOs.

Sometimes, they do work with primary care providers depending on the situation. Other specialties he works the closest with include medicine, surgery, all kinds of surgical subspecialties, pathology, psychiatry, internal medicine, endoscopy, GI bleeds, and just about every subspecialty there is.

[19:33] Special Opportunities Outside of Clinical Medicine

Maninder doesn't see a lot of opportunities outside of clinical medicine but there's teaching on one hand.

But if you wanted to go into the industry, Maninder admits all the big stuff is coming out. The big thing right now is the percutaneous valves they're doing. it's probably the only research going on relating to valves. There's a lot of percutaneous devices coming out for patients with atrial fibrillation. And a lot of things coming out related to assit devices for patients with heart failure. That said, the industry is booming as more and more procedures are getting available and people are getting well.

"Cardiac anesthesia and cardiac surgery is booming because of all that's going on in the industry."

[21:02] What He Wished He Knew that He Knows Now

Just the intensity of it at times is what he should have known before. Because you don't appreciate it while you're in the moment. And you only appreciate it when you have a nice easy day or case. So at times, he thinks the intensity gets a little bit too much. But even if he had known that, he still would have gone through the same.

What he does now during intense situations to remind himself that there are things that you can't fix. You do the best you can. You have to have all your algorithms so you don't miss anything. Just be a good leader and be a good communicator. Make sure you don't leave any stone unturned. Be loud and clear

"It's okay to ask for help from the standpoint of just having a fresh set of eyes."

[22:52] What He Likes the Most and Least

Maninder's favorite part is echocardiography, which is essentially one of the main reasons he got to do his electrocardiography elective as an anesthesiology resident. This was the time when he was still considering between pediatric and cardiac anesthesiology. And so it was the last thing that made him switch over to cardiac anesthesiology.

On the flip side, what he likes the least is not having enough cases. Not enough crazy cases. But he's quite sure that will change when he's 50 years old. But at this point, he says it would be nice to do more craziness.

[24:05] Major Changes in the Future and Collaboration Between Specialties

A lot of devices are coming up in the cardio scene like microregurgitation when patient would have to go in for an open chest procedure. Now, they can do a percutaenous device so the patient can go home the same day or the next day. They do the procedure on valves. They started with aortic valves and now they're doing mitral valves. These are the patients that are high risk for all the long rehab that goes with an open heart surgery.

They're doing more and more assist devices for the heart transplant patients waiting for an organ to come in. When the organ comes, they'd come in and call them essentially a bridge therapy, which is a bridge to their transplant.

Moreover, there's a lot more management for atrial fibrillation, which are high risk patients for stroke, secondary to atrial fibrillation. And who has contraindication for being on anticoagulants. They have procedures to close up the atrial appendage so patient don't have to be on anticoagulation.

As cardiac anesthesiologists, they don't deploy the valves directly but they are an integral part of that. For example, they identify the appendage for the cardiologist or they are finding exactly where to put the valve in. Too deep or too shallow, the valves are not going to sit exactly where you need it to sit. This is all guided by electrocardiography. And this is what's going to help a cardiologist and a surgeon do the procedure.

"Even though we are not actually deploying the valve, we are actually telling them exactly where to deploy the valve."

As a result, it makes you feel like you're a big part of the team because they rely on the information you're telling them. This is a concrete example of collaboration. Maninder also likes to tell his residents that they are the eyes of the surgeon. Sure, there is pressure, but you need to back yourself up and train the best possible way you can. And there are times when you have to make those big decisions because they need you.

[28:50] Final Words of Wisdom

If Maninder had to do it all over again, he would still have chosen cardiac anesthesiologist. Lastly, his advice to students interested in the field is to just do it. Don't think twice about it. It's one of the best specialties. From a job security standpoint, you're doing something that not many anesthesiologists can do in terms of cardiography. You've gotten all this training so make sure you're always in demand. Be prepared to work hard and people will appreciate your hard work. You will essentially become the go-to person for every sick patient, for every big case, and for managing patients. And if you don't shy away from those things, then it's the best field you can possibly go into.

[30:06] Last Thoughts

If you're thinking about anesthesiology, take a look at cardiac anesthesiology. Find a cardiac anesthesiologist to shadow. It's the best next step you can take on this journey.

Links:

The Premed Years Podcast 256: A Look at Carle Illinois College of Medicine with Dean Li

44: A Look at Academic Pediatric Neurosurgery Oct 10, 2017

Show notes

Session 44 Dr. Michael Egnor is an academic Pediatric Neurosurgeon based in NY. We discuss his long career in the field and his thoughts about what you should know. Michael has been out of fellowship training now for 26 years and is currently a faculty member at Stony Brook University. Also, check out MedEd Media Network for a selection of podcasts to help you on this journey to becoming a physician. [01:25] His Interest in Medicine When Michael was very young, his mother had a brain aneurysm that ruptured. She survived but she had some neurological sequelae. So even when he was young, he was already involved with neurosurgeons. He thought that to be a neurosurgeon was the pinnacle of what one could accomplish in terms of profession. Moreover, he found medicine fascinating. He recalls that he read a book Not as a Stranger back in high school. It was a novel about a doctor but the title just fascinated him. The title actually came from a passage in the Chapter 19 of Job in the Bible. Job was asked how he deals with all of the horror he experienced and all the terrible things he has seen. He knows what he's going through ultimately will allow him to see life and actually to see God, not as a stranger. That is if you would come to know him and what it means to be him in an intimate way. "To be a physician, you get to see in an intimate way what life is all about and understand what it means to be a human being." He was also inspired by Dr. Christiaan Barnard who was the first surgeon to perform a heat transplant. He recalls seeing the news about it as a kid and got fascinated by it. He is specifically fascinated by congenital heart defects. As well, the brain fascinated him. That said, he knew he wanted to be a doctor and a surgeon, just not sure as to what kind. Then he went to the army in high school because he needed money to go to college. He served as a medic in the army for three years. And getting accepted to college, it gave him a deferred admission so he started college when he was 20. Right after college, he went to medical school. Being older going to college, he considers himself being more focused than some of his classmates. He knew what he wanted to do so he worked really hard to get into medical school. Out of medical school, still undecided between neurosurgery and cardiac surgery, he started general surgery internship in Mt. Sinai in New York. And halfway through his internship, he realized he wanted to do neurosurgery. He knew that 20-30 years down the road, he would still be fascinated by the brain and not as much by the heart. So he applied outside of the match. He called neurosurgery programs.They needed a resident at the University of Miami so he went there with his newly married wife. He spent six years in Miami, training in neurosurgery and came back to Long Island where his wife's family is from. Then he got a job at Stony Brook as one of the faculty. [05:50] Brain versus Heart Not that the heart isn't a wonderful topic of research, it struck him as a fascinating machine. But with the brain, he thinks you can take the knowledge much further. The other thing that enthralled him was neuroanatomy and how the brain was structured. To him, it was like almost as I if he was learning a secret to what life was all about and it was in the structure of the brain. So he felt the brain would keep him interested indefinitely. While the heart for him was to mechanical for him. "Almost as I if I was learning a secret to what life was all about and it was in the structure of the brain." [07:17] His Path to Pediatric Neurosurgery He didn't get out of training as a pediatric neurosurgery, He did general neurosurgery but he has always liked pediatrics. He likes the patients and has a fair amount of empathy for parents. He also has a personality for it. And in some ways, he thinks neurosurgeons and pediatricians are thought a being at the opposite ends of the spectrum of medical personalities. Pediatricians tend to be warm, nice people who are nice to the family and patients. Neurosurgeons are thought of to be egostistical and dysfunctional people who just operate like crazy. But these stereotypes are not entirely true. Pediatricians respond well to neurosurgeons and vice versa. What happened at Stony Book was for a couple of years, they didn't have a pediatric neurosurgeon. Since pediatricians like him, they sent him a lot of patients. So the chairman of pediatrics ultimately asked if he was willing to just become a designated pediatric neurosurgeon. And so he agreed. So there's a way to get boarded in pediatric neurosurgery outside of the fellowship track.It was a matter of submitting case logs for several years and taking a written exam. [09:30] Traits to Lead to Becoming a Good Pediatric Neurosurgeon Michael explains it's a blend of two very different species. Pediatricians tend to be people who are warm, nice people. They love kids and want to take care of them. Neurosurgeons are egotistical people and surgically oriented. This path is great if you find you love the surgery and are fascinated by the brain. You like some of the technical challenges of neurosurgery and on the other hand you want to take care of kids. For example, you find conditions like hydrocephalus to be very challenging and fascinating from a scientific standpoint. "It's a hybrid of two different ways of practicing medicine." Neurosurgery is an interesting specialty. As much as he has met the nicest people who are neurosurgeons, there are those who are crazy too. Michael says, neurosurgeons have to have some degree of almost irrational confidence in their abilities. It's something normal human beings don't want to do. You're taking tumor out of someone's brain where you stand a reasonable chance of killing them if you make a mistake. It's not something even people who are inclined to surgery have a particular comfort of doing it. So you have to be fairly egotistical to do this for a living. And how does one pull that off in the real world? Neurosurgeons have different ways of doing it. Some neurosurgeons just concentrate on being technically as good as they possibly can. Others are psychopaths in a non-criminal way. What Michael means is some of them don't take into account the humanity on the other end of the operating table. they just do the job as well as they can and then if it works out, great. If not, they'd call out the next patient. Some neurosurgeons limit their practice so that they only do things they feel comfortable doing. While others don't put it together well at all and don't do such a good job. [12:25] Types of Cases and Patients As a pediatric neurosurgeon, a large fraction of his practice is children with hydrocephalus. And he follows them into adulthood so he also has a fair amount of adult patients. Michael mentions the issue in pediatric neurosurgery that pediatric neurosurgeons who work in adult hospitals question as to where they will follow their pediatric patients when they grow up and become adults? Some pediatric neurosurgeons who work in children's hospitals can't do that. This is because patients can't be cared for at the hospital they work at. In Michael's practice, he deals a lot with hydrocephalus in both children and adults. He also deals with hydrocephalus in older people. He sees elderly people who have normal pressure hydrocephalus. Other cases he deals with are brain tumors, Chiari malformations in both children and adults, as well as syringomyelia in their spinal cortices. He also sees patients with craniosynostosis, infants with deformed skulls, and of course, trauma both adult and pediatric. As to what percentage of patients coming to him that already have a known issue, Micheal says it's a very common scenario to see a child with brain tumor. And the pediatrician feels a lot of guilt about it because almost a child who has brain tumor has several months of symptoms. And pediatricians work up a child with some vomiting and headache. And after 1-2 months of evaluation, they get scanned and the tumor is found. And so he tells them that in some sense, the neurosurgeon has the easiest job because virtually, patients come to him already with scans showing what's wrong with them. The primary care people, the pediatricians, or the internists for adults have a tougher job because they see a large volume of patients. Only a small fraction of them have serious problems. Then they have to find the ones who have the serious problems. The major issues he faces are: is the patient's diagnosis responsible for the patient's symptoms? This can be tricky. People can have headaches from the chiari malformation and don't need surgery. Michael finds it a challenge to sort out whether the symptoms of the patients are really caused by the disease identified on the scan. You have to be sure since the remedy you're offering is surgery. You want to make sure you're operating for good reasons. "That's one issue I face quite a bit is making sure the diagnosis is the cause of the symptoms." [16:25] Typical Week of a Pediatric Neurosurgeon. Taking Calls, and Percentage of Patients Ending Up in the O.R. Michael describes his week since it basically depends on whether the hospital has a lot of trauma or not. But his typical week would be that he'd be on call once or twice during that week at night. He takes a general surgery call. During the day, he has two operative days a week. On average, he takes 2-5 cases a week. He has 2-3 half-day clinics a week where he sees 15-20 patients per clinic. He has some academic time, usually one and a half days a week where he writes papers. They don't have residency in neurosurgery so he's a residency director for a program without a residency. This said, he's in the process of applying for residency. He teaches medical students as they rotate through the service he teaches and in the ethics class. Of the patients he sees in clinics, only a relatively small percentage, about 10%-20%, go to the operating room. Many of the patients he sees are follow-ups after the surgery. Many of them are children with shunts he sees annually. They don't need surgery but he sees them manually. It's very important that if you have a shunt for hydrocephalus, you have a neurosurgeon that knows you. And that you know them and that they neurosurgeon is always available to you. He finds that annual visits keep everything fresh so they know each other. Common cases would be a kid who bumps his head on the baseball field, has a mild headache and gets a scan. And something would be seen on the scan that has pathological significance but the primary care doctor sends the child to him. Most of the calls he takes would be coming to the hospital for surgery. They don't have residents so any surgery is done by the attending. They have physician extenders but he still has to come in and do the surgery. Nowadays, generally, residents don't operate alone so even if they had residents, he would have to come in. About a third of his calls, he would have nights coming in. [19:45] The Path to Pediatric Neurosurgery, Competitiveness, and Research Basically, neurosurgery residencies have been for five or six years including the internship year. That's followed by a year or two of fellowship, if you want to do it. This past two years, the ACGME and the residency review committee (RRC) for neurosurgery have standardized neurosurgical training. Now, it's a seven-year program including a year of fundamental clinical skills, which used to be the internship. And then six years of explicit neurosurgical training. Now they try to fold in the fellowship experience into the seven-year residency. So you don't have to do fellowship after you do it during the residency. There is research involved in neurosurgery. In fact, programs are required to have a research curriculum, whether it's training or research methods. Residents are expected to be academically active, to publish during their residency. And programs are reviewed by the RRC based in part on the research output of their faculty and residents. "It's a major emphasis in the residency review committee in neurosurgery to foster research in neurosurgery." Although he doesn't have the numbers, Michael thinks that half of the applicants get into programs. He would rate it as moderately competitive. It's a small specialty with about a hundred programs in the country. There are a whole lot of people interested in going into it but his sense is about 50% of applicants get in. As to the reason for it competitiveness, it appeals to a fair number of people, particularly people who are highly motivated. You have to really want to practice medicine at a fairly intense level to want to get into neurosurgery. Moreover, people may be attracted by the status or the financial aspects. Most neurosurgeons do fairly well financially. And there aren't enough people repelled by the volume or nature of the work. "It's fairy popular given what a small specialty it is." According to my data, there are are only 218 physicians. Michael agrees this is just about right. Pediatric neurosurgery is one of the less popular neurosurgical specialties. Within the neurosurgical profession, popular subspecialties include spinal neurosurgery, general neurosurgery, vascular. The reason for this is people don't like dealing with shunts. Many neurosurgeons, too, don't like dealing with kids or with families. Another reason is pediatric neurosurgery doesn't pay as well as other neurosurgical specialties. It seems to be a general rule across all pediatric subspecialties is that the pay isn't as good as it is for adults. But Michael points out you don't go into it for the money. [24:00] How to Be Competitive for a Residency Spot Besides being a good student and being a human being which always help you, Michael cites two things students should focus on. First is research. Have some publications appealing to a neurosurgical residency program. The second is to have some hands-on experience particularly with the programs you're applying to. When he was a resident in Miami, they took two residents a year. There was an unwritten rule that one resident was taken based on the CV and the other based on personal experience. When somebody would rotate through their service, you get to know them personally. It turned out that the people who did the best in the residency were almost the people who had rotated to the service and who they knew personally. You're going to work with the resident for seven years in fairly intimate ways in the middle of the night, saving lives, and doing all these stressful things. You really want to be somebody who you know you can work with, somebody you can trust and stand with for seven years. "The residency in neurosurgery is so long and it's such a stressful process. It's almost like a short marriage." Michael suggests that for people interested in neurosurgery, try to arrange external rotations at the programs you're most interested in applying to. This way, when your application comes across their desk, they would know who they're dealing with. Nevertheless, the research is a big deal. But the programs have a lot of stress on them from the ACGME and from the RRC to have residents that do research. It's one of the criteria by which re-certification of the program is determined. Plus, if you already have an established researcher in your program, it's more likely for them to make their program look good. That said, having a research background is very appealing to programs. In the long run, having research background makes you a…

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43: Community Based Interventional Cardiology Oct 03, 2017

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Session 43 Dr. Venkat Gangadharan is a community based Interventional Cardiologist. We discuss his interests in cardiology and his thoughts about the specialty. He also gives his opinions on the latest changes in our healthcare system regarding reimbursement cuts as well as turf wars between specialties. Also, check out all our other podcasts on the MedEd Media Network, including The Premed Years Podcast, The MCAT Podcast, The OldPreMeds Podcast, and The Short Coat Podcast. [01:08] Interest in Cardiology Knowing he wanted to be a cardiologist right on his second year of medical school, Venkat did what he could to figure out. By the time got into residency, his mind changed and considered things like pulmonary critical care or cardiology. Then he got the chance what the cath lab was like and got to see what they do when they treat heart attacks. And he got sold right then. He's the type of guys that likes instant gratification in terms of treating patients. He wants to see them get better right then and there. So he found doing cardiology and interventional cardiology was the way to go. He knew he wanted to do interventional cardiology by his second year of cardiology fellowship. He recalls applying everywhere across the U.S. He thinks it was the toughest thing being one of the several thousands trying to get the same position. He has interviewed in at least ten different places. It was so difficult for him that he finally ended up matching in a program at the last minute. He decided to take it and to him it was the greatest decision ever. "No matter how competitive you are, you're one among several thousands that are trying to get the same position." What he really likes about cardiology is the physiology behind it. Plus, it required some amount of critical thinking and problem solving. But at the end of the day, there were define medications for certain purposes. There are risk factors you know you could treat. And the problems had definitive treatment modality and cure to some extent. Basically, he's fascinated by how the heart works. [04:40] Traits that Lead to Becoming a Good Interventional Cardiologist Venkat cites some traits in order for one to become a good interventional cardiologist such as being dedicated and hardworking. You need to be analytical and be able to think on your feet. In the cath lab and you have a patient's life in your hands, there are probably a million different decisions running through your head. With so many things running through your head, you just have to choose the right one and make sure the patient gets through it no matter what. With heart attacks, for example, the chance of people dying from it is so low nowadays. Everybody has got a chance. Compared to back in the days during the infancy stage of interventional cardiology, there were no facilities to treat people. There was no place to send them. “With the technology we have, there's not one person in the country that should not have the chance to live at the hands of a cardiologist.” That said, you have to be able to think outside the box. You have to be analytical and mechanical. Venkat explains that interventional cardiology is all about physics and the give and go. Additionally, having that adrenaline junkie kind of mentality is an edge. When you're taking an emergency call, you will have to wake up in the middle of the night to have of your faculties all ready to go. Drive to the hospital. Then have all of your fingers ready to go to and adept to put a stent or fix a blood vessel to fix a person's life. You need to love the rush for you to be able to mental faculties to take care of that problem in the wee hours of the night. [07:22] Private Practice versus Academic Setting Venkat explains the reason he chose private practice was being the easiest choice at that time. There are far more private practice physicians at that time than there are academic positions. Second, you have to have a certain mentality and persona to be an academic interventional cardiologist compared to a private practice physician. "I wouldn't say it's money driven per se, but I would say it plays a huge role in the decisions you make when it comes to the job you pick." As a private practice physician, you have the ability to dictate your own life as well as the ability to treat your own patients. You have the ability to learn things at your own speed without having to answer to anyone else but your own practice. These were what Venkat was looking for. [09:07] Types of Patients and Typical Day in His Life As an interventional cardiologist, Venkat sees everything from valvular heart disease to atherosclerotic vascular diseases. It's truly mind boggling that the amount of coronary disease that is out there and how young a person can be by the time they get affected. Venkat finds it humbling to be doing intervention in a 34-year-old when you're the same age as he is and living the same kind of life he is. For him, this is eye-opening and it makes you realize how life is short and you need to take good care of yourself. So when he things sees on the screen, it makes him think twice. It's surprising to see how bad people's arteries could be at such a young age. As a private practice physician, Venkat says it's tough being just an interventional cardiologist. So he also practices a lot of general cardiology and interventional cardiology, But his mind is always focused on what he can do to fix something. He gets to the hospital around 6 or 6:30 in the morning and do some rounds. If anyone comes in with a heart attack or he's on call, he drops whatever he's doing and go and save that life. Then he goes to the office or clinic and trying to recruit patients to your practice so you can maintain a lifestyle and a career. "It's very rare in private practice to find a position where you just do interventional cardiology." You have to be ready to handle any situation presented to you. Venkat takes emergency calls about three to four times a week. Being a young doctor, his practice is made up of only two interventional cardiologists. He usually gets a call about three times a week. But not all private practice is like this. The larger the private practice, the less call that you're going to take. From a general cardiology perspective, he takes calls once a week and he does one week in the month. Initially, when he started out, it was pretty rough not realizing it was this much work. But Venkat explains that you will get used to it. [12:21] Work-Life Balance Venkat thinks having that work life balance is a million dollar question. Over the past three years, he had thought about what life was like outside of his work and the balance he had between work and his home life. He has a two-year-old son who misses him all day long. There are plenty of days he'd feel bad about coming home late or working as much as he does. But at the end of the day, being a young physician and knowing this is your career, this is the time to make a living. This is the time to earn for your family. After which, you can decide what's going to work for you and where you want to spend your time more. [13:33] The Path to Interventional Cardiology Residency and Fellowship Training Once out of medical school, you decide to make an internal medicine residency. When he was applying, he looked for decent cardiology fellowship knowing it was what he was going to do. The likelihood of you getting into the cardiology fellowship at the residency program you trained at is better than one than you'd get at another place. This is followed by another three years of cardiology fellowship. At this time, you're introduced to cardiac catheterization and different aspects of interventional cardiology. Also around the second year, you also make the decision if you want to become one and start applying to interventional cardiology fellowships. The difference between interventional cardiology fellowship applications and the general cardiology fellowship applications is that many of those programs are paper applications. This means you have to seek them out. Find out what their application process is. Do every step you can and apply. Then follow up several times if they've received your application. "Try to hone in on the programs that you really want to be a part of." Things they would usually look at are your degrees of research you've done during fellowship, your progress in testing during fellowship and training, and where you trained which goes a long way. As to why he thinks matching into interventional cardiology is so competitive, Venkat believes it's one of the more rewarding cardiology fellowships. The number one killer of people in the world is heart attacks. And interventional cardiology is essentially designed to treat those. So the amount of people applying to be an interventional cardiologist are far more than the people applying to be an electrophysiologist or a nuclear cardiologist. And for electrophysiology in particular, the testing is very difficult. It requires someone to be very cerebral and a mentalist to handle that kind of profession. [16:18] Bias towards DOs, Subspecialty Opportunities, and Turf Wars Venkat actually has not seen any bias towards DOs. In his own practice, he has a partner who is a DO. He took a very long way to become what he is today. But he's a successful interventional cardiologist. "At the end of the day, the MD and the DO designation is just a designation. The person you are is the physician that you are." Venkat adds that you can be an MD and be an awesome physician. You can be a DO, and still be an awesome physician. He really doesn't think this has any weight in terms of whether you have a chance of being an interventional cardiologist or not. It's about what you do with the time you spend and the training you spend that makes who you are. In terms of subspecialty opportunities after interventional cardiology, Venkat explains there is a new development in structural heart disease. In the country, there's only a handful of programs that are accredited structural heart disease fellowships. The ACC and the AVIM have yet to recognize a designated fellowship for this. Coronary heart disease is not the only thing that plagues people, Peripheral vascular disease is also what plagues people. So there are specialized fellowships to do a training in endovascular work. Venkat explains that as interventional cardiologists, they're actually an interventional cardiovascular physician. So the vascular aspect of things is largely untapped and majority of that training can be obtained after a fellowship. Venkat also admits having turf wars brewing between cardiovascular and vascular surgery. When it comes to peripheral vascular disease, it's a turf war between a vascular surgeon, an interventional cardiologist, and an interventional radiologist. He adds there are programs out there with long, trusted interventional radiologist to do the procedure or long, trusted vascular surgeon to do the procedure. As interventional cardiologists, they are making the push to take that on themselves. "The breadth of peripheral vascular disease is so poignant in this country. There's opportunities everywhere." But Venkat says that you won't see many private practice interventional radiologist or private practice vascular surgeons doing a lot of endovascular work. Majority of them have some sort of academic affiliation. You will see a lot of private practice interventional cardiologist doing all of that work. [20:10] Working with Primary Care and Other Specialities Venkat wished primary care physicians knew the breadth of disease they see and the complicated nature of disease present in their patients. He really wished they would understand the medications they use to treat these conditions. Unfortunately, Venkat lives in a place where managed care is a strong push in the area. By this. primary care physicians are limited in the medications they can offer their patients. Many of them end up changing the medication he places his patients on. Or they deny the stress test or deny the arterial ultrasound the patient needs to gather some more information for their complaints. It actually blew his mind when he first got there. But that was the reality. And in the three years there now, he still couldn't grasp the idea where primary care physicians are literally dictate a patient's life regardless of the symptoms the have. "I still couldn't grasp this idea where primary care physicians are literally dictate a patient's life regardless of the symptoms the have." Venkat describes it's like the patient has to show up in the hospital to get the real care they deserve. They go to their primary care physician because six times out of ten, they're going to get denied. This is saddening. Venkat says he had to rescue people at death's door when they could have been rescued two years earlier. Other specialties he works the closest with include pulmonary and critical care, infectious disease, and nephrology. [23:28] Special Opportunities Outside Clinical Medicine Venkat explains that the more senior you become as an interventional cardiologist or cardiologist even, the opportunities outside of medicine start to open up. When you're a part of a large hospital system and you have a good relationship with the hospital administration, most of those avenues are open for you. One of his partners is the chief of internal medicine in the hospital as well as the chief of cardiology at the hospital. It's a rotating door when it comes to that position. "Cardiologists are often taken in high regard because we have our fingers in every aspect of things." Other cardiologists have also migrated to other industries. His mentor has left interventional cardiology practice of 45 years and is now engulfed in an industry that promotes one of the products he helped design and bring to market. So you have the opportunity to migrate over to an industry and be a speaker and teach the world about what you do. [24:55] What He Wished He Knew and What He Likes the Most and Least Now knowing what the process is like to get better framed in what he does, he wished he probably should have sought out an extra fellowship at the end of his one year of interventional cardiology. Had he known the amount of opportunities out there, he probably would have given it a better shot. Secondly, although a private practice physician, he wished he had given academic interventional cardiology a strong push at the time he was making the decision for a job. He never knew it was this busy. But he's a young guy so he's pushing through it. What he likes the most about being an interventional cardiologist is doing procedures. He loves working with his hands. He loves the adrenaline rush of fixing a heart attack. For him, waking up at 2 am is not difficult. If he could save a life and they'd walk out the door the next day, alive, he feels he has done his job for the day. "To me, the procedural aspect of this whole profession is what makes the best thing everyday." What he likes the least, on the other hand, is the bureaucratic aspect of it. Running a private practice or trying to develop a career as a private practice physician is very difficult. Unless you have the business know-how or the business acumen, it's difficult to make yourself well-known in the community that has several people just like you. But it does teach you what the business of medicine is like. "One of the things we lack as residents and fellows is that nobody ever told you what the business of medicine is like." Reality is that everything costs money. Ev…

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42: Academic Neuromuscular Neurologist Talks About Her Specialty Sep 26, 2017

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

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41: A General Pediatric Neurologist Discusses Her Specialty Sep 19, 2017

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Session 41

Dr. Denia Ramirez is a general academic Pediatric Neurologist. She talks about her journey to becoming a pedi neuro doc and other things about her specialty. Several weeks ago, we had a pediatric neurologist who specializes in headache medicine. She has been out in practice now for five and a half years after her residency in pediatric neurology. She is in a combined academic and community setting at the University of Tennessee Medical Center (UTMC).

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[01:33] Her Interest in Pediatric Neurology

When she did her pediatric residency in Costa Rica, she got amazed by how a child gains milestones. She got interested in how things changed, and how they can shift from being so little and happy to somebody and completely against anybody who's a stranger at eight or nine months old. Her father-in-law was also a neurologist. It was around that time when she met her husband. So she got to see more of what a neurologist is not only inside but outside. This is basically what sparked her interest in neurology.

Other specialties that piqued her interest include emergency medicine. She realized the demands and the amount of time she was going to be out of home if she decided to go that route was probably too much for her. Since she still had to take care of family and do other things as well.

[03:20] Traits that Lead to Becoming a Great Pediatric Neurologist

First of all, you'd have to like kids. Not only for peds but also for adult neurology, you have to know your neuroanatomy. You have to know your localization well and learn the process in which we're taught to think to try to reach a diagnosis. More often than not, you're going to hear people you have to be smart to do this or that subspecialty.

"You have to like it. You have to enjoy it. You have to be dedicated. That holds true for any single subspecialty you get yourself into."

For Denia, one of the most wonderful things is when she's in clinic, she's essentially being paid to play with kids. She loves what she does and she loves talking to kids. She loves talking to parents. She loves to work with them and this makes her job much easier.

[04:40] Types of Patients

Denia says she sees almost anything. Child neurology has been a relatively new thing. She gets kids with epilepsy and the whole spectrum of those kids. There are those who come every six months. She helps them walk through the process and helps them until they outgrow it. She also sees kids with severe brain lesions or have genetic epilepsies. They also see kids with headaches. A lot of very normal kids who had one or two febrile seizures and parents are understandably worried and concerned about what that means. They also see kids with developmental delay with learning problems or kids struggling in school. Everybody wants to make sure that they're not missing something that is bigger. They see kids with neurodegenerative diseases. They see a lot of other different things like difficulty in walking, kids with ataxia, and so much more.

"The nice thing about pediatric neurology that is a relatively small field, there's not a lot of us."

Being a very small field, Denia says how they're so open and very supportive of each other regardless of the training program. And as much as they want kids with movement disorders to be seen by a movement disorder specialist, for example, but you don't always have that luxury. You reach out for them but you continue to take are of those kids.

[07:00] Generalist vs. Subspecialty and A Typical Day and Work-Life Balance

Denia cites three reasons for choosing to generalize instead of specializing. First, she has already done her residency training once back home and she'd have to repeat it. She felt she was at a point where she really needed to be more productive and do something. Additionally, she likes the idea that she gets to have all sorts of patients. Melinda adds she doesn't want to be stuck in a small bucket of things she sees over and over. She likes that she can see almost anything.

"The diversity continues to be a good stimulation for my knowledge, for my learning, and for continuing learning."

A typical day for her would be doing rounds. They don't have admitting services but they have consulting services. For the most part, she sees patients at East Tennessee Children's Hospital, not affiliated with UTMC.

Then she holds clinic between 10 and 11 am. She does reading and goes through a couple of journals to see if there is anything new that can contribute to her knowledge. Then in the afternoon, she sees patients. At the end of the day, she normally checks the charts for the next day. She finishes her notes and then her day is over.

She describes 50% of her time is spent doing clinics and another 50% is on doing rounds. Half of the time would be spent in the hospital. Some days, if they don't have any consults. she spends mornings catching up with any undone work. She'd call patients and see patients in the afternoon.

In terms of taking calls, she's available when it's needed but she doesn't have to be available. At the University of Virginia where she was at recently, they'd do one week of call. Some of them did more weeks of the year, some did less. It basically varies depending on your track. And then on the week you're on call, you have to be available for your residents 24/7 for the entire week.

Denia says having good work-life balance. As anything in medicine, you have to be organized at it. As long as you're organized, as long as you keep your priorities, you can do it.Denia still gets to cook everyday and go out on weekends. They don't have kids but if she had kids, she still thinks she'd be able to do things with her children.

"In peds neurology, once you're comfortable with it, it's easy to get yourself into that process."

[12:14] The Residency Path of a Pediatric Neurologist

The classical path includes two years of pediatrics and three years of neurology. In those three years of neurology, you'd do a year of adult neurology and then the last two years are allocated for pediatric neurology. So it's all five years in total. Some people join a program after they've decided they wanted to do pediatrics. They've finished the whole three years of pediatrics and then they'd do the next three years.

Another path available to some is you can do a year of internal medicine, a year of pediatrics, and then the three years of neurology, whether adult neurology or pediatric neurology. There are some residents who start as adult neurologist and really like pediatric neurology. For them to be eligible to sit for child neurology, they're required to do an extra year of pediatrics aside from the year of internal medicine they've already done. Then they''ll have to do a year of child neurology and they're done. This path is a little bit longer.

Nowadays, most programs have the five-year path. When Denia started, there weren't that many programs that would give two years of pediatrics and three of pediatric neurology. You had to go into two different programs. Some pediatric programs didn't like it because they were losing the resident. But most of the programs now have the options where they can do five years as a pediatric neurology resident.

You can be dual certified in pediatrics and pediatric neurology if you do two pediatrics and three neurology years. But you have to make sure you meet the criteria that the AAP has established for you to be able to sit for the peds boards. The reason people like to be dual certified is because some still like to be able to do pediatrics.

"Some stand-alone children's hospitals would ask you to be dual certified in pediatrics and pediatric neurology."

Denia cites what her mentor told her that there is so much shortage that you end up not using your pediatrics board even if you're eligible to do it. As for Denia, she doesn't think she would sit for the boards in peds. And what she has heard from those who did it, is that they're not sitting through the re-certification. Unless you're doing it for a daily basis, you're going to end up studying for a test.

[16:51] Is Matching Competitive?

Although competitive, Denia says there's plenty of opportunities. Pediatric neurology is a well-held secret. It could be because the five-year training may seem so long. But it really isn't as Denia would describe it. If you want to get into a field, you can get into a very good program with good letters of recommendation. But not to a point where there's one slot and 500 people are fighting for it.

[18:10] Bias Against DO's and Other Subspecialty Opportunities

Denia hasn't seen any bias against DO's, speaking for her field.

"There's no bias. If you're good, you're good. We don't mind how you ended up finishing med school."

Once you're a pediatric neurologist, there are other opportunities that you can specialize in including movement disorder, neuron EQ, and neuropedic critical care, pediatric neuromuscular, neuro immunology, epilepsy and neuro physiology, neurodegenerative diseases and white matter diseases, and mitochondrial and genetic diseases.

When she was interviewing and trying to make her decisions to what she wanted to do, her mentor gave her this advice.

"Once you're done, you essentially can do whatever it is that you want to do."

And her mentor was indeed right. He also told her she can go wherever she wants to go since she's needed everywhere. And Denia thinks he's been right about that. She has a lot of friends in the field who have gone through different paths. And they're equally successful. It's a field that is very supportive and has a lot of opportunities.

[21:35] Working with Primary Care & Other Specialties and Special Opportunities Outside of Clinical Medicine

Denia explains that you need to work with them on getting rid of lot of myths regarding headaches. They see a lot of headaches. And they see a lot of children with headaches who could be handled at the primary care level. Another thing is when do you refer a child for seizures and when do you use your skills to reassure the parents that those are not of concern?

Ultimately, Denia advice is that when in doubt, grab the phone, Give them a call. They're always available. Don't order tests because you're worried that you don't know how you're going to interpret the test. You're opening a can of worms for you and for that family.

Other specialties she works the closest with include developmental peds, genetics, NICU, and PM&R. And in terms of special opportunities outside of clinical medicine, there are people doing outreach and volunteer work. In the next five to ten years, Denia sees telemedicine being one of the fields that is going to develop within neurology. This gives you the opportunity to still see patients in a different schedule. This would be great for parents who want to stay longer at home. Or for those who don't do well being in an office for certain amount of time. That said, you can provide the care from the convenience of your house.

There are also opportunities working for federal agencies such as FDA. An ongoing discussion within the field is how they can diversify as pediatric neurologists in the way that other colleagues have.

[25:35] What She Wished She Knew and The Most & Least Like Things

Denia wished she knew how much the medical field was going to change then it would have helped her anticipate some of the things that came as a surprise to them. For example, how to measure for productivity. This not only touches pediatric neurology, but medicine as a whole. She also wished she would have taken a little bit more time to do all the things she wanted to do before going to med school. So she tries to pass this onto her students and to the residents.

"You need to take time for yourself. It's okay to take breaks."

What she likes the most about her specialty is working with the kids. She feels it's fulfilling to see how kids don't feel well and they let you know where they don't feel well. And then they'd feel better and start to recover. Knowing you've helped and have made a difference in their life is gratifying. What is equally gratifying for her is to see how kids, in the midst of difficulties, continue to push. They're fighters. It's amazing to see how they never give up.

"It's amazing how they never give up. Kids never give up. And that is extremely touching."

On the flip side, the least liked thing about her specialty is to deliver bad news. For years, she has tried to develop within her field in terms of research to say that she may be delivering bad news but people are doing something about it. She's trying to be part of the change so they can finally say what they can offer. You're going to have to walk the parents through the process of thinking that their child's life is going to look different than what they envisioned. But that's okay and you're there to support them.

The one field she doesn't particularly enjoy is neuro oncology. So she tries to stay away from it as much as she can. But if she had to do it all over again, she still would have chosen pediatric neurology.

[29:40] Denia's Advice for Premeds and Med Students

Denia recommends grabbing every opportunity you have to observe and shadow someone in the community. Try not to go into the hospital. It has the most extreme cases and it's not going to give you a good idea or a real perspective of what child neurology is and has for you.

For medical students, Denia recommends that if you're doing your peds neurology rotation, make sure you don't stick to the inpatient. Make sure you also go to outpatient. If you have an interesting patient as an inpatient, talk to your attending physician to let you get involved with it. Make sure you do a rotation. Make sure you express your interest and you're ready to get involved. Take as much as you can from those rotations.

"Get a good perspective of what the field has for you because it's broad."

[32:45] Final Thoughts

Tell me what you think about this episode and shoot me an email at ryan@medicalschoolhq.net. If there's a particular specialty you'd like to hear sooner, rather than later, shoot me an email again. And if you have somebody you wish to recommend for me to interview, hit me up!

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40: A Private Practice Obesity Medicine Doc Shares Her Specialty Sep 12, 2017

Show notes

Session 40 Dr. Alexandra Sowa is a private practice Internal Medicine physician who specializes in Obesity Medicine. She talks about the specialty with us in the podcast. This is a specialty that is relatively new but very important, In the United States and around the world, obesity is becoming more of a problem. But here in the U.S., obesity and being overweight affect two-thirds of our population. Our guest today is trying to change that as an Obesity Medicine specialist. For more stories, tips, and strategies you can learn as a premed or nontrad or you’re preparing for the MCAT, check out all our other podcasts on MedEd Media. [01:17] Interest in Obesity Medicine Not having any idea what it was, Dr. Sowa first got interested in it when she was sixteen years old. It wasn't a specialty then but she was part of one of those scholar med invitationals in Washington, D.C. A speaker named Dr. Pamela Peeke gave an amazing speech about prevention and the role it plays in good medicine. She remembers walking away from that event wanting to go into public health. She knew it was she was meant to do. She wanted to prevent the disease. So in college where she went to John Hopkins and took a double major in public health and writing. But she struggled with the idea of doing traditional public health on a mass scale or the med school. Until she decided she wanted to get into medical school and do prevention. But it wasn't a thing when she was applying but it was always something that she carried with her. So when she finally found Obesity Medicine in the middle of her internal medicine residency, that was it! She wants to manage disease and prevent it from progressing to the main diseases we think of in internal medicine like hypertension, diabetes, sleep apnea, and osteoarthritis, cholesterol problems. She wanted to get to the cause of it. [03:17] Traits that Lead to Becoming a Good Obesity Medicine Doc Alexandra cites compassion and openness as important traits to becoming a good obesity medicine doctor. There is an intense amount of stigma around treating, managing, being a person who carries excess weight. "You need to be aware of how difficult it can be to be a patient who is overweight." She uses the word obese and she's proud to proclaim that she's an obesity medicine doctor. You need to know that comes with many years of beating yourself up with how much you weigh and people treating you differently. Doctors, even a lot of times, are vocal about hating that population of people. So again, you have to be compassionate and be willing to be open to understanding that it is a disease. It's multi-factorial. It's not a lack of will power that leads someone to have excess weight. Additionally since it's not a well-established field, you have to be cowboy. It wasn't until 2011 that The American Board of Obesity Medicine was formed and formalized. And it got streamlined under a board process. So there aren't many specialists You have to be risk-taker. Think outside the box. Carve your own path in that regard. Another foundation to any specialty is just being really good at your primary training. Alexandra is an internist and she believes you still need to be a really good generalist to be a good specialist. "You still need to be a really good generalist to be a good specialist." Meanwhile as Alexandra was still going through her training, another specialty that was pulling her was Endocrinology. She thought she was going to be an endocrinologist. She thought managing obesity and the diseases comes along with it. And the only pathway is endocrine. Sometimes she would wish to have a little more training in it so she won't have to refer to an endocrinologist. But she's still happy she did her formal training. [06:07] Types of Patients and Running a Private Practice Alexandra sees a lot of patients with diabetes. Most doctors don't know there is a way to manage most people who are Type II diabetics with diet. She also sees people with fatty liver or joint pains and sleep apnea. All these problems are related to excess weight. She see overweight people to morbid obesity. She also sees people with normal weight but have metabolic abnormalities like really low HDL's and high LDL's. They are pre-diabetics and they just want to know what they can do to prevent the progression of the disease. Alexandra decided to run private practice since she likes the idea of ownership of her practice and her patients. She likes the autonomy and being able to create her own schedule. She's able to create the relationships with patients she wants. And she felt that in her previous practice, there was just that focus on the bottom line. She had to see a lot of patients per hour. "In obesity medicine, you just can't do it effectively in a 20-minute slot. So you sacrifice what you're offering to patients." There are five FDA-approved medications for long-term use in weight loss. And if you offer a 20-minute slot, you can write a prescription in 20 minutes. But you can't do much of the really important work and the counseling. You can't have a personalized discussion about diet and exercise. You can't talk about all of the things that go into how and why you're eating a certain way. Or what their goals are. You can't do that effectively, kindly, and compassionately in twenty minutes. So she decided to go on her own and practice medicine the way she wanted it. And the only way to do it is to do your own practice. [09:20] Gaining Knowledge of Nutrition One of the biggest complaints about physicians is they don't know enough about nutrition and diet. Alexandra says this wasn't taught enough in medicine. In residency, you're taught to check the BMI and tell them to eat less and exercise more. There was one clinic that was focusing on nutrition and it was within the bariatrics clinic. And this was the only exposure she got. But when she had found this field, she sought out board certified experts. She was lucky enough to get to rotate with a well-renowned doctor, the godfather of the field. He started doing research back 25 years ago and has been a pioneer in making the field. So it was an eye-opening experience for her being able to work with him and being exposed to his clinic. That's when she started to realize that it can be in the form of the diet or pharmacology. The diet piece came in more after residency and as she was working toward her board-certification. She just started reading. And she was reading outside of the traditional textbooks given to her in her internal medicine residency. She attended conferences and made connections with people doing diet modification in ways that blew her mind. Down at Duke, Alexandra says they have an amazing multi-disciplinary group that does diet in different ways. They have low calorie diet or ketogenic diet (low carbohydrate diet). They also have meal replacement diets. So they tailor-make the plan just for the patient and what works for them. Because of this, she has become much more in control of the diet plans she creates for patients. She doesn't use nutritionists nearly as much as she did when she started out. She feels like it's something she needed to teach herself so she could have that great relationship with patients. And it's working out really well. [12:15] A Typical Day Alexandra believes you have to think about what you want your life to be like. She has made a conscious decision to split some of her time up into boxes. She's a mom of two so two of her days are spent at home. This means some of her office work is done in the mornings. But MWF, she's in the office and comes in at around 8:30AM. She starts seeing patients at 9AM. And in her new practice, she's dedicating 40-60 minutes with each patient that comes in. So she's no longer seeing 20 patients a day. Aside from seeing patients, she does admin work. She's doing a lot of meal plans and a lot of virtual correspondence with patients. She does coaching along the way. Every two weeks, she would check in with the patient if they're doing well or they're dieting or exercising. It's a nice reminder to patients so they feel that their doctor is invested in this with them. She's also building up a new practice so there's a lot of learning a new skill set. She's a small business owner now too so there's accounting and lawyers. She has to deal with insurance and stuff. These take up a little bit more of her time now since she's at the start of her business. Nevertheless, she thinks it's a good balance. [14:48] Talk About Insurance Reimbursement, Taking Calls, and Work-Life Balance Alexandra admits insurance companies don't reimburse very well. So she has decided to step out of the insurance model so as not to compromise her care for patients right now. But she hopes that as more data come out and as more companies realize that it does make a big difference in ten to twenty years. That if they're able to take 10% body weight off an obese person, they're preventing a slew of diseases. So a lot of money is saved. And maybe they would realize to focus on a specialty. But as of the moment, it's not so great. "I have made a conscious decision to step outside of the insurance model, just so I don't have to compromise my care." In terms of taking calls, Alexandra has a partner as an internist and obesity medicine doc, and they're doing 50/50 call. But in obesity medicine, there aren't a lot of emergencies. She does use medications and it's rare that someone has a reaction. Sometimes too, when they're dealing with a specific bariatric population where they just had surgery, that might warrant some urgent follow-up. But it's not something with a very out-of-office hours burden As to having that perfect balance, Alexandra still doesn't know the answer. But she has a made a few big decisions on prioritizing her family. She also thinks men and women shouldn't be afraid to talk about this. Doctors train for a very long time and females are going to have a baby somewhere along the way. Alexandra had her baby at the end of her third year of internal medicine residency. While being pregnant that year, she decided not to apply for fellowship and to pursue this path. So the first decision she made was to step outside of training to have a little more control of her hours. She chose a job right out of residency where she didn't have to work five days a week. Her second son is now one year old. So Alexandra made her own hours and decided and when and how much or when to work. "On one hand, you've got to work a lot owning a business but it's working for myself and that makes me feel it's all worth it." [18:44] Training for Obesity Medicine Alexandra stresses the importance of obesity medicine being that two-thirds of our country make up obese people. This is a huge underserved population. That said, Obesity Medicine covers the whole umbrella of anyone treating anybody with excess weight to lose and doing it in a thoughtful and trained manner. The field of Obesity Medicine includes a variety of specialties including surgeons, pediatricians, internists, family medicine, and OB GYN. So it's not just limited to Internal Medicine. You can actually sit for the boards with any specialty. To give you a better understanding, Alexandra explains the American Board of Obesity Medicine was founded in 2011. They created a track out of training which means you have to be board-certified in a primary specialty. Then you have to accrue a certain amount of credits and attend conferences over about a two-year period. Another option is the fellowship. When Alexandra was looking to be certified a few years ago, there were not many fellowships. But the field is now exploding. In New York City for example, the number of fellowships has grown from zero to four. So in order to get into Obesity Medicine, the first path doesn't require doing a fellowship and the other is to have a fellowship. But she believes a fellowship would be great. It gives you the opportunity to have access to learning from more seasoned mentors. "The test is pretty hard so you really have to put all of your effort into being a self-learner." Nevertheless, The Obesity Society and the Obesity Medicine Association have fantastic, ongoing lectures and conferences. You get to have access to new content. They're also creating their own journals. Alexandra recommends learning and soaking everything you can so you just grow with the field as it grows. [22:30] Working with Primary Care and Other Specialties and Special Opportunities When asked what she would have wished for primary care physicians to know about the obese and overweight population is that it's not a lack of willpower. She says this is the number one misconception that makes patients so disappointed in the healthcare system. They've been told what to do traditionally, but it isn't working for them and their bodies. She explains that obesity, excess weight, or metabolic disease is multi-factorial and it goes all the way back to how much your mom gained during pregnancy, the kind of birth you had, etc. It's not just calories in and calories out. And so she encourages the doctors and medical students out there. "It's not as simple as this traditional model that we've always learned. It's complex and there are new ways of tackling it." Alexandra adds that you should try not to be close-minded. She believes words like diet doctor, medication, or diet has gotten a bad rap or connotation. People roll their eyes and think it's a fast fix and not true. She adds everyone is different and everyone should be treated in a different manner. Other specialties she works the closest with include Endocrine and Bariatric Surgeons. Also, in her field outside of Obesity Medicine, because of her interest in training in nutrition, other specialties include gastroenterology. She sees and treats patients who have IBD and help them to manage bowel disease with specific diets and ways of eating and looking food as medicine. In terms of special opportunities outside of clinical medicine, Alexandra sees this as a great area to write for education. Not every person has to go see an obesity medicine doctor. A lot of people can make some of the changes of the tools they have on their own. So anyone interested in writing or doing Facebook live video. She sees a huge opportunity for people to connect with the public at large with the information that the specialty provides people with. [26:27] What She Wished She Knew About Obesity Medicine and the Most and Least Liked about the Field Alexandra wished she had been more aggressive in creating research content within the field and connecting with mentors. It actually took her a while to find other people who were in the field. She realized out of her training now that people are happy to connect and they're happy to help you, especially in this field because they're so passionate about it and they want to see it continue to grow at the rate it has. "People are happy to connect and people are happy to help you." What she likes most about her specialty is the ability to change other people's lives. She has helped people who for years, have not been able to take off a single pound or worse. Or she has helped those who have gained and gained weight when nutritional medical system has failed them. They come to her and they start losing weight for the first time in their lives. They've taken off their medications and they cry for joy when they come back to see her. It's the first time someone…

Full show notes at the publisher

39: Academic Pain Medicine From an Anesthesiology Background Sep 06, 2017

Show notes

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

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Session 48

[02:47] General Summary of the NRMP Match Results and Data for 2017

[08:50] Table 2: Matches by Specialty and Applicant Type

[12:13] Trends in the Match Program (2013-2017): Growth, PGY-1, Osteopathic Students

[16:37] % of Unmatched U.S. Seniors and Independent Applicants and SOAP

[18:44] Charting the Outcomes in the Match 2017: Apply Broadly

[22:44] Mean Number of Contiguous Ranks, USMLE Step 1 and Step 2 Scores

[24:14] Medscape Lifestyle and Physician Compensation Reports 2017

[27:44] Final Thoughts

Links:

Session 45

[01:35] Why He Chose Cardiac Anesthesiology

[05:15] Traits that Lead to Becoming a Good Cardiac Anesthesiologist

[07:10] Why Anesthesiology Subspecialty is Important

[09:10] Types of Cases

[11:06] Community versus Academic and Taking Calls

[13:20] Work-Life Balance

[14:25] The Path to Residency and Fellowship

[17:10] Bias Against Osteopaths and Working with Primary Care and Other Specialties

[19:33] Special Opportunities Outside of Clinical Medicine

[21:02] What He Wished He Knew that He Knows Now

[22:52] What He Likes the Most and Least

[24:05] Major Changes in the Future and Collaboration Between Specialties

[28:50] Final Words of Wisdom

[30:06] Last Thoughts

Links:

Session 41

[01:33] Her Interest in Pediatric Neurology

[03:20] Traits that Lead to Becoming a Great Pediatric Neurologist

[04:40] Types of Patients

[07:00] Generalist vs. Subspecialty and A Typical Day and Work-Life Balance

[12:14] The Residency Path of a Pediatric Neurologist

[16:51] Is Matching Competitive?

[18:10] Bias Against DO's and Other Subspecialty Opportunities

[21:35] Working with Primary Care & Other Specialties and Special Opportunities Outside of Clinical Medicine

[25:35] What She Wished She Knew and The Most & Least Like Things

[29:40] Denia's Advice for Premeds and Med Students

[32:45] Final Thoughts

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