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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:

38: Discussing Pediatric Oncology with an Academic Doc Aug 29, 2017

Show notes

Session 38 Dr. Julie Krystal is an academic pediatric oncologist. Julie has been out of training now for two years. She discusses what she loves about her job, where she sees the specialty going and what you should do. Please be sure to also check out all our other podcasts over at MedEd Media for more resources. [01:00] Interest in Becoming a Pediatric Oncology Julie always knew what she wanted to do. Back in high school, she wanted to be child life person where you get to do arts and crafts with kids in the hospital. So she was volunteering at Stanford Children's Hospital where she grew up in California. She was working with a lot of oncology patients. She then realized that the more she got to work with the doctors and see the fellows, they were actually doing a way cooler job than the child life people. That's when she decided it's what she wanted to do in high school and stuck with that. She felt strongly better all throughout her training, through college and all the way through her residency. She did give other things a try since pediatric oncology as she describes is a tough path in many senses. So at some points, she tried to convince herself to like other things - better hours, better pay, etc. But nothing else was the right fit for her except for pediatric oncology which she felt was the one thing she really wanted to do. What she likes about the subspecialty is you get to have a sort of primary care relationship over long periods of time. They remove the kids from their pediatrician while they're with them and while they're getting chemo or treatment. So the relationship goes over many years because these kids get to stay with them. "You have that longitudinal sense that you get from primary care but you have much more interesting complex medical problems." Julie describes it as somewhat the best of both worlds. It's something really interesting subspecialty-wise and that relationship that's so important. Whenever she tells people what she does, their first reaction is almost always negative. They think it's awful and sad. So she always tell them that it's not sad actually. The majority of children are cured from their cancer and they go on and have wonderful adult lives. It's her privilege to be with the family during the worst, most horrible thing that's happening to them and to see them through to the other side. So this part of it just really appeals to her where there is challenge and mostly a happy ending. And if it's bad, it's really bad and really sad. But most of the time, there is knowledge that you're able to get the family over something that's really hard. Then you get to see their child go on and grow up and do wonderful things. So for her, it's a wonderful role as a physician to get to do that. [03:40] Traits that Lead to Becoming a Good Ped Onc Doc Julie cites a few things to become a really good ped oncology doctor. First, is being a sunny and optimistic person. There are sad and depressing moments. The lifestyle is tough. It's academic and it involves long hours. There's no money in it. If you're doing grants and you're fighting to the nail against everyone else to get funding, things can get challenging. So you have to be willing to devote yourself. This job involves long days and long nights. So you have to go into it knowing that. "You have to be accepting that this is your life and it's not a glamorous, fancy, sports car kind of gig." [05:18] Types of Patients and Doing Clinical Trials Julie mostly takes care of kids with brain tumors. In peds oncology, things can be specialized these days. There's hematology and oncology. She's specialized to oncology and within oncology, there are doctors who do leukemia. Some doctors do bone tumors. While she mostly takes care of kids with brain tumors, like everyone else, they have to do a certain number of weeks of the year of in-patient service. When you're on it, you take care of admissions and all the new diagnoses that come in. Nevertheless, she keeps up to date with everything by doing that kind of work. She gets to see a little of everything. The vast majority of childhood cancer is leukemia. Those are the things that in the average week of service, one or two diagnosis of leukemia will come in or one brain tumor. But the vast majority of new diagnosis every week are leukemia. Other things common in the pediatric age group are the bone tumors. Brain tumors are the most common phallic malignancies and there are a lot of those. The majority of those have a good outcome. Julie explains there's not a lot of jobs in academic peds oncology. There's more fellows graduating every year than they have open positions. Part of the reason has to do with funding since it's only academic institutions that have a lot of NIH funding. So it's very hard to find academic positions. Hence, people tend to shy away from brain tumors but Julie did otherwise. She found it to be interesting and it's a place where there's a real need. "By doing something that other people are hesitant towards, I was able to get a job that I really love." The other piece of work she does that's not directly clinical is working on early phase clinical trials. This is also something she loves and feel passionately about. There's a lot of new cancer therapies in adults and it's much harder to get those in the kids. So she works on getting early phase clinical trials up and running in her hospital. It's something she never envisioned doing but the opportunity kind of fell on her lap. She further says you don't really foresee all the stuff that are coming ahead of you but if you keep your mind open, really cool things will come your way. [8:20] Why People Shy Away from Brain Tumors Julie thinks people shy away from brain tumors because they're this own little thing. Leukemia and lymphoma are things everybody knows about. We all know what to do with it. But for brain tumors, they're much more of a niche. "If one walks in the door and you don't know what to do, it can feel really scary because it's a whole different world." Another reason she sees is that we've made huge progresses in lots of pediatric tumors. Especially in leukemia, the cure rate is over 90%, and in some cases, 95%. This is phenomenal. But they haven't had that huge leap for all types of brain tumors. There are certain types of brain tumors where the cure rate is still very low unfortunately. And she thinks people shy away from that because it's intimidating. It's hard to go through that professionally. But the way Julie looks at this is we still have room to make that progress. It's exciting to be able to keep working and trying and keep doing studies until we find the next thing that's going to make the biggest difference for this diagnosis. Moreover, she's aware of the challenges and working with families can get overwhelming. But there's room for so many great things to happen still. [09:40] Taking Calls and Work-Life Balance For Julie, she doesn't necessarily take calls. It takes three years for the fellowship and the first year of it is purely clinical. And after being a fellow, you'd be an attending and things are so much easier. So the call they take is when they're on service Monday through Friday. They're on during the day and they're also available at night. But the fellows take the first calls - from the ER, from the service, parents calling in, or from outside hospitals. And the fellows only contact the attending doctors in cases where they're looking for guidance or they're not sure what's going on. Some nights they take ten phone calls, some nights, none. So she does a week of that, eight weeks for a year. It's not a fully clinical position since she has research time. She finds this to be manageable as she gets to do other things like research and clinical trials she likes to do. Attendings don't do in-house call of any type. It's something when you're available at night time from phone. So you can still live your life. the fellows call in and ask you questions. So it's very doable. Being a mom with two kids, she explains your really have to try hard to make time outside of the hospital. On academic days, things go early in the morning and late at night. So you have to be really conscientious about it. As for Julie, she plans her schedule carefully to make sure she gets to see her kids. Since her kids are so little and they go to bed very early, she just sets an alarm or make a stopping point. She will set a time when she'd leave the office regardless of what she's doing with her work. So she gets to spend time with her kids. They go to bed and she goes to work at night. It's very important to her to make sure she has that time with them. When she's on service, those eight weeks a year, it can be very challenging. Some nights, she doesn't get to see them since she can't just leave. She thinks it's really something you have to be conscientious about. So she makes sure she plans out all of her days. So yes, you can do that but you have to be flexible and you have to plan around that and make it a priority. "It's really something you have to be conscientious about... and you have to be willing to work at home." [12:55] The Path to Residency and Fellowship Julie explains that you do a general pediatric residency for three years. Most people during this training may only have a month of peds oncology exposure. So she encourages people to get more exposure. Because during peds residency, she was terrified about oncology because they had to deal with really sick cases and they're complicated. "Get as much exposure as they can to see what it's actually like." She says that just seeing those kids on the inpatient side doesn't give you a glimpse of what is actually like to do this job. Like she said, it's only a job she does eight weeks our of the year. That leaves all the rest of they year where she's doing other things - not being with those super sick kids admitted in the hospital. So she encourages residents to try to get more exposure and get exposure to the outpatient side, the research side. See what attendings actually do. Moreover, once you do peds residency, you do another three years of fellowship, the first year being a purely clinical year. The second two years are research years, be it laboratory research or clinical research or MPH. Then you're finished. But if you want to torture yourself some more as Julie humorously says, there are sub-fellowships. So you can do an additional year of training. In things like brain tumors, you can do an additional year of training. There are brain tumor fellowships for an extra year. There are bone marrow transplant fellowships for an extra year. If you wanted to super sub-specialize and do additional trainings to get more exposure, it's something you can go on and do an extra year in that. The fellowship is all combined. The three-year fellowship is one thing you match into. It's Pediatric Hematology/Oncology. You do train in both. But most people during their fellowship are gravitating towards one or the other. They gravitate towards hematology or oncology. Most very large academic centers are separated. In her division, people are either hematologists or oncologists or bone marrow transplanter. There are smaller programs where it's combined. So they only have one service and the attendings take care of everybody. Some people like this to get a little flavor of everything. But most large academic centers are very specialized into specific niches. But everybody at this point still has to do everything in the fellowship. As opposed to the adult side, you can do a hematology fellowship or an oncology fellowship. You don't do both. But in pediatrics, it's a combined fellowship and you have to train. And the boards cover everything so you have to train for both things. Julie says matching for fellowship is not competitive. Again, this is something people try to shy away from. So most people who want a spot can find one. So it's not out of your reach if you don't have good board scores. There are a lot of fellowship spots in the country so there's plenty to go around. [16:26] Bias Towards DOs and Subspecialty Opportunities There are lots of DOs in the field. In fact, she didn't even know some of the people who were DOs. She thinks people are accepting of it and they're treated the same as an MD. Other subspecialty options available include coagulation, hemophilia, bleeding disorders, and survivorship. Survivorship is relatively new. Thirty years ago, there were no long-term survivors of childhood cancer because they have all died. Now, these kids grow up and they're thirty years old or forty. They do have certain health problems or at risk for certain health problems due to the treatment they got. Survivorship is a whole new discipline that follows these patients through their adulthood. They're being monitored in terms of what kind of testing they should get or what they should do in terms of their lifestyle. Fertility issues are a big deal for survivors. There are also programs for solid tumors and blood banking. Every hospital has a blood bank and the directors of the blood banks are all hematologists whether adult or pediatric. So you can work in blood banking. "Blood banking is a more lifestyle friendly choice." [18:06] Working with Pediatricians and Other Specialties Julie says general pediatricians worry about missing something. They're worried they're going to miss a leukemia. She feels it could be hard being a general pediatrician. Kids come in and complain of headache. And how do you know who you should be sending for scanning and who shouldn't. When kids get diagnosed with brain tumors they always blame themselves. But Julie tells them it's okay. Most kids who have a headache do not have a brain tumor. The brain tumor is the zebra here. So she wants pediatricians to know to trust themselves and follow their workup and not to second guess what they're doing. Follow their normal steps and do the things that they're doing. Every kid doesn't need an MRI who has a headache. Similarly, when they see a kid and feel they need to get CBC and need to make a call to them, pedia oncologists are available. Pediatricians call their practice a lot and she really appreciates when they do that just to get general guidance." "Pediatricians have a really hard job because they need to not miss these huge important things but also not overreact to everything." What they should know, Julie adds, is that they're doing a great job. And not to second-guess themselves and regret they didn't do something sooner or later because they're probably doing it just right. Moreover, other specialties Julie works the closest with include surgery, ID, nephrology, pulmonology, GI, and others. They get to work with all other specialties because what they do affects every part of the body. Cancer and chemo affect every part of the body. So there's no service that they don't get to consulting. And because it's a unique population, their relationships with those subspecialists is really good since they work closely together. So they the opportunity to learn a lot from them and vice versa. [21:11] Special Opportunities Outside of Peds Oncology Julie explains how the industry is a big thing in terms of pharmaceutical companies. They are always looking for pediatricians to do drug development, clinical trials,…

Full show notes at the publisher

37: A Deep Dive into Dermatology Match Data and Surveys Aug 22, 2017

Show notes

Session 37

This week, we take a deep dive into the match data for dermatology. We cover the Match data from 2016 and 2017 to give you an idea of what you're up against. Dermatology is one of the hardest specialties to match into. Historically, it has been known as the ROAD specialties (Radiology, Orthopedics, Anesthesiology, and Dermatology).

"Dermatology is still one of the more competitive residencies to apply to as a medical student."

As we dive into this data, it gives you an idea of what you should be thinking about or doing when it comes to starting your journey. Hopefully, this will help you determine how much effort you put into getting the best possible board scores and everything else you need to get into dermatology.

Also, check out everything we have at MedEd Media Network including The Premed Years Podcast, OldPreMeds Podcast, and The MCAT Podcast.

[01:51] Match Summary

As always, all of this data come from the NRMP Main Residency Match Results and Data

First off is Table 1 which shows the summary of the match. It starts with PGY-1 positions and Dermatology has 11 programs, 26 positions. Don't freak out since there are actually a lot more dermatology spots offered.

Dermatology has a prelim typically a medicine or transitional or surgery year that you do before you start your dermatology residency. As a medical student when you are applying to dermatology, you need to apply typically to a dermatology residency. This starts at PGY-2. Then you apply for a prelim year or an internship year which is your PGY-1 year at either a medicine, surgery or transitional program.

So you can't go look at those numbers on Table 1 alone. Instead, go down to the continuation of Table 1 which shows the PGY-2 positions. There you will will see they have 121 programs and 423 positions offered. Looking at this chart across the column, the total number of U.S. Seniors applying out of those 423 spots is 479. So there are more U.S. Seniors than there are spots available.

For this purpose, U.S. Seniors for the NRMP refer to students who are in an allopathic/MD medicine program and they're still in school. Now, out of those 479, 81.8% matched into Dermatology. That's a pretty good number and it's one of the higher numbers around.

"If you are a DO student or an international medical grad, your chances are already starting off not that great."

[05:00] U.S. Seniors, U.S. Grads, Osteopaths, and U.S. IMGs

Table 2 shows that out of 423 positions, 415 were filled on the main match. 346 of those 415 were U.S. Seniors, 48 were prior U.S. grads, which means prior MD graduates. These are those that possibly didn't match their first time around and then reapplied. Or maybe they didn't apply to a residency program the first time around because they weren't very competitive. They wanted to do some research. Maybe they really wanted to go to one specific program so they went to do some research in that program, reapplied, and got in.

There were 7 osteopathic students which makes up less than 2% of the 415 spots that were filled. It a very low number. Just to give you an idea, let's look at other specialties. Anesthesiology has 1,146 spots, 164 of which were osteopathic students. That's over 14% of Anesthesiology but less than 2% for Dermatology. It's possible there's still some bias tin the Dermatology world for DO's.

There were 3 International Medical Graduates or IMGs who are U.S. citizens that went to a foreign or international medical school and 11 were non U.S. Seniors or non U.S. citizens that went to an international medical school.

So it's high numbers for U.S. Seniors and good numbers for U.S. grads. Not good numbers for osteopathic students, and terrible numbers for U.S. International Medical Graduates. Lastly, it's pretty bad numbers for non-U.S. citizen international medical graduates.

"High numbers for U.S. Seniors and good numbers for U.S. grads. Not good numbers for osteopathic students."

[07:20] Growth Trends, Unmatched Applicants, and SOAP

Table 3 shows the growth trend of each specialty from 2013 to 2017. Dermatology has been growing and growing with 13.3% in 2013. In 2017, there was a 15.8% year over year growth. There were 399 spots in 2016 and 423 in 2017. There are more and more programs opening up for Dermatology which is good for you if you're interested in Dermatology.

"There are more and more programs opening up for Dermatology."

Figure 6 looks at unmatched U.S. Seniors and independent applicants ranking all the different specialties. Dermatology ranks up as the second highest for all of the programs with 33.8% total unmatched.

The majority of that are the independent applicants. They're outside of the U.S. Seniors and those were 47.3%. Almost half of the applicants were applying independently. Again, these are the IMG's and osteopathic students. I assume the U.S. grads are included here as well. The U.S. Seniors that went unmatched made up 13.8%. At a quick glance, it's the third highest behind Plastic Surgery and Orthopedic Surgery. So Dermatology is very, very competitive. Looking at Table 18 is the SOAP (Supplemental Offer and Acceptance Program) process, for PGY-2 positions, Dermatology had four positions available and all four were filled.

[09:48] Ranking, Steps 1 &2, Research, AOA

Chart 4 is one of the most telling charts when it comes to residency matching. When you match or apply to match, it depends on what programs you're applying to. A lot depends on how many program you are ranking. It's a big algorithm that matches you to programs.

"You submit a rank list. Schools submit a rank list. And the magic happens."

The median number of contiguous ranks is eight. This means that student that matched put Dermatology program eight times in a row. Those who did not match was only three. So you have a much lower chance of matching if you are much more selective when it comes to matching. The same goes if you're also being selective with the programs your'e applying to or you're interviewing at. Or you're not a competitive applicant and you didn't interview at a lot of program so could not select a lot of programs to actually match to. A lot of it comes down to how many programs you ranked. It's a numbers game. You apply to more medical schools, your chance goes up. You apply to more residency programs, your chances goes up. The same with fellowship programs.

Chart 5 dives into the mean number of different specialties ranked. Typically, if you want Dermatology, apply to Dermatology programs.

"If you have a Plan B, you're less likely to succeed in your plan A."

There's a lot of psychology research that shows having a plan B decreases the likelihood for your Plan A to succeed. But the data here shows that those who matched in Dermatology applied to a mean number of 2.2 different specialties and those that didn't match is 2.3. So the numbers are not very off. This could be skewed since in dermatology, you have to apply to a categorical or prelim year. I wonder if that data is being included in this. It doesn't mention anything in the graph data, but I wonder if that's the reason the numbers are so high at 2.2. It's much higher than everything else except for radiation oncology.

Looking at Table DM1, it gives us all the hard data behind Dermatology. The mean number of contiguous ranks is 8.9 versus 4.2. Mean number of Distinct Specialties was 2.2 versus 2.3. The mean USML Step 1 score was 249 for those that matched and 239 for those that didn't match. The mean Step 2 score is 257 to those that matched and 246 to those that didn't match. Sometimes, Step 2 score isn't really that useful. But the Step 1 score is huge here. The mean number of research experience is 4.7 for those that matched and 3.8 for those that did not match. Mean number of abstracts, presentations, and publications is 11.7. You need to get out there. You need to do your research.

"You need a very, very strong Step 1 score and a strong Step 2 score... you need to do your research."

AOA (Alpha Omega Alpha) comprised 2.8% of those that matched. This means they were very successful in their medical school classes early on. Their pre-clinical is 52.8% of those that matched and only 25.8% for those who did not match.

Chart DM2 shows those that matched versus those that didn't with the number of contiguous ranks. You can clearly see that those that did not rank a lot of programs did not match. Then as soon as you get past that eight mark, it goes down. And after eight, only six people didn't match. So you have to rank a lot of programs.

"You have to be competitive enough to get interviews and to rank a lot of programs."

[15:40] Medscape Lifestyle and Medscape Physician Compensation Report

The Medscape Lifestyle Report 2017 talks about the lifestyle of a Dermatologist. As to which physicians are the most burnt out, Dermatology is near the bottom at 46%. (See Slide 2)The lowest is Psychiatry at 42%. As to how severe is the burnout, Dermatology is hanging at the top at around 4.3. Highest is 4.6 with Urology. (See Slide 3). Slide 18 shows which physicians are the happiest and Dermatology is number three on the list at 43% happy at work and 74% are happy at home.

The Medscape Compensation Report 2017 is the fun part. Highest salary is Orthopedics at $489K a year. Dermatology is number eight on the list at $386K. Below Orthopedics are Plastic Surgery, Cardiology, Urology, Otolaryngology, Radiology, Gastroenterology, and Dermatology. These are the top eight and all of these are procedure-based specialties. (See Slide 4)

"The way our healthcare system is set up, those who perform procedures and do surgeries are compensated with more money."

Even if what you're interested in is not within these eight, that's okay. You'd still make a good living as a physician. The lowest on this list is pediatrics at $202K. Dermatology pay according to this survey on Slide 5, only went up 1% (See Slide 5). Which physicians feel fairly compensated, Dermatology is the second highest at 65% (See Slide 18). Looking at slide 38, those who would choose medicine is up there at 80% and the highest is 83%. So Dermatologists are happy. They like being a doctor. They would choose it again. Who would choose the same specialty? Slide 39 shows it's Dermatology. They love their jobs. If you want to be a dermatologist, it might be good for you to check out Dermatology.

[19:25] Be an Intern

I'm looking for an intern. If this is something you're interested, email me at ryan@medicalschoolhq.net. I'm looking for one savvy for social media who can oversee my social media accounts and help me go out and find physicians to interview here on the podcast. It would be a great help to me and we can turn this into an extracurricular for you. We'll figure out a way to make it worth your time in helping this show succeed for every premed student, medical student, and even for residents out there looking for fellowships. In the subject line, kindly place Specialty Stories Intern. And I will get back to you as soon as you can.

Links:

MedEd Media Network

The Premed Years Podcast

OldPreMeds Podcast

The MCAT Podcast

NRMP Main Residency Match Results and Data

Charting the Outcomes 2016

Medscape Lifestyle Report 2017

Medscape Compensation Report 2017

36: What Does Academic Colorectal Surgery Look Like? Aug 15, 2017

Show notes

Session 36 Dr. Scott Steele is an academic Colorectal Surgeon and Chairman of the Colorectal Surgery Department at Cleveland Clinic. We discuss his love of the specialty. He has now been practicing outside of his fellowship for twelve years now. Dr. Steele also hosts his own podcast called Behind the Knife. Check it out as well as a host of all our other podcasts on the MedEd Media Network. [01:17] His Interest in Colorectal Surgery Scott knew he wanted to do surgery from the first time he got his clinical years and did some primary care. He also considered orthopedics since he likes sports. But colorectal surgery dawned on him when he met some mentors. Not being a sexy topic, he didn't really give it much time. But he found a mentor when he was in residency. Towards the end of his second year, going into his third year and on his fourth year, he began thinking about colorectal surgery. He hung around them and went to the meeting which he found an incredible experience. He thought they did both great in surgery and academics. They take care of patients that have diseases that he likes. They do some outpatient and inpatient surgeries, colonoscopies, and major oncological reconstructions. So it was something he was interested in. He initially thought about doing heart surgery but he thought he wanted a little bit more of variety. He knew he didn't want to do orthopedics in medical school after he did one rotation at the University of Wisconsin. Although he likes orthopedics and how it's related with sports, it just didn't trigger him. "I was more in the process of easily ruling things out." So Scott did this process of ruling things out. Surgical oncology is okay but colorectal did great cancer operations as well. Surgical oncology tend to not do the wide breadth of people. They tend to serve old people, a lot of them are dying in a lot of cases. It was something he didn't want to do. Minimally invasive surgery was a burgeoning fellowship at that time and it was its own fellowship. But he thought colorectal also does minimally invasive surgery. In fact, now minimally invasive surgery is a standard component of any particular field. So it's not in and of itself. So he made the jump from heart surgery to colorectal surgery. Scott was a general surgeon. He was in the military and he spent a year after his residency at Fort Hood, Texas where he practiced general surgery. So he basically did the vast bread and butter of general surgery. But growing up in a small town in northern Wisconsin that had amazing surgeons. And as a general surgeon, he didn't want to get pigeon-holed in being the hernia guy or the bowel obstruction guy or the lap chole person. He knew he wanted to do academics. He knew he wanted to do a subspecialty. So the more and more he went into colorectal surgery, the more he realized it fit his personality. It fit all the things he was looking for in a career. "The more I went into colorectal surgery, the more I realized it fit my personality. It fit all the things I was looking for in a career." [06:03] Traits that Lead to Becoming a Good Colorectal Surgeon Scott says that it's more on how we are as people. But what he found with colorectal surgeons is that they don't take themselves so seriously in broad, sweeping strokes. They have a ton of fun. They are generally good people. But they also have a side where they're really busy clinical surgeons in the community and academic centers. And for those that did academics, it was great medicine. There was basic science research and others did hard core epidemiological research. He adds that when you walk into a clinic and pick up a chart or log on the EMR and see what they're doing, patients have a special part of their body. They may not even tell their spouses of many years about what's going on with them. It tends to be something that's very intimate and very personal. It bleeds or itches. They feel something and that patient in many cases think they have cancer or they think something's wrong. If your arm itched or bled or you felt something, you'd look at it. But that part of the body is so hard to look at. So patients have an extreme amount of trust in you. Within five minutes of talking to them, you're asking them to pull down their pants and look at their back side. A lot of things can be in that person's mind. And in all of those aspects, you have to be able to go in and establish patient rapport right off the bat. Make them understand that despite their misconceptions, it's okay. It's very routine. And many people experience the same type of symptoms they're experiencing. So you need to keep it a little bit light. Let them know you take their symptoms seriously and that you're going to walk them through the process. Keep in mind that in the United States alone, colorectal cancer is the second or third leading cause of cancer-related deaths every year. It's something we don't talk that much about. Scott says it's something they can intervene and interact with that given how serious the topic is, you don't yourself too seriously. "Colorectal cancer is the second or third leading cause of cancer-related deaths every year." [09:51] Types of Patients As a colorectal surgeon, you see all age ranges and a mix of benign and malignant diseases. Scott is the lead editor of The ASCRS Textbook of Colon and Rectal Surgery and in the book, they talk about how they organize colorectal diseases. The organize it into six folds. First, is endoscopy. It's a large percentage of what they do. They use scopes and they're able to do a lot of advanced procedures through it. Second, they see the plethora of anorectal disease such as hemorrhoids, fissures, fistulas, etc. It's the routine but stuff they do and a big part of the practice. Third subset is they see the malignancy - anal cancer, rectal cancer, colon cancer. Those are the major operations you can do minimally invasive procedures. You can use laparoscopy and open surgery. You can do robotics and all the different neat tools and tricks you do. Fourth, is they get to see a lot of the benign disease which includes a lot of the inflammatory diseases such as IBD, the Crohn's disease, ulcerative colitis, and diverticulitis. Fifth is you also get to see pelvic floor disorders. Those are the patients with obstructive defecations and those with rectal prolapse or fecal incontinence. And last is your miscellaneous type. But the first five types mentioned by Scott are the ones where when you talk about colorectal disease, you can break each of those down. You can see how you have all the plethora and combine that with scopes where you can do things endoscopically. They have one person in their department who is a very gifted and technical surgeon. He was able to take off early cancers through the colonoscopy and save people from having to go major surgery. It's that wide breadth of patient variety, ages, outpatient, inpatient, scopes, major operations that is the unique part of colorectal surgery. Contrast that with things like surgical oncology or cardiac surgery and that's what drew Scott into the field. “It's that wide breadth of patient variety, ages... scopes, major operations that is the unique part of colorectal surgery.” [13:20] A Typical Week For Scott, he spends his Mondays in the operating room. He has all-day clinic on Tuesdays. Wednesday is his admin day as the Chairman of the Department. He typically has a lot of meetings. Thursday is an operating day and Friday, he does scopes and some afternoon meetings. This is a pretty standard week for people where you have a mixture of clinics and other things. The person who started Relay for Life, Gordy Klatt, was a colorectal surgeon. He died a couple of years ago. He was a community colorectal surgeon and one of the last independent providers. Scott covered for him for seven years. Scott was in the military and would take some vacation and cover for him. He had a much different practice. He saw clinic a half a day everyday. He would operate on most days as well. The admin days are part of many private practices but it wasn't part of his. He ran his own business with his wife being his business manager. He would have major operating days maybe three days a week. And he would do colonoscopy on a certain day of the week. He would also always come back to his clinic. So there is a wide variety depending on where you're at and what is the practice you're in. If you have a big group practice or a multispecialty clinic such as the polyclinic in Seattle or if you're working at an academic medical center like the Cleveland Clinic. It has a very busy high volume center. "Depending on what your niche is and what you'll be able to do really would determine your practice." Somebody in his department that does pelvic floor may see a little bit more clinic than somebody who's an IBD specialist who may have a mixture of clinic and operating days. So this varies according to the individual unique practice that you want to set up. [16:00] Operations and Calls Scott says they treat colorectal disease. And as a part of that, the referral pattern you're in would determine a lot of how much medical management has already been done. Many pelvic floor disorders, for example, need medical therapy or workup. Fecal incontinence in many cases can be treated with bulking agents and some Imodium and some pelvic floor retraining. So they won't need an operation anymore. There's also a study that 50% of hemorrhoid consults are not hemorrhoids alone. Or there's something that never needs an operation. Diverticulitis can be treated with antibiotics. So you can see that a lot of these disease processes are treated with multispecialty type approach that medical management is a major part of it. So on a typical clinic, not accounting your post-ops or your follow-ups, anywhere between 20% or 30% depending on your individual practice may require surgery. But all of them have some semblance of needs for the colorectal surgeon to treat either surgically or medically. "They look at you as an "expert" of the hindgut to treat whatever is going on so you do have to know your medicine." With regard to calls, Scott says they vary more than anything else. It depends on who takes the call and how many people are there in the practice. It also depends if you're asked to do general surgery and colorectal or just colorectal surgery alone. It also depends if you have acute care surgery or you have fellows and residents. Scott thinks that they're one of the largest colorectal departments, if not, the largest in the United States and maybe in the world. They have well over 20 colorectal surgeons. So for them, call is busy. But they can be extremely busy when you're on call because it's a major referral center. At their clinic, they get patients all over from the northeast Ohio to Kentucky, West Virginia, and all over the world. So a lot of the diseases that can happen that affect the colon in such a busy hospital. They have fellows and residents. It's a very busy fellowship and a very busy residency. Scott says they are up all night long. It's a busy call but they're not crushed with calls. He has been on call a lot more in other places that he has worked. Additionally, you have to determine that as a subspecialist, especially a subspecialist branching out from general surgery. This could include bariatrics or minimally invasive surgeon, surgical oncologists, colorectal surgery. In each of these, you're oftentimes asked to take general surgery call. When he was in the military, his call was colorectal surgery and also general surgery call. That mixes in your bowel obstructions, cholecystitis, appendectomies, hernias, etc. That can drastically change your call in terms of the number and the types of patients you see. Some people want to do that. Scott did general surgery call for seventeen years. But he doesn't do it anymore and he doesn't do trauma anymore. He's fine with that. But other people are looking for jobs as a part of their colorectal practice that they can still do a little bit of general surgery. Unless you're going to a major medical center where it's a colorectal call only, you may be asked to do some general surgery calls. And that has its pluses and minuses. Some of their east side hospitals take a bit of general surgery call. That's part of the institution you're working at. People primarily at the outer institutions away from the main campus take general surgery calls. But that's part of the hospital they're a part of. They also have other jobs in the hospital. You're working with people and you get to know the fellow doctors you're working with. You help out. You cover for them and vice versa. So that's a unique aspect of that. Scott took general surgery call because he liked it. At times it's rough. But he can say that especially earlier in your career and especially if you're going to a community based setting, don't be surprised that you're going to be taking some general surgery call. "If you're going to a community based setting, don't be surprised that you're going to be taking some general surgery call." [22:45] Work-Life Balance Scott explains that time is the most precious commodity that you have. That's why you need to prioritize. Really determine what do you want to do in life and what do you want to be. What are your goals? Regardless of your specialty, you have to prioritize and figure out what type of practice you have. What type of priorities do you have and where do you go? Earlier in his career, he knew he wanted to do academics. So he had a very hard time saying no. Anybody would ask him to write a chapter and he would do it. Or they'd ask him to review an article or travel or teach a course or cover a call, he'd do it. Being in the military, he started being deployed. And then he got deployed for a number of times. The next thing he knew, he has one daughter, grew up and realized he's missing a lot of her life. You're going to be busy. If you want to do academics, there's never enough time for academics. There's no such thing as protected time. And even for those who have "protected" time, everything else impinges on it. So you have to really set aside time to decide what you're going to do. Scott has had friends who started on academic career and did a bunch of stuff. Then they felt they didn't have the passion for it. So they stepped back from it or did it selectively. And that's great because it works for them. Scott likes academics a lot and says that unfortunately, you have to find time. He reviews for a number of journals and serves as an editor for several textbooks. He has traveled the world and has met wonderful people. He has operated in places he never thought he would operate on. He would have never thought he'd see some of those places and had the unique experiences. "Academic surgery has been a very fulfilling and wonderful career. " But Scott knew he wanted to be the guy who wants to be involved in the journal and the textbooks. He wanted to be involved in teaching fellows and residents. So when he sits down with fellows, he asks them who they want to be. Training is funny especially in medical school and residency. You constantly have people come up to you and say how you could chose this profession and that. You feel this angst that you can't talk bad about. Or you can't say what you really want to do. Especially when you're training in academic insti…

Full show notes at the publisher

35: Private Practice Pediatric Ophthalmology Aug 08, 2017

Show notes

Session 35

Dr. Chris Fecarotta is a Pediatric Ophthalmologist. He has been in private practice for five years now. He shares with us his reasons for choosing the specialty and what you should think about if this is a field you’re considering.

I would love for you to recommend The Premed Years Podcast to your premed friends along with our other podcasts on the MedEd Media Network.

[01:30] Interest in Pediatric Ophthalmology

Chris admits he didn't know he wanted to be a pediatric ophthalmologist until late in the game. He figured it out at the beginning of his fourth year. Knowing he always wanted to do kids, he went into medical school thinking he would be a pediatrician of some sort. But he didn't know exactly what.

Then he discovered as he went along that he wanted surgery more. He had a friend who had some family members who were in ophthalmology. He talked to them about it and though it was an interesting field. So he decided to put the two together and thought about doing pediatric ophthalmology. He shadowed a pediatric ophthalmologist and went into residency thinking it was what he would do and stuck with it.

"The eye is a very fascinating organ. It's a lot more complex than people think."

Chris says he likes the very small surgery. He likes the patient environment considering he's not a huge fan of doing in-patient work. So pediatric ophthalmology fit all those things very well. He also likes how it can afford a reasonable lifestyle. There are not that many emergencies in it and you can really make a big difference in children's quality of life by improving their vision. These are the things that really appealed to Chris.

[03:16] Traits That Lead to Being a Good Pediatric Ophthalmologist

Chris stresses how important it is to enjoy working with children. It's a very challenging field as he describes it. It's not the easiest thing to convince them that it's okay to examine their eyes. So you have to be able to work well with children. You have to be very patient and have a very good rapport. He also adds the importance of being detail-oriented, especially for ophthalmology since they deal with a very small organ.

Chris says there are people who have the natural ability to do surgery especially small surgery. But he doesn't think it's not something it can't be learned. It's not something you need superhuman dexterity for. Some with normal dexterity can do it with dedication and practice.

"I don't think this is not something that can be learned. I think it's very possible to learn it."

Chris explains there are varying levels of natural ability just like with anything else. There are people that find they're just not really cut out to do surgery. But that's rare. Most people can learn it and do just fine.

[05:35] Types of Patients and Typical Day

Chris treats mostly children with strabismus (cross-eyed) or amblyopia (lazy eye). These are the bread and butter of pediatric ophthalmology as well as nasolacrimal duct obstruction. He sees all age ranges and premature babies who have retinopathy of prematurity all the way up to young children with strabismus and amblyopia. He also sees teenagers continuing their eye care. He also treats adult strabismus. So he treats all ages, mostly children.

"Pediatric ophthalmologists also generally treat adults with strabismus from a variety of causes as well."

As a private practice doc, Chris gets to the office between 8:00 am and 8:30 am. He sees patients through the day. He doesn't typically take a full lunch although he tries to sneak food in-between patients. Then he's generally done between 4:00 pm and 5:00 pm. He takes call but it's generally not very demanding. There are eye emergencies but there is not that many of them. Usually, most things can be triaged and then seen the next day.

An example of eye emergency where he as to go in is an injury where the eye is ruptured globe. It's an emergency if the eye is cut and the contents of the eye are exposed. It usually needs to be surgically repaired that night. Another eye emergency is a retrobulbar hemorrhage from an orbit fracture or trauma to the eye. If there's bleeding behind the eye in the orbit, it can cause a compartment syndrome that can compress the optic nerve. So it needs to be decompressed. Angle-closure glaucoma is another one but this does not happen in children. So it's not a pediatrics problem but this is one of the other few emergencies in the ophthalmology field. Other than these emergencies, most things can be pushed off until the next day.

[08:18] Private Practice and Work-Life Balance

What caused Chris to move from academics to private practice was his friend offering him the job along with his wife. It was more of a personal decision for him than anything against academics. He mentions both private practice and academics have upsides and downsides.

Only 10-15% of his patients are brought in from the outpatient setting to the operating room. Most of his patients are not surgical in pediatric ophthalmology. In general or adult ophthalmology, there is a higher percentage of surgical patients. Most of the adults are there for cataract surgery. Pretty much everybody, if they live long enough, gets a cataract and needs surgery.

"The volume of surgery for pediatric ophthalmology is less than general ophthalmology."

In terms of work-life balance, Chris thinks it's one of the most ideal fields for that. If you like surgery and you like children and you want a reasonable life, Chris thinks it's a great choice. There is also a big need for them. There's not that many pediatric ophthalmology so it's easy to find a job, not to mention that it's very rewarding.

[10:12] Path to Residency and Fellowship

The path to ophthalmology residency includes an intern year. Most people do a transitional year but you can also do a medicine year. Some programs will let you do a pediatric year if you want to specifically do pediatrics. Then you would have to do ophthalmology residency consisting of three years. Then a year after that, you can do a fellowship in pediatric ophthalmology of strabismus. So it's five years after medical school graduation. It's not as long as other surgical fields.

Chris says ophthalmology is competitive to match in out of medical school but pediatrics is easy to get a fellowship in.

"It's not a very popular fellowship so there's open spots usually. Most people can get a spot if they want."

There are a couple of reasons Chris thinks the fellowship is not as popular. First, he doesn't think most ophthalmologists go into the field looking to deal with children. He thinks he's an exception but most are not that thrilled about seeing children. They didn't go into it for that reason.

Children are much more difficult to examine than adults so it's challenging. And he thinks a lot of people are intimidated by it or don't want to deal with the hassle of examining the child. Another possible reason is that it pays less than general ophthalmology for a variety of reasons. One, is there's less surgery. Just because the field is less surgical, a lot of children are on medicaid. So the reimbursement for pediatric ophthalmology is not as strong as for general ophthalmology. So Chris things these things discourage people from choosing it. But if you like children and it's what you want to do then it's a great field to choose. He would still encourage anyone to do it if they like kids.

Like all the competitive fields, the most important thing to be competitive for ophthalmology is to do well in your classes and your USMLEs. Chris thinks it's your letters of recommendation that can get you in the door to an interview. Then have a good interview where you're likable and people can see working with you for three years. Chris believes that research helps but doesn't think it really makes or breaks anybody.

"You get your foot in the door by your academics and your letters of recommendation. Then your interview is really what seals the deal."

With regard to sub-I's, Chris thinks it's not a bad idea to make yourself known by doing a sub-I. But you have to make a good impression otherwise you've pretty much killed your chances of going there. So you better make an A+ impression or else you'll actually probably hurt yourself.

[14:30] Bias Towards DOs, Subspecialty Opportunities, and Working with Other Specialties

Chris thinks it's challenging for a DO to get an ophthalmology residency but it's not impossible. There are DOs in ophthalmology. There are specific DO ophthalmology residencies so it's definitely possible. And once you're in ophthalmology, getting a pediatrics fellowship is not hard at all as what Chris has mentioned. The hard part is if you were a DO and got into ophthalmology residency. After that, you can do pediatrics if you want without a problem.

Once you're a pediatric ophthalmologist, there are other opportunities to further subspecialize. Although most people don't do it, you can do a second fellowship. But if you want to be very academic and you want to be the world's expert on pediatric glaucoma, you could do a second fellowship in glaucoma. You could do neuro ophthalmology and do pediatric neuro ophthalmology. There are only four or five of them in the country. And this can help you in terms of finding jobs and being an academic.

"You can subspecialize within pediatric ophthalmology but the vast majority don't."

Other specialties they work the closest with include pediatric ENT, pediatric rheumatology, and pediatrics. The general pediatricians are usually the referral source for a lot of patients.

To make their job easier and provide more care for the patient, pediatricians being able to provide history always helps. He also thinks most pediatricians know they need to do that. So he doesn't really have much problem with that. He doesn't think most non-ophthalmologists are comfortable with the eye. So he would encourage them to refer to pediatric ophthalmology if they're concerned about anything. Better be safe than sorry. They would be happy to see any patient any time. So they should send patients to them if they feel uncomfortable and let them help.

Moreover, Chris recommends to primary care doctors to have the book The Wills Eye Manual in their office. It's the most common manual of ophthalmology out there. Most eye providers have it in their office. They can look up the different diagnosis, treatment, follow up, differential diagnosis, etc. They can use this book as a reference for anything they want to look up about eyes.

When it comes to special opportunities outside of the office, Chris says that if you're going to be an academic pediatric ophthalmologist, there's always good pathways to be a chairman. There's also lots of research you can do.

[18:59] What He Wished He Knew and His Most and Least Liked Things about the Field

Chris was initially discouraged from pediatric ophthalmology by other ophthalmologists who said that the pay wasn't very good. While it may be true they make less than general ophthalmologists, he doesn't think it's a reason not to the the field. He feels they get paid pretty reasonable. So he would probably go back in time and tell himself not to worry about that.

"If you like kids, I think you should go ahead and do it and not worry about the money because the amount you get paid is reasonable."

What Chris likes the most about being a pediatric ophthalmologist is being able to play with the kids everyday. It's a lot of fun. He thinks they're adorable. There's everyday that they say something that would make him smile or laugh. For him, it makes the whole day worth it. On the flip side, what he likes the least is the small 5-10% of children who are very difficult to deal with. He had to pry their eye open to get him to do an eye exam.

[20:00] Major Changes Coming to the Field and Chris' Final Advice for Premeds

Chris mentions some interesting things on the horizon for ophthalmology. recent research has been focused on treating amblyopia with a certain type of iPad game. It encourages stereopsis in using both eyes together to treat amblyopia. This is an exciting development in their field that he's waiting to see the results from.

Retinopathy of prematurity is a disease they commonly encounter and there are some new treatment options in the last five years. They're waiting for really good results from it. So there's a lot coming around the corner. It's a very rapidly moving and progressing field.

"Ophthalmology is a very exciting field for technology and innovations. There's always new stuff going on."

Lastly, if Chris had to do it again, he would have chosen the same field in a heartbeat. He thinks it's a really great field. His advice to premed students out there is to not jump into making a decision. Take time. Do rotations and explore as much as you can before making a decision. Once it's made, you can't really change it. It's difficult.

[21:45] Last Thoughts

If you are thinking about pediatric ophthalmology or any pediatric subspecialty for surgery, this gives you an idea of what is out there for you. If you have any recommendations for specialties we haven't covered yet or you know somebody you'd like to hear on this podcast, shoot me an email at ryan@medicalschoolhq.net.

Links:

The Wills Eye Manual by Adam T. Gerstenblith

The Premed Years Podcast

Specialty Stories

www.medicalschoolhq.net/group

ryan@medicalschoolhq.net

34: Community Based Interventional Gastroenterologist Aug 01, 2017

Show notes

Session 34 Dr. Sushil Duddempudi is a community-based Gastroenterologist who specializes in interventional endoscopy. He has been in practice for ten years now and specifically as an interventional endoscopist for the last seven or eight years. He used to be in academic hybrid private practice. Check out what he thinks about the field and what you should be doing if you're interested in this field. Also check out all our other podcasts on MedEd Media Network. [01:45] An Interest in GI and Interventional Endoscopy Dr. Sushil Duddempudi knew early on that he was going to be in a procedure-based field. It's a running joke in the field that GI people aren't smart enough to do anything else so they use procedures as much as they can. Then leave the complex stuff to the nephrologists, neurologists, and everybody else. Sushil started residency leaning towards cardiology until realizing he hated EKGs. So he gravitated towards the GI field. He says it's not uncommon for students somewhere during their intern year where they're interested in one area. Once he started the GI fellowship, he knew he was into doing procedures. He found interventional endoscopy as a good fit for him because it lets him do procedures most of the time. But he still has this continuity with his patients which he loves. So about two-thirds to three-quarters of his time is spent doing procedures. Then maybe a quarter to a third is spent in the office seeing patients. "GI is a pretty cut and dry field compared to some of the other fields." Sushil describes they usually have a definitive diagnosis early on after seeing a patient and he likes the finality of it. GI borders that surgical mindset and a lot of GI's have mindset.They see a problem and they want to take care of it. Also with GI, there is finality. If the patient has rectal bleeding and you had a colonoscopy then you'd have an answer 99% of the time. When patients have abdominal pain unless it's functional, most of the time, they come up with an answer. Moreover, Sushil likes the opportunity to do procedures. Other specialties he did consider include ENT or Neurology which would have probably worked for him as well or one of the subspecialties that are procedure-based. Ultimately, he ended up in GI. [04:40] Traits that Lead to Being a Good Interventional Endoscopist Sushil describes how many of those starting GI fellowship often say they want to do interventional endoscopy. Then over their first year or two, they'll select out. "You have to enjoy doing procedures." Some fellows he has worked with and trained over the years come in with a certain special knack. Some people just have good eye-hand coordination better than others. 90% of it can be taught and trained. But the people they look up to in the field are born with a little bit of it. This is what Sushil differentiates them from the rest. They are the guys doing the hard core cutting edge stuff. So it's a bit of something you bring within you into the fellowship and then 90% of it is just practice. [06:15] Patient Types and Typical Day If you're an academic interventionalist, you can tailor your practice to focus on that. This could mean 75% of your practice doing procedures. Community-based interventionalist flip it all the way around. In gastroenterology, the bread and butter is still colonoscopy. If you're a community-based interventional endoscopist, you could be doing around 25-75% general and then the remainder is advanced interventional endoscopy. Then as you get older and you've done all the cutting edge stuff and you want to settle in a little bit, you can then focus on general gastroenterology. Then you can do the interventional stuff maybe 25% of the time. For general GI, the younger groups tend to come in with more functional disorders and abdominal pains. As they get older into their 50's, they start to do a lot of colonoscopy screenings. Also in the 50's and 60's, they start to see a lot of GI cancers. "Interventional endoscopy is very focused on GI cancer. That's where a lot of the techniques are being used." For general gastroenterologists, most of them will do roughly about a half day in the morning. They start at around 7 or 8 to about 12 or 1pm doing endoscopy. Generally, you are in an outpatient surgery center. Then the afternoons would be spent in the clinic. Sushil says that more and more gastroenterologists are coming out of the hospitals and staying in their office in surgery centers. Moreover, a new breed of GI hospitalists are starting to happen where you're focusing on inpatient training. This happens less in the big cities. But generally it's a mix of outpatient procedures an outpatient office visits which is 90% of what gastroenterologists do. While the other 10% would be composed of inpatient. If you're an interventional endoscopist, you'll me a little more focused on the in patients because that's where a lot of the work comes in. This involves cases like bile duct construction, GI tract tumors, etc. Although they see this in the office, a lot of work comes in the emergency room. In Sushil's practice, the way they do it in the group is that most time is spent in the hospital early on. Then after two years, you will transition out to the outpatient side. So the new guys coming in cover all the hospital work. Then the partners are just focused on the outpatient work. "Like many practices, it transitions over time based on your interests, time constraints, the type of practice you have." [10:56] Work-Life Balance Sushil didn't actually feel he had any work-life balance. But he would say that in general, interventional endoscopists are in the hospital the latest. "It's definitely a field that you're committing extended hours compared to general GI guys." This is because more of your work comes in in the inpatient setting which is always unpredictable. Your day could be extended. And the procedures you do tend to be a little longer . They are a bit less predictable than a colonoscopy or endoscopy which you can do in fifteen-minute blocks. Interventional endoscopy procedures are a bit harder to put into certain blocks. [12:30] The Path to Residency and Fellowship For interventional GI, sometimes called advanced endoscopy, you do your three-year medicine residency. Then you do three years of general GI fellowship. And then there is another year of sub-fellowship. This has actually has crept up in the last five to ten years. Currently, there is only one ACG-accredited post GI fellowship that is liver transplant. And there are are five non accredited which include interventional endoscopy, clinical hepatology, motility, inflammatory bowel disease. Interventional endoscopy is the most popular. Just a year or two ago, interventional endoscopy actually went into a formal match process. Previously, you just apply to all the programs in the country and you get interviewed, you get offers and pick one. Now, it's a formal match process. It's also expected that in the next couple of years, it will be a fully accredited ACGME fellowship just like interventional cardiology. If you didn't do the special training, you wouldn't be able to do certain procedures in GI. Currently, a lot of the older generation gastroenterologists still do ERCPs. Most of the younger people don't because they did numbers of them on their training of all GI fellows. So once it comes to full fellowship and board certification, it's expected that new trainees, if they don't do the actual training, won't be allowed to be allowed to do ERCP, EUS, and stents, and other interventional procedures. Interventional GI fellowships are pretty competitive as Sushil describes it. GI and cardiology balance it back and forth when it comes to post-medicine fellowships. "GI, number-wise, is the most competitive fellowship." When Sushil applied eight years ago, there were only about 30 program in the country. Now, it's close up to 75 with about 35,400 GI fellows graduating a year. So he reckons only 25% apply for the advanced interventional training. Although he wouldn't describe it as ultra-competitive but the majority of fellows he had trained that wanted to get it got in. Some may have to wait a year. But most fellows interested, eager, and did the right electives and the right types of research, got in. Sushil says you have to be focused and you need to take the right steps. Then there's a pretty good chance you're able to get into a spot. [16:37] What Makes a Competitive Applicant Sushil cites some qualities of a competitive applicant. He adds most interventional endoscopy directors look for people that have that extra knack (eye-hand coordination). Some of the hard skills are hard to train in one year. You need fellows that already have some experience. Moreover, you are gauged through letters from your program director and the number of procedures done during your general GI training. He adds it's important to consider who you want to hang out with for the whole year. "Unlike other fellowships, interventional fellowship is a one-fellow-a-year at any program." So it's basically just you and you're generally working with one to three core interventional endoscopy faculty. So you're spending a lot of time with just a couple of people. Compared to general GI training, you're rotating around different hospitals and different services. So you work with a number of faculty. This is different from interventional endoscopy training since you're only focused with one person or two. So who do you want to hang out with for a year? Lastly, be nice to them on your interviews. [18:30] Bias Against DOs and Working with Primary Care and Other Specialties Sushil had the opportunity to train alongside DO's throughout his career. There have been some who were awesome while there have been some who weren't so good. This is also true for MDs and just with any other specialty out there. But in terms of inherent institutional bias against DO's from the program directors, he doesn't think there is any. They don't look at it one way or another if a resident DO has gotten into general GI fellowship or interventional endoscopy. He adds that once you got to that level, you're met a lot of floors already. So he really doesn't think it's as relevant. Looking at interventional endoscopy fellows across the country, Sushil estimates that at least a third of them or maybe more are foreign grads. In terms of working with primary care physicians, Sushil explains how fellows complain all the time about nonsense or bogus consults. But because he thinks his career has been mostly private or quasi-private settings, his view has changed. "If a primary care or hospitalist called me, what I know and what they know are two different things." While he may see it as a simple question and answer and it's going to take him two seconds, they may see it as something more complicated. If you'd ask Sushil the protocols or the GNC7 or up to 9 in primary care, he would have a tough time treating hypertension diabetes. That's because he hasn't done it so long. Hence, he looks at it as something they don't do very often. They have a question. They need some help. So if a primary care physician has a question, the best thing to do is just call your local GI guy. Mostly, GI guys are laid back and not too uptight. His referral networks all have his number so they can always reach out to him whenever needed. As a specialist especially in GI (maybe more so in other fields), Sushil explains they're here to provide a service for them. They're here to do procedures and solve problems primary care physicians don't have the tools to solve. So when they call, help them out. Other specialties he works with the most are general GIs and surgeons for interventional endoscopy. They work a lot with specialty surgeons like biliary and colorectal as well as interventional radiologists. Things they can't take care of generally go to surgery. "That's where interventional GI has found its niche. It's at the interface between medicine and surgery." They don't cut on the surface or on the skin but they do almost all of their cutting inside. Sushil describes it as the next evolution from open surgery to laparoscopic to robotic. Now there's a new thing called NOTES (Natural Orifice Trans Endoscopic Surgery). They're doing surgical procedures through natural orifices. As a result, there is less incision time, and less recovery time. They're still trying to figure out where the interface is going to be. Whether it's surgeons doing these procedures or interventional GI guys or a radicalization of medicine surgery that are going to end up being guys that do these types of procedures. [23:57] The Most and Least Liked About His Specialty What Sushil knows now that he wished he knew back then is that anybody on their feet a lot for doing procedures have got to have very comfortable shoes. He wished he had bought a quality pair of shoes right after training. He went from one brand to another until just back to regular sneakers. What he likes the most about being an interventional endoscopist are procedures. He loves doing it. He loves the definitive nature of it. He likes that a patient comes in with a certain specific issue. And he's able to solve that issue most of the time. He likes to be able to give them definitive answer. What he likes the least is being oftentimes the first person to inform someone that they have cancer since they deal with a lot of GI oncology. Sushil explains it's very rare that an oncologist has to give someone a cancer diagnosis. Usually by the time they're going to an oncologist, diagnosis has been made. Unfortunately, they get a lot of referrals for lumps and bumps on a CT scan and they're the first one to have to break the news to the patient that they have cancer. No matter how many times he has done it, he feels terrible every time. Colon cancers are pretty terrible but a lot of stuff they do in interventional endoscopy is pancreatic, liver, and gallbladder cancers which are generally not so treatable. [27:00] New Changes in the Field of Interventional Endoscopy Sushil sees the field as having this continuous evolution. If you went in for a colonoscopy for whatever the reason and they found a four-centimeter polyp, they'd stop the procedure. They'd work the patient up. They'd give them a referral to go to see a colorectal surgeon. About ten to fifteen years ago, that changed. Gastroenterologists started doing advanced training, becoming interventional endoscopists. They started doing removing those polyps out themselves. It's relatively rare that a non-cancerous polyp in the colon is sent for surgical resection. It's relatively rare nowadays for a procedure called a PTC to be done. This was a procedure done routinely after cholecystectomy. The procedures they're starting to do now are coaching more and more on the surgical fields. Patients often went for surgery before for a lot of GI polyps and tumors, etc. A lot of that is now done more being minimally invasive that's being done by laparoscopic surgeons. But even more minimally invasive than that is where a GI guy comes in. "We're continually moving into this more and more non-invasive type procedures." A their technology is getting smaller and smaller, they're able to go into areas that thy were never able to go in before. Lastly, if he had to do it all over again, he still would have chosen the same thing. He enjoys GI and interventional endoscopy…

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33: An Academic Pediatric Neurologist - Headache Doc Jul 25, 2017

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Session 33 A lot medical students go through the process end up at a time where they have to submit their rank list and they have no clue what they want to do. And this is a lot of unneeded stress. In this podcast, I talk to a specialist that you can't get hold of so you can understand what is out there for you. Today's guest is Dr. Lauren Strauss, an academic Pediatric Neurologist who specializes in headaches. She is a DO at a large academic medical center for an allopathic residency program. She is currently the Residency Program Director at Wake Forest Baptist Medical Center for Pediatric Neurology. Listen to her thoughts on the field and what you should be looking into. Also check out our other podcasts at MedEd Media. [01:50] Interest in Pediatric Neurology Lauren has an interesting background having started in engineering. She did her major at UPenn in bio-engineering. She has always loved science and math. Her grandfather being an engineer and not having any doctors in the family, Lauren decided to do engineering. She thought bio-engineering would be offering her a big variety. What she found she loved the most was being able to do projects that brought them over to the hospital and allowed them to interact with clinicians. When she decided to do her senior engineering project, she ended up in the Neurology lab where they did research related to vertigo. At that time, she didn't know she wanted Neurology but she knew she liked other things outside of engineering. After graduating in engineering, she decided to take a year off while looking into medicine as an option. She worked at a pediatric practice for her pediatrician. She worked there for a summer which later turned into a whole year. Then she realized she wanted to go to medical school to be a pediatrician. It was during their pediatric subspecialty month that she could rotate through a lot of different specialties and neurology was one of them. It still didn't hit her at that point that it was what she was going to. When she picked a full month in a pediatric specialty, some subspecialties she signed up for were already filled except for pediatric neurology. She did the rotation anyway. "It was the perfect opportunity mixed with meeting the right people at the right time." Then she decided to apply to Pediatric Neurology. Lauren describes it as a hard decision to do. Nowadays, most programs are categorical where you do your pediatrics and neuro in the same location. But at that time, there were still some where you could train at two separate places. Hence, it was a difficult process. When she talked to her medical school at New York College of Osteopathic Medicine, they never had anyone else who had done Pediatric Neurology. She is very happy she did take the plunge though. Where she ended up doing her training was pediatrics at a larger children's hospital at Long Island Jewish Medical Center. Then she did her child neuro training at Boston Children's Hospital. She then found out that a lot of people will pick an interest within Neurology and academics and go on and subspecialize with fellowship. She initially considered epilepsy since majority of the practice in pediatric neurology is developmental delay epilepsy and headache. Since she had an engineering background, she felt it was best for her to go into epilepsy. The reading of EEG's relies on physics. She soon discovered her love for patient interaction and taking a history from a patient and solving a puzzle. But she didn't love reading an EEG as much and sitting by herself. [06:18] Becoming a Pediatric Headache Specialist Lauren says a lot of people don't know you can subspecialize in headache. As a new emerging specialty, Headache Medicine is part of a UCNS (United Council for Neurologic Subspecialties) fellowship. A lot of people going into the field are adult headache specialists being the paved route. It's much easier from the adult side. "Headache is a new emerging specialty." Lauren notices that headaches in kids can be as young as age two but majority of them are in the pre-teen or teenager years. She loves the challenge of convincing the patient to give her that history. She also loves the overlap with some of the social dynamics and healthy living. She loves how to coach them back towards a better life. She also likes the fact that a lot of headache patients tend to get better if you have the right tools in place. She finds this very satisfying. So when she looked into Headache Medicine, she explored her other options including a pediatric pain fellowship as well as an adult pain fellowship. She likes procedures but realized she didn't like it to the extent that majority of her practice was going to be procedures. So she ultimately settled in doing a headache fellowship. She ended up doing an adult headache fellowship at the Brigham and Women's Hospital, one of the first headache centers established in the country. Their adult headache fellows were very interested that she was doing her child neurology training locally. So they got interested in collaborating with and training a future pediatric headache specialist. Lauren is actually one of the pioneers of the said field. She knew that when she graduated fellowship, she wanted to have all of the necessary tools. If she left the programs in Boston, then she would want to be at a center where there is no other pediatric headache specialist. She is currently at Wake Forest being one of the few fellowship-trained pediatric headache specialists in a several-state-region. Moreover, she is heavily involved, not only in patient interaction, but also in education and community efforts. She is streamlining protocols for the emergency room and educational materials for patients. It's very common but there is also a lot of need in headache since not everyone has gone onto this subspecialty level. [09:07] Traits that Make a Good Pediatric Headache Specialist Lauren illustrates that anyone interested in going to pediatrics has to be a little bit more patient and creative. "You have to be able to adapt to new situations." When you're examining children or taking a history from a child or family, you have to be willing to go out of order. The child might not let you examine at the beginning of the visit until the end of the visit. So you have to be able to charm people. You have to use your communication skills to warm up the child or the parents to what you're trying to ask and what the plan is going to be. In headache, those skills are taken into the extremes. The patients and their families are dealing with a situation where their child is very much in pain. They don't initially know other families are dealing with the same condition. So it can be very isolating and very anxiety-producing. It can be a huge struggle. Moreover, a lot of these patients can be very disabled by their condition. They can look like other children but they're dealing with special issues. They could miss school and have many other challenges. As a specialist, they have to be able to coach them and be firm at times on helping them get back. Hence, communication is very helpful. Lauren adds that you want to be a little bit of a problem-solver. You may want to ask a few more questions to make sure it's migraine and not something else. You have to be able to understand the exam and how that fits into the history. [11:15] Patient Types and Procedures In general neurology, they see all ages up to eighteen in pediatric neurology. In the outpatient setting, they will usually do evaluation for young children who are delayed in walking or talking. They try to understand if it's something they're going to catch up on. Or is it something related to a genetic condition or a metabolic condition? You need to assess if you need to do another workup. How do you help them get the right services they need so they can catch up on their milestones. Additionally, they see first time seizure patients or refractory seizure patients. They try to see how they can help diagnose the right epilepsy condition. They have a lot of patients that get better. They can make a diagnosis of a seizure disorder that they know by the time they're teenager, it may go away or in a few years. So they have to make not only a diagnosis but also be able know whether it fits into an epilepsy syndrome. This way you can help the family understand what the true prognosis is. So epilepsy is a big bulk as well as headache. Since her passion is headache, most of her outpatient practice over time has become headache. Headache patients come in various types. You can see someone with their first headache that may be had some interesting features to it. They can have a visual aura. Children, just like adults, can have very interesting aura symptoms for their migraines. They can see a cracked glass, speckled colors, sparkles, shooting stars and a whole gamut of things. And this can be very scary for the first time it happens. Part of Lauren's expertise is sorting out how consistent it is with migraine or if there's any workup needed. She also sees patients with repeated headaches or those that never go away everyday. Some of the typical medicines they would use over the counter won't seem to stop it. So it's also part of her practice to sort out which medicines they can use to help the patient. Or if there are certain things in your lifestyle that contribute to this such as overuse of caffeine found in local soda or sweet tea. "People don't even realize that they have a young child who's exposed to a lot of caffeine." They also focus on avoiding skipped meals, hydration, exercise, and addressing other concerns like bullying or other things going on at a school setting. Moreover, Lauren is also trained in procedures to help manage pain. They can do a nerve block. The patient takes a numbing medicine and the specialist injects on the scalp to numb it and give it temporary or long-lasting pain relief. They also do Botox which is a muscle paralyzer which you can use in managing chronic migraine. You inject in 31 places on the scalp and the neck. It affects the nerves locally to prevent them from spreading neuropeptides and inflammatory markers to perpetuate pain. Lauren explains there are a lot of interesting ways to treat headache including coaching and procedure. This keeps her practice very interesting. [15:10] Choosing Academics versus Private Practice Lauren initially thought really long and hard about what she wanted her career to look like. She thought private practice was very attractive because you have more control over your schedule. You might see consistent types of patient population You might have more consistent hours. The reason she ultimately chose academics is she wanted a job where it could grow with her as her interests change. As a young faculty, she knows she loves education but she doesn't really know if that's her path. If she went into private practice, she thinks she would have missed a lot of things - being with the residents and medical students and seeing the collaboration and the discussing of interesting patients. Since she has been at Wake Forest, she started up a Headache Case Conference. They host it once a month where they get together and talk about their most fascinating headache patients. Because of this, they can get back up on patients they need more guidance on as well as be able to hear from other providers. She loves this kind of collaboration and learning all the time. Lauren is glad she chose academics. She has gotten so passionate about education that she is now the Residency Director for their Pediatric Neurology Program. She now helps design curriculum and make sure block schedules look nice. She looks into ways to improve the education for their residents at all stages. "I love education. I can't imagine, now in this role, going back into private practice." Another thing she likes about academics is that it allows you to be part of both the inpatient and outpatient sides of it. She loves being in clinic and it's the majority of what she does in headache managements. But she also loves being occasionally on inpatient service. You see so many different things there that by the time you see them on clinic, they've already been stabilized and they no longer have ongoing concerns. Academic allows you to be varied and depending on where you get hired, you can have all different types of job descriptions. [18:00] Work/Life Balance Lauren stresses this is something very important to look at when choosing a field not only for women, but for anyone when choosing their career. You never know what your home life is going to look like when you're making these big decisions. "Having flexibility or knowing what kind of support you have from your family is helpful." Lauren knew she was going to likely possibly leave the area where her family lived. She would be in an area without initial extended support and friends. She wanted to be in a place where she didn't have to work nights and weekends all the time. Lauren loves the balance in pediatric neurology. She generally works Mondays through Fridays and works one weekend every six weeks. She's not in-house for those calls and works from 9-11 doing patient rounds and then she goes home. She also answers pages from home on the weekends she's on. For Lauren, it's manageable because it ends up being an 8-5 job with lunch breaks. Then she can also squeeze the meetings. But in general, her practice is very manageable for having a family. [19:35] Residency Path and Fellowship Training Lauren explains that a lot of programs have moved towards combining your match into being able to apply once into both pediatrics and child neurology at the same hospital. At Wake Forest, you come for a two-day interview. You will be interviewed by the pediatrics group and then by the child neurology group. But when they make a decision and you get your match result, it's at one program. Lauren did her training at two separate places. It does have its benefits like being able to know all these different hospital systems. But she reckons it's nice to spend all five years (two in pediatrics and three in child neurology) in one place. It allows you to build connections much easier and you spend less time worrying about computer systems. Then you can focus more time on learning as you transition from pediatrics to child neurology. What's different in their field is you spend two years purely in pediatrics. Then when you transition over to child neurology, you will spend a bulk of that first year in adult neurology training. You're treated just like another adult neurology resident. Lauren describes this as a hard transition to go from general pediatrics to dealing with adult patients who may have internal medicine problems. Some of those conditions may have overlaps in pediatrics in ways. Moreover, programs approach problems differently. At their program, their pediatric neurology residents don't do in-house call on the adult neuro side. "You have to be careful when you choose programs that it's a match for your personality and what you're hoping to go into for your career." How competitive Pediatric Neurology is depends on where you want to practice. Some of the top five programs tend to be larger programs but they're biggest hits in the major cities. So several of those programs can be very competitive if you had your heart set on one of those programs. But in general, pediatric neurology every year will have a few spots that are unmatched across the country. Relative to some other specialty fields, Pediatric Neurology is less competitive. Compared to adult neurology…

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32: A Community Plastic Surgeon Gives Us a Look at His Job Jul 18, 2017

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Session 32 Dr. Russell Babbitt is a Plastic Surgeon in private practice for the last seven years. He took the time to share with us his thoughts on what he likes and what he doesn't like about it and what you, as a premed or medical student, should start doing now to become a better applicant for Plastic Surgery. [01:18] His Love of Plastics Around that time when the show ER was popular, Russell started medical school thinking he wanted to do Emergency Medicine but realized it wasn't for him. Instead, he liked doing surgical rotation along with his plastic surgery rotation which he describes as gelling very well. He also started college as an art major so the visual-spatial aspects really appealed to him once he got into plastics because it wasn't just a cookbook, do-this-do-that case but it involves applying spatial problems to different situations which appealed to him. The second he got onto his plastic rotation, he knew it was where he needed to be. Russell went to UMass for medical school and during their third year surgery rotations, they had a three-month block spent on general surgery and the other half was subdivided into other subspecialties. Many of them ended up rotating through plastics. Other specialties he did consider include general surgery and vascular surgery. He likes the disease processes in general and being able to intervene into a lot of different illnesses and have the ability to take care of sick people across the board. Ultimately, he was meaning to be a well-rounded surgeon and the fact that plastics builds on that was nice. [04:30] Traits Leading to Becoming a Good Plastic Surgeon Russell cites meticulousness as the primary trait of becoming a good plastic surgeon as well as being a good visual-spatial thinker. Being a good communicator is also very important since. You need to be willing to sit down with the patient and explain the disease process, the problems, the solutions, how you're going to get there, oftentimes, there are many ways to get there and there's many different things that can happen. Russell further explains that the doctors who don't communicate tend to have more difficulties regardless of what the outcomes are and this is especially true in plastics. Beyond that, you also have to be a good technician and be able to develop a plan, know what you're going to do, and see the technical problem you're going to solve and actually execute it. Also, you must be able to see the long term outcome, not just the proper three-dimensional result but it has to look good three to four months and years down the road. Blood supply also has to be intact at the end of the day. One of his mentors once told him that when he's out in private practice, one of the things he has to do is while doing a skin graft, you have to make sure every mitochondria survives. "You have to just be really meticulous in every single thing that you do and that people are watching and the patients are watching. That's one of the things people look for in a plastic surgeon." Russell adds that another innate trait in a plastic surgeon is being anal. In terms of having an arts background, although not necessary when you become a plastic surgeon, a lot of people that go into medicine in general tend to be very agile-thinkers so Russell thinks a lot of it can be taught. But he personally thinks it helps a lot in terms of little shortcuts that allows him to know what to do before he even thinks about it. This may also help in certain other areas where it would have been hard to to teach it. [09:00] Types of Patients and Typical Day Russell sees a mix of 50% cosmetic and 50% reconstructive patients. To his surprise, he's doing a lot of breast reconstruction. They have a very busy breast reconstructive program where he's the director at a local hospital. This was something he didn't expect to be doing a lot but he ended up doing it anyway. The reason for breast reconstruction is almost always breast cancer in various stages or it may be due to genetic predisposition where the patient has a high risk of developing breast cancer in the future or maybe that the patient has an active diagnosis of breast cancer or very late stage precancerous lesions which would require mastectomy and therefore they would then need Russell to reconstruct the breast. He describes it as a very intense process and oftentimes, he is the one the patient sees the most of throughout the process. They see them after surgery and on a weekly basis to fill tissue expander that expands the breast's skin envelop after radiation and mastectomy. Nevertheless, Russell sees this as a nice aspect of what they do. Another thing they commonly do is reconstruction after skin cancer resections with dermatologists which can sometimes be very large defects. On the cosmetic side of things, they do a bit of facial cosmetics like face lifts, rhinoplasty, ear correction, fillers, Botox, facial rejuvenation, liposuction, tummy tucks, and a lot of breast surgeries. "15% of what he does involves taking care of complex cosmetic breast patients which is a fairly challenging field." Russell finds himself in the operating room at least two full days a week and even up to three full days a week. He works between 40 and 60 hours a week. During his office-only days, he gets in around 9 am and finishes around 6-7pm. His OR days start at 730am and finishes between 4 and 5pm. He does his larger cases first thing in the morning and then the local type cases like mole removals or lesion removals or skin cancer reconstruction in the afternoons. Russell has an amazing physician assistant who has been with him for about two years now that sees a lot of his postoperative patients in the office. They are very much on the same page and because of the high demands, they've gotten so busier across the board. Nevertheless, they try to balance things out to avoid burnout and try to make it sustainable. [15:00] Private Practice Goals for Work-Life Balance Russell would like to have his weekends off so he covers himself 24/7, 365 days except when he's on vacation. Other than that, he's available for patient issues that only he can answer unless his PA is available to answer it. He doesn't do office hours on a weekend and reserves it for family time and he tries to be home every night to help with the kids to bed and stuff. Pretty much, he's going all out throughout the week and works as hard as he can to get as many patients. Most importantly, he makes sure they're taking enough time with each patient. One reason he shies away from being employed is he doesn't want to be in a position where he's being told how many people he has to see a day. He's okay with this perspective. "I don't want there to be other metrics that I need to have to use. Other than that, the patients are happy. We're taking good care of them and that my bills are paid." Basically, this is how he likes to do it right now compared to his colleagues where it's not how they're living so he feel extremely fortunate for it. [17:30] Patients that Go to the Operating Room Russell estimates their conversion rate in the high 80%. These people come to his office because they want to see him and they're not doctor-shopping as much. They've waited a decent amount of time to see them so they're there to see him and are typically there to have surgery. Also, nobody goes to the operating room without seeing him in the office first with the exception of local anesthesia procedure where they get to meet him that day, he talks to them, and they'd have to wait for the procedure. But if somebody gets general anesthesia, they may see his PA first and then get a second appointment with him to have another formal sit-down discussion if they're going to go forward. He doesn't do internet-based consultations since it's not how he wants to do things in terms of how he wants to care for patients. Russell says there are patients coming in who are insecure about something and they come to see you for one thing. "Just because one thing that bothers. it doesn't mean there are other things that may be addressable as well. It is a strict policy in our office to not mention those other things or to try to market other things." In other offices, patients would come in for tummy tuck and then the surgeon there would ask you to consider getting a neck lift or breast done, or whatever. They basically walk in to talk about getting fillers in their lips and they walk out with $30,000 worth of clothes and a whole new complex because they didn't realize all those other things need to be addressed. "As a plastic surgeon or cosmetic surgeon, you have a lot of power to make somebody feel better about themselves or feel worse about themselves." Doing it ethically and conscientiously, Russell sends a lot of people in the office telling them they don't need surgery and don't listen to anybody that tells you that you do. He emphasizes that this is the right thing to do because at the end of the day, they're still physicians that took an oath to do the right thing for people and he feels it's job to make sure that if people need to do surgery, it has to be done safely and in the right circumstances. He needs to do it well and do it safely. He needs to do it under the right circumstances for the right patients. Russell admits he is bothered by a lot of plastic surgeons out there that are making a lot of decisions for financial reasons impacting other people's lives negatively and they're doing a surgery for that reason which makes them all look bad collectively, reason plastic surgeons and cosmetic surgeons have a bad name sometimes. [22:05] Taking Calls Russell is in a position where he doesn't cover much call at the surrounding hospitals. In metropolitan areas, most hospitals require call as a stipulation of privileges for credentials. He doesn't have to do that, which means being allowed to use their operating rooms. The majority of what he does would be at a freestanding ambulatory surgery center which is a facility not attached to or affiliated with a hospital but he still has to do everything that is like a major operation they do at a hospital. He also has a lower threshold for doing certain things in the hospital than some doctors do because it's cheaper to do things in an ambulatory center than it is to do at a hospital. He actually anticipated to take calls when he took the position he took but when he got there, he was told it wasn't necessarily expected. But he does stay on as a courtesy like if he's available for something thing where if he can go, he will. So he's like "always on, but always not on." This seems to work well and they like the fact he's available if he's available. Nevertheless, Russell describes having a symbiotic relationships with the ER, where he is available in the middle of the night if they need to call him and if they need to send a patient to his office later on for a suture removal. [24:35] Residency and Fellowship Training There are two typical approaches. One is to finish medical school and go into general surgery, neurosurgery, orthopedics, or ENT and then match after that into a plastic surgery fellowship. The other approach is matching into a categorical plastic surgery program, which is a dedicated program for plastic surgery. Neurology is the other pathway they can do it from. In Russell's case, he did his general surgery program at UMass and transitioned into the plastic surgery program so it was more of a traditional approach and a bit hybrid because he was able to transition out after his third year general surgery being the only type of residency you can do it from. With the traditional fellowship pathway, you don't have to finish general surgery but you have to finish all the other types of residencies before you go into a plastics fellowship. Russell was already at UMass for his general surgery training, did two years in the plastic surgery laboratory, and worked on various projects with them so he was a known commodity. Additionally, Russell says you have to be very competitive with the rest of the applying population. All in all, it was a seven-year pathway. Categorical might be six and then general surgery can end up being nine consisting of five years general surgery, two years of research, and two or three years of plastics although he thinks all plastic fellowships are now three years mandatory. Many will also do an additional year of hand fellowship because it's so competitive. The year he applied, there were only 92 plastic surgery fellowship spots in the country excluding the categorical spots but just post general surgery positions. Plastic surgery is among the subspecialties in surgery that are the most competitive. Dermatology might be the only one most competitive in terms of everything else but in terms of the categorical spots, plastic surgery, Russell believes, may be the most competitive now. [28:30] How to Be a Competitive Applicant Russell illustrates that to be competitive, you have to set yourself apart by showing interest in plastics early on. The good sub-I's pretty much have an inside track to the spot because it's a month-long interview. Some international students even spend extra time doing research and this makes a huge difference. You're much more like to want to match somebody that you know and you know is good. Additionally, you want to show them that your hands are good and that you're conscientious and good with patients and the staff. Know that the staff can have a remarkable amount of power. "The chairman's secretary is going to have more say in the ultimate decisions of who gets into the program than potentially sometimes the junior faculty." You need to be nice to those people when you call or you're trying to coordinate something with the program since they have the ear of the program directors and the higher up's. Russell adds that we tend to focus a lot on research, volunteer work and stuff, but all that is part of the baseline. You have to be good at all those other intangible things on top of those. These are the awesome people that can make your like a lot easier. Additionally, Russell recommends doing international volunteer work if you have the resources because it's very helpful as well as research in plastic surgery being at the forefront of tissue engineering so there are always labs looking for residents and medical students to do stuff. There's a lot of data mining right now which can be a little dry but you can eventually find your way into something more interesting and surgical. And remember, this boring data stuff that nobody else wants to do it, could be your foot in the door. [32:40] DO's, Subspecialties, and Working with Primary Care and Other Specialists Russell thought general surgery was the way he would go, finishing it for five years and then decide later on if he wanted to do plastics then continue on. The more he was doing rotations for general surgery and plastic surgery as part of it, the more he knew it was where he wanted to go. Then it went solidified by the time he went to the plastics lab and he finished his second year of residency. Whether there were negative biases towards DO in the field, Russell would describe it as rapidly diminishing if there was any. One of the strongest sub-I's they had in the program who ultimately did not match into their program, ended up as a major ambassador to this side of things. Nevertheless, he sees it's diminishing. “Whatever factors may have led that person to that pathway had nothing to do with that pers…

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31: What Does a Headache Specialist's Job Look Like? Jul 11, 2017

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Session 31 Dr. Kristen Sahler is a community-based Neurologist who specializes in headache medicine. She has been practicing for four years outside of her fellowship and she shares with us what drew her to it and her advice if you're interested in it. [01:28] Her Path to Headache Medicine Kristen knew she was going to be a neurologist when she was fourteen years old having been motivated by having a family member with Tourette's syndrome so very early on, she was learning about it and about the brain and got fascinated by all of it. She then hyper-focused on that pathway and never gave up on it. As for getting into headache medicine, it wasn't on her radar until her third or fourth year of medical school on her neurology rotation where she was sent to see a headache consult. She became fascinated by the patient's story and thought her interesting visual aura was cool and learned about migraine. By the end of medical school, Kristen has already carved out that headache was the field for her which was confirmed as she went through residency every step of the way. What she likes about the field is how interesting it is having all these strange phenomenon and visual disturbances. But essentially, she has always been interested in the central nervous system and in neurotransmitter systems which hearkens back to his brother with Tourette's syndrome. With migraine, it's predominantly common with the serotonergic system which she's interested in. "I like that there were so many treatment options and that we could really turn the course of someone's life around." Additionally, she was interested in Parkinson's disease being a neurotransmitter-based disease but she didn't feel as much excitement seeing the inevitable decline of patients experiencing it since you can't change the course of their disease. Whereas a lot of the other primary headache disorders have disorders that can change people's lives taking them from being completely disabled an in pain everyday to nearly pain-free. [04:37] Traits that Lead to Being a Good Headache Specialist Kristen cites patience as the one skill she uses the most day-to-day considering how headache patients don't give the greatest history. You don't always know how to describe they're feeling so you need to guide them through it to get the information out of them that you need. Another trait is liking the detective work because there are so many things that can cause a headache and not each one is a migraine or whatnot so you need to be able to fuss out what the underlying causes are. Lastly, you need to okay with psychiatry because there's a lot of overlap between headache disorders and psychiatric disorders. In particular, migraine is comorbid with anxiety, depression, and bipolar so she sees a lot of people with psychiatric co-morbidities which she's not managing but she needs to be able to be patient with them ad help them cope through these things. "If you're somebody who does not like to deal with psychiatry, it's probably not a good field for you." Alternatively, if you're really interested in psychiatry, you could choose to manage both issues. In neurology, they study a good amount of psychiatry so you could choose to be a headache specialist and also manage their anxiety or depression and just choose to do both. Kristen though doesn't like to manage the psychiatric issues because she feels she's not up-to-date on the management side of it but she's comfortable seeing patients with those diseases. Kristen says she never thought of any other specialty pulling her from her path to neurology. Although she was interested in some fields but she never once thought they were the right field for her. She thought psychiatry was interesting but when she looked to the day-to day of what a psychiatrist does, she knew it wasn't for her. She thought internal medicine is the best field because for her the most impressive people went into internal medicine. She practically thought of them as rock stars but she knew still that it wasn't the field for her. She wanted to be that person who was going to dig her hole really dip and narrow and just do headache but do it really, really well. [08:03] A Typical Day in the Life of a Headache Specialist Kristen is doing outpatient for majority of the day. She takes some calls at a local community hospital but not very often. She's usually in the office for seven hours seeing office patients, new consults, or follow-up visits for patients she's already seen. She predominantly does headache so she is a 75% headache specialist and the other 25% is being a general neurologist dealing with a variety of issues including dementia, epilepsy, Parkinson's multiple sclerosis. The reason being is that she's in a multi-specialty group so her referral days is a group of primary doctors, OB/GYN's, pediatricians who want to have somebody with general neurology skills. She also likes to have a little bit of general neurology since some days, she feels like she's seen so many really complicated headache patients back-to-back which can be emotionally and cognitively exhausting so having someone coming in with, say, a carpal tunnel syndrome is nice break for her. If you're in a headache specialty center as a headache specialist and you're only doing headache and you're not going to be doing any general neurology at all. But her typical day is just seeing patients in the office, managing callbacks, medications, and emails that may come in. Patients may call in complaining about a bad migraine so she spends about an hour everyday speaking with them on the phone and helping them through it. [09:55] Types of Procedures She does procedures for patients too. This is another trait she wants to point out if you want to be a good headache specialist is that you should like procedures. Kristen does simple procedures such as nerve blocks, trigger point injections (focused on muscles, neck, head, and shoulders) as well as another type of nerve block called the sphenopalatine ganglion block which is a catheter that goes up through the nose to block the nerve cluster behind the sinuses and she also does Botox for chronic migraines They're all relatively simple procedures which you can do in the office. They are quick and easy and they relieve pain very effectively and they're pretty lucrative, relatively speaking for the amount of time it takes to do them. "It's a nice supplement to the day-to day of being a headache doctor since you're not just sitting and talking all the time because sometimes you're doing things with your hands." Not to mention, these are very low-risk procedures and the complication rates are pretty much next to nothing. They're very low-stressed procedures but they can help the patients a lot. Another procedure she does are lumbar punctures but if you don't want to do them, you're going to need to refer them out to get them done somewhere else. [11:38] Taking Calls and Work/Life Balance Kristen works at a stroke center and they don't have any other support. They have a neuro hospitalist who's in the hospital from 9-5 Mon-Fri so she's never torn away to the hospital and she can just focus on her office these times. But every once every two weeks, she will have a shift from 5pm - 9am where she's on call for any hospital issues. Generally, they get an acute stroke code around every other day so it all comes down to luck. For example, she got a stroke code at midnight and had to get out of bed, go to the hospital to see the patient, give them TPA, admit to ICU, and go back to bed. That is unfortunately the reality of taking call at a stroke hospital but most headache doctors don't do the stroke call coverage. Again, this is because Kristen still does a bit of neurology so she's involved in a general neurology coverage group that she's doing these calls. "Most headache specialty centers don't have the kind of call that would require you to go in after hours." Kristen says she has a fantastic work/life balance which is partly her own choosing because she had chosen to only schedule patients 32 hours a week. She split her days up, some days longer while others shorter but she only schedules patients for 32 hours a week, doing an extra hour a day doing phone calls and messages which adds up to about 36 hours a week of clinical work which she thinks is a perfect number for her considering she has two young kids so she still has to take care of family and she wants to have the time to do this with them and not rush the time. With headache, you have that freedom over your schedule. If you're at a surgical center, you can just set your office hours and decide what works for you. [14:25] Residency Training and Competitiveness The road to residency training includes doing an intern preliminary year although Kristen thinks you can't do a transitional year for neurology. it has to be a preliminary year then do a neurology residency for three years and then one year in headache fellowship. "There's more and more headache fellowship positions every year. It's really an expanding field." Kristen did her fellowship at St. Luke's Roosevelt in New York City. After finishing your headache fellowship, you have to take the board certification for headache medicine. If you didn't take the boards, you could still call yourself a headache specialist, just without that additional board certification. Also, you have to do the neurology board certification after your neurology residency. Kristen thinks Headache Fellowship was competitive when she applied for it only because there were fewer headache fellowship spots. But now, the number of spots available in the last four or five years has nearly double so it has become less competitive now than before. Because it's becoming a popular field and people are knowing more about it, more schools are now starting their headache fellowships. She adds that if you want to be a headache specialist, you will be able to get into that position and find that role. Additionally, Kristen says a lot of neurologists get really turned off by headaches since they feel like patients are demanding and crazy although she feels otherwise seeing that her patients are in a lot of pain, are suffering, and they have some anxiety and depression who are the patients that need the most help. So she never got turned off by it. Alternatively, the majority of neurologists pursue neuromuscular. Kristen says that more often than not, you're going to end up being the only person in your class of neurology residency that wants to do headache. "The diagnosis for primary headaches disorders are made by clinical criteria, no blood tests, no nerve tests, no MRI, nothing. So you need to be confident in your ability to look at a pattern and identify that as being a certain diagnosis." [17:50] How to be Competitive for Headache Fellowship Kristen recommends getting involved in either headache research or in the Move Against Migraine Campaign by the American Migraine Foundation which is a political campaign and also a social awareness campaign. "13% of the country has migraine. !8% are women and 6% are men." The campaign seeks to educate people on how common it is and how debilitating it is and help getting more research money to go to migraines so they can get more treatments for people. Kristen is involved in helping spread the word for such campaign. And if you just start offering your help, this would be very impressive to anybody in the headache world. [19:13] DO's, Subspecialty, Primary Care, and Other Specialties Kristen doesn't see any negative bias towards DO and nobody couldn't even tell who was a DO in their residency because nobody cared. Moreover, Kristen explains there are no further subspecialty within headache. But she has colleagues that focus more on one type of headache which is easier to do for migraine. There are some headache specialists known as the "migraine guru" as well as those known for being the go-to specialist if you need in-patient management. So you can essentially carve out a niche for yourself. In terms of working with primary care providers, she would want them or anyone referring any patients to her to not give them any opioids or any Butalbital medications. A lot of patients come to headache specialists who have been managed by primary care for a period of time and they're given Butalbital-caffeine combination medicine, for example, just to help them get to the neurologist and help their pain until they see a neurologist. Unfortunately, those types of medications worsen migraines and a lot of headaches. Not to mention, that they can develop dependency on them. Kristen recommends that if you're worried the patient has to wait a certain amount of time and you worry about their pain, don't give them a pain pill. She prefers for them to call her and talk to her to ask to get them in sooner rather than have to see them in three to four weeks and have to not only manage their headaches but help them detoxify from such medications since headache specialists don't use those kinds of medicines in headache. Nevertheless, Kristen welcomes any type of headache issue primary care providers would send in her way. Aside from primary care, other specialties she works the closest with include internal medicine, OB/GYN, pediatricians, psychologists, and psychiatrists for co-morbidities. [23:25] What She Wished She Knew About Headache Medicine Kristen would have wanted to learn early on how to cope with failure. As a headache specialist, she is often the third neurologist they've seen or the third headache specialist they've seen and they've already tried everything in her toolbox but you can't cure all people. This was hard for her when she first started. "When you're a young physician of any kind, you put your heart and soul into every day and you really invest yourself in it and if someone doesn't get better and you feel like you failed, that's tough." It took Kristen a little bit of time to process that and learn how to not take it as a personal failure but to learn how to conceptualize it and move past it although this might be one of the skills that you just have to learn as you go. [24:35] Most and Least Liked Things About Headache Medicine Kristen likes the ability to help to people and seeing that huge impact they can have in someone's life, helping them get back to work, get them functioning, and be a better mother or spouse, and basically get them back to their lives and feel good about their themselves. What she likes the least is the failure part since you're going to see the toughest cases so you're not going to always have those wins. She really dislikes the stroke call she takes but again, for most headache specialists, it's not going to be part of the deal. She also would have hated the different psychiatric co-morbidities if she was asked four years ago, but she has now adapted to it and understands it so much better now alongside her skill sets that have already expanded. [26:15] The Future of Headache Medicine Kristen mentions a new and exciting class of drugs coming into the market soon called the CGRP antagonists which are monoclonal antibodies targeting the one of the main neuropeptides that transmits migraine pain signals which is probably going to hit the market in 2018 to early 2019. This is the first preventative medication for migraine specifically targeted just for migraine which she sees as a very exciting new treatment and revolutionary in terms of migraine ma…

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30: A Deep Dive Into Ophthalmology Residency Match Data Jul 04, 2017

Show notes

Session 30

This week, we're doing a deep dive into the 2017 Ophthalmology Match Summary Report which is actually outside the NRMP match.

The match is the program you apply to while in your medical school to determine where you're going to do your residency. The people that made the algorithm actually won a Nobel Prize for it and it's used in a lot of different things now other than the match. However, not every specialty participates in the main ERAS match which stands for Electronic Residency Application Service put on by the NRMP (National Resident Matching Program). Most specialties are part of the main match so when you hear "The Match," this is what most people are talking about.

Today, we're covering Ophthalmology, the rare exception that does not participate in the normal match but it's done by the SFMatch system. While normal medical student match for their specialties in march, students applying for Ophthalmology match in January.

[03:30] Spots Offered, Filled, and Left

Looking at Page 2 of the Ophthalmology Match Summary Report 2017, they have data going all the way back to 2008 so it's nice to see a ten-year data for matching. In 2008, there were 454 spots offered and 468 in 2017. It hasn't been growing a ton and what's interesting is the number of spots left open after the match which is 1 in 2008 and 6 in 2017. Ophthalmology is typically one of those residency matches that are very competitive and the fact here are 6 left.

"Keep that in mind when you are applying for other residency programs that the match data the NRMP gives out shows that those that don't match are typically not ranking enough programs."

As for Ophthalmology, there are 6 spots left probably because students weren't applying broadly enough. Everybody wants to be in New York or California and nobody things about the "flyover" states in the middle of the country. If you are flexible, this is a big opportunity for you to look at those other options as well.

[05:35] Means for Matched and Unmatched

The matched mean for 2017 was 243, which is a very high number, and the unmatched mean is 227.

Once you're in medical school, you know that the MCAT and GPA are important but usually, a strong application can help overcome some deficiencies in some areas.

But this is one of the unfortunate things with the match is that when it comes to matching.

"Your Step 1 score or COMLEX Level 1 score for DO's is basically it. It's a huge part of your application and it's what opens the doors for you for these competitive residencies."

[06:50] Allopathic and Osteopathic Students

Still found on Page 2 of the data, the U.S. Allopathic Seniors made up 80% of those that matched in Ophthalmology. U.S. Allopathic Graduates were 7%. So 87% of all the physicians that matched were from U.S. MD schools. 4% were from osteopathic schools.

"For you DO's out there, it's a slimmer chance but there is the opportunity."

You can't just base on this data to say that you're not going to a DO school because that's not always the case. This doesn't mean you shouldn't go to an osteopathic school. It just means it's going to be harder for you to go into ophthalmology if you go to a DO school. There could be a number of reasons why it's harder. Probably it's because you don't have exposure to academic medical center where most of these ophthalmology residencies may be. So you're not getting the exposure MD students are going to get. Or it could be because you need to travel around a bit for your clinical rotations so it's harder to build relationships with program directors and get that experience and research. So if you're in a DO school, don't give up on being an ophthalmologist. Just think through what else you may need to do.

[09:10] U.S. Allopathic and Osteopathic Seniors and Graduates

Looking at Page 3 of the data, 26% of U.S. Osteopathic Seniors matched. It's interesting to note that while 34 registered for the match, only 19 participated in the match and 5 of those matched. Comparing that to 89% of U.S Allopathic Seniors that matched, it's a big difference.

For U.S Osteopathic Graduates who are DO students that took some time off probably to do some research or maybe they didn't match in the prior year, nobody matched while for US Allopathic Graduates, 19 matched which makes up 44%. These are those who graduated from an MD school and went off to do the research to strengthen their application.

36% of International Graduates matched which is a higher number than osteopathic students. Again, this does not mean that you should go to a Caribbean school because your chances are higher just because you based it on these numbers. Interestingly in 2016, U.S. Osteopathic Seniors made up 41% match rate versus 23% for International Applicants.

[11:25] Choosing Your School

This is the key reason why I don't recommend, if you're premed, looking at match data to choose where you go to medical school because it varies from year to year, student to student, class to class. It has nothing to do with the school. It could be affiliated with the top ophthalmology residency and you get great exposure and it's going to increase your chances of getting into an ophthalmology residency but it's you that goes out to form that relationship with the residency program and form that network with the other residents, program directors, and the attending physicians.It's you that goes out to get those letters of recommendation. It has nothing to do with the school. It's you that does well on your boards and goes out and networks and builds those relationships to match in a competitive program.

"Don't look at the school match list to determine where you should go to school."

[12:40] Average Number of Applications

Page 4 shows the Average Number of Applications per Matched Individual which is 70 in 2016 and 72 in 2017. Applying to medical schools, most people are freaking out over 20. This is 70. It's not as bad as medical school where you're writing secondaries for every school.

"If all these 70 schools want interviews with you, that's a lot of travel, a lot of money."

Compared to USMLE NRMP data where the matched versus unmatched usually has a big divide, for Ophthalmology match in 2016, those that went unmatched applied to 73 programs, which is just 3 programs more than those that matched. In 2017, there were 72 average number of applications per matched individual versus 67 for those that did not match.

[14:20] USMLE Step 1 Scores

The USMLE Step 1 Scores Information is shown on page 7 of the data. From an average USMLE Step 1 score of 232 for those that matched in 2008, it went up by 11 points to 243 in January 2017. For those unmatched, the average USMLE Step 1 score was 212 in 2008 and 227 in 2017, which went up by 15 points. When you see numbers like this, it means it's getting more and more competitive. It was even higher in 2016 with 244 that matched and 229 for unmatched.

“If you're thinking about Ophthalmology, research is important as well as getting those connections, getting those relationships, and Step 1 scores are obviously huge.”

[16:00] Medscape Lifestyle and Physician Compensation Reports

Based on the 2017 Medscape Physician Compensation Report, Ophthalmology is a little bit higher at $345K for average annual physician compensation. Orthopedics is at the top at $489K. Around Ophthalmology is General Surgery at 352K and Emergency Medicine at $339K.

Ophthalmology had a 12% increase in their compensation from last year. For the percentage of physicians that feel fairly compensated, Ophthalmology is at 53%.

Whether they would choose medicine again, Ophthalmology is on the higher end at 79% and whether they would choose the same specialty again, Ophthalmology is there near the top at 93% so they seem to like their job.

Moving on to the Medscape Lifestyle Report 2017, Ophthalmology is near the bottom of burnout at 43% while Psychiatry is the lowest at 42%. As how severe is burnout, it's still near the bottom at 4 on a scale of 1-7. As to which physicians are the happiest, ophthalmologists are the second happiest at 74% outside of work and 42% at work.

[18:20] Final Thoughts

Ophthalmology residency is outside of the normal match (ERES/NRMP) which is through SFMatch. They match earlier in January instead of March for the NRMP. Check out the SFMatch.org for more information including some links and FAQs. They have lots of good information to help you get ahead so come match time, you're not surprised with information at the last minute.

Links:

SFMatch.org

2017 Ophthalmology Match Summary Report

2017 Medscape Lifestyle Report

2017 Medscape Physician Compensation Report

NRMP

29: What is OB/GYN? A Community Doc Shares Her Thoughts Jun 28, 2017

Show notes

Session 29 Dr. Renée Darko is a community-based OB/GYN. In our podcast, she talked about her path to OB, what you should be thinking about during med school, and some tips as you're going through the process of deciding whether OB/GYN is right for you. If you haven't yet, please listen to Episode 127, I dove into the residency match data for OB/GYN. [01:30] Community Setting Practice Renée practices in a community setting. Although at one point, she considered an academic setting while she was in residency but shortly before she graduated from residency, she started realizing that she needed to explore a little bit more of the setting she wanted to be in so she began doing Locum Tenens in terms of practice rather than joining a group or an academic center. During the time she was doing Locum right after she graduated from residency, she also did a Health Policy Fellowship to give her a little bit of time to think of what she wanted to be and what she wanted to do. Renée graduated from her residency in 2010 so she has been practicing for seven years now. [02:44] An Interest in Pediatrics to OB/GYN Renée did not want to be an OB/GYN when she first entered medical school. In fact, she says it was the last thing she ever wanted to do. She actually wanted to be a pediatrician. The she did her pediatric rotation in her third year of medical school and she hated it, not because of the kids or the parents, but she just didn't enjoy the medicine of pediatrics and realized it wasn't for her. During the last rotation of her third year was OB/GYN and knowing it was the last rotation and knowing she wasn't going to like it, she thought she didn't know what to do. But upon her first week of OB, she absolutely loved it. She loves the versatility of it as well as going to the OR, doing the deliveries, and doing the procedures in the office. She then realized considering an OB/GYN more seriously. Renée's experience in pediatrics was somewhat a repetitive cycle which she didn't like. She didn't enjoy it because she didn't think she was very good at it mainly because it didn't interest her. Whereas she found OB to be a lot more versatile even as a generalist. They were doing things that could be potentially considered as subspecialties like surgery. She basically likes the fact that she can work with her hands and do a bit more to keep herself busy. Before she started her path to OB/GYN, Renée had not considered a procedure-based practice. She never really thought about the procedures being a major part of what she would be doing as a physician. She thought that if she liked a particular population, being a new mom and that she loves kids, then that's the population she wants to work with. She realized she needed more than just the population. She needed something that was going to motivate her, keep her busy, and something that she was going to enjoy. So to her, the practice of OB/GYN was just of more interest to her. This is another example of keeping an open mind going into medical school. [07:15] Traits that Lead to Becoming a Great OB/GYN One trait that leads to becoming a great OB/GYN is being a good listener and allowing the patients to feel comfortable with you. When Renée was in residency, one of the things her attending used to say to her is that you're not your patient's social worker. Part of the reason she was being told that is because she would go in doing more than just prescription or procedure. She would actually sit down and listen to patients as they tell her their lives and all things that affect people outside of just looking at their differential diagnosis. Hence, Renée recommends thinking about the things affecting your patient's health. She adds this is a very intimate type of specialty so you need to go in thinking that and realizing that the patient is going to tell you intimate details and for you not to shy away from listening to those details otherwise you might miss things. [09:22] Keeping an Open Mind Renée was so dead-locked on being a pediatrician that she didn't let herself open to looking at other specialties. Apparently, she was so hooked to pediatrics until their peds rotation when she realized she didn't like it. Again, it was only till the end of his third year that she did an OB rotation so she felt she missed a lot of other opportunities and that she should have considered other specialties. That said, Renée loves OB/GYN and she says she wouldn't trade it for the world. [10:25] Types of Patients and Typical Day As an OB/GYN, you deal with patients on the OB (obstetrics) side composed of pregnant patients and the Gynecology side consisting of non-pregnant patients ranging from teens to the elderly. Aside from pregnant patients, she also sees patients trying to conceive, those with fertility issues, menstruation issues as well as women going through menopause. Basically, she sees a wide variety of patients and this is what makes her job more interesting instead of just one diagnosis she sees constantly throughout the day. Renée's typical day would be going into the office at around 8:45 and sees about 10-12 patients in the morning and around the same thing in the afternoon. The first patient may be a pregnant patient and if it's her first visit, she has to assess all of her risk factors - her age, previous pregnancies and/or complications, genetic disorders (including the father), medical conditions. The she does an exam on her to make sure she's doing okay and measure the size of her uterus. If she's far enough along, Renée can listen to the baby's heartbeat. Then they make a plan as to how the pregnancy is going to go, things to expect, follow-up appointment, and what to expect for next time. Every patient may be a different diagnosis and coming for a different problem. The next patient may be an elderly woman having the hot flushes. So her patients vary everyday in terms of the number and versatility of patients she sees. [13:58] Taking Calls For Renée, she doesn't take a lot of calls although previously, she had to take calls three to four times a week which can get pretty hectic. Basically, the number of calls you take as an OB/GYN depends on how many people you have in your call rotation. Calls vary as well in that there are different models of OB. One of the more popular ones is the Laborist model where you're in the hospital and that's all you do so you typically won't see patients in the office. Renée didn't practice this in the past. However, if you see patients in the office and take calls at night, you can either take call from home if you live close enough. You can take call in the hospital where you have to stay in the hospital overnight or you can take call from home and do something called second call, the most recent kind of call she has taken, which Renée describes as when someone else is taking the primary call. For example, the family practice doctors who practice OB (common in a rural setting) are the first line of call so they take care most of the pregnant patients that come in. But if they ran into a problem such as a complication or the patient is more high risk than they anticipated or if the patient needs a C-section, she will then be called and she will come in from home into the hospital. [16:40] Work-Life Balance Renée says she has work-life balance right now but she has significantly changed how she practiced. She is currently doing independent contracting so she gets to choose when to work and when not to work which is not a typical model most OB's would follow. But she describes her previous model as difficult and cumbersome to balance your home and work life, bringing work at home a lot of times or staying at work late to finish things. In fact, sometimes when appointment ends is when work has only begun such as notes to catch up on, accumulating messages in her inbox, and looking at lab results coming in which she ordered days before for her previous patients. Renée typically goes home at around 7:30-8:00 pm. She still has to put dinner and decompress then go to sleep and do it all over again when she's not on call. [19:50] Path to Residency OB/GYN residency takes four years. Typically in your first year of residency, you're doing mostly general OB and GYN rotations. For Renée's residency, she did OB rotations in different hospitals as well as a GYM rotation along with GYN ER where she saw patients in the emergency room as an OB/GYN resident. In your second year, you're going more into the subspecialties such as MFM (Maternal Fetal Medicine) or high risk obstetrics dealing with not just pregnant patients but also those with high risk issues, Gynecologic Oncology dealing with women's health type of cancers, and Urogynecology which entails a lot of surgical experience. In your third year, you're expected to take on a little bit more of responsibility. By your third year residency, you're considered a senior resident and you may have a team that you're actually leading. Your team may be made up of a second year and a first year resident and you're leading that team. Throughout your residency, you're also doing "night float" which means taking night call maybe from 6 pm one night to 6-7 am in the morning. You're doing this for four to five days out of the week. Again in your third year, you're taking a little more responsibility with your OB rotations so maybe you're making more decisions and the same thing with gynecology in the OR doing a more advanced type of procedures. Whereas in your first year, you may have been doing minor procedures like tubal ligations or LEEP. In your third year, you might be doing a little bit more of hysterectomy (removal of the uterus). Then your fourth year is even more responsibility. You're leading a team and doing night float but you're doing OB, GYN, and potentially maternal fetal medicine. All these are broken up into rotations so you're not going to be doing these all at once but you're doing it four to six weeks at a time. Renée describes it as a pretty busy residency but you get so much out of it. [23:45] Matching Into OB/GYN and Choosing a Program Renée says matching into OB/GYN can be competitive and she recalls her year to be a pretty competitive year. She adds the importance of going into doing audition rotations like your sub-internships pretty early in your fourth year and seeing where you want to be so you're not blindly picking where you want to go. It's a surgical specialty so you want to be sure that wherever you go, you're going to be in a place that does enough surgery. Delivering babies is fine but if you have a program that is so obstetrics-heavy and not enough gynecology, especially surgeries, Renée suggests reconsidering going into that program. At the end of the day, you have to really know how to work your hands to do surgery. You will learn how to deliver a baby wherever you go but doing hysterectomy, particularly vaginal hysterectomies and other types of gynecological procedures, you're going to really want to get good training in that. So when inquiring about the program or doing a Sub-I or interviewing, be sure to ask about it and get a sense of what your training is going to look like, particularly your surgical training. [26:30] Bias towards DO's Renée is a DO and applying to residencies, she actually never experienced any bias. She did the MD match and chose to opt out of the DO match because at that time, there weren't enough programs in the region she wanted to be. She is from New York so she wanted to come back to the New York/New Jersey area and there weren't enough DO programs at that time that she was interested in. Anyway, she didn't experience any type of bias. In fact, their program chair specifically told her she wanted Renée to be in the program. [28:20] Subspecialty Opportunities You can just do OB although Renée recommends that if you're just coming out, you probably want to do OB/GYN. You can also just do GYN. Other subspecialties are Maternal Fetal Medicine (high risk obstetrics dealing with pregnant patients with high risk issues) which consists of a three-year fellowship, Urogynecology (an additional three years and very surgical-heavy), Gynecological oncology (dealing with cancers, another surgery-heavy specialty which is also an additional three years), and Pediatric Gynecology which is one year. There is also the Reproductive Endocrinology and Infertility, which Renée was originally interested in and where you deal with infertility patients and other endocrinology disorders which is another three-year fellowship. [31:00] Working with Primary Care Renée explains that depending on what organization you talk to, OB can be considered primary care. But she doesn't think it's primary care in the sense of how they look at it. I personally think it's primary care for women's health but there's still a primary care physician for a woman's overall care. Nevertheless, she wants primary care physicians to understand that they are the first line for women's health so it's important they have a relationship with primary care physicians with regard to women and women's health. Renée sees some women going to their family practice doctor and they've seen them for years but they haven't had a pap smear or breast exam in years. She adds family med doctors are pretty good at doing mammograms but the breast exam is still recommended. As an OB/GYN, Renée stresses that the clinical exam is still extremely valuable in evaluating patients. These are the kinds of things she wants for the primary care physicians to keep in the back of their minds to always ask their women patients if they've seen their OB/GYN or if they've already had their pap smear. This is even important with teenagers because Renée says there are a lot of instances where they could have treated or prevented issues but they've missed the boat on that. [34:30] The Laborist Model What she wished she knew about OB/GYN which she didn't know going into it is how flexible it actually can be. The Laborist, also called the OB Hospitalist Model, is currently getting popular. As a laborist, you're primarily in the hospital rather than being in the office and having to take calls and having to do everything in one day. Now that she knows that, Renée is actually taking more advantage of it and seeing it as her saving grace being a new mom and so it's really important for her to spend time with her baby. She gets that flexibility of being able to work in the hospital alone and set her schedule in the hospital where she gets all the work done in the hospital so she doesn't have to bring her work home and be able to spend more time with her son. [36:35] Most and Least Liked Thing What she likes most about being an OB/GYN is talking with patients. She is very candid with her patients so they would feel comfortable talking with her especially about sensitive topics where they may feel ashamed of so they're trying to hide it such as domestic abuse or sexual abuse or postpartum depression. Sometimes, they're not comfortable telling a perfect stranger but Renée sees it as a privilege for someone to be able to say that to her. So it's all about the trust her patients put into her that she's carrying for them. On the flip side, what she likes the least about being an OB/GYN is when it gets too busy where she feels like she doesn't have the time she needs to either talk with her patients or have the time she needs with her family. Another thing she doesn't like is having bad outcomes especially on the obstetrical side when you're deal…

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Session 37

[01:51] Match Summary

[05:00] U.S. Seniors, U.S. Grads, Osteopaths, and U.S. IMGs

[07:20] Growth Trends, Unmatched Applicants, and SOAP

[09:48] Ranking, Steps 1 &2, Research, AOA

[15:40] Medscape Lifestyle and Medscape Physician Compensation Report

[19:25] Be an Intern

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Session 35

[01:30] Interest in Pediatric Ophthalmology

[03:16] Traits That Lead to Being a Good Pediatric Ophthalmologist

[05:35] Types of Patients and Typical Day

[08:18] Private Practice and Work-Life Balance

[10:12] Path to Residency and Fellowship

[14:30] Bias Towards DOs, Subspecialty Opportunities, and Working with Other Specialties

[18:59] What He Wished He Knew and His Most and Least Liked Things about the Field

[20:00] Major Changes Coming to the Field and Chris' Final Advice for Premeds

[21:45] Last Thoughts

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Session 30

[03:30] Spots Offered, Filled, and Left

[05:35] Means for Matched and Unmatched

[06:50] Allopathic and Osteopathic Students

[09:10] U.S. Allopathic and Osteopathic Seniors and Graduates

[11:25] Choosing Your School

[12:40] Average Number of Applications

[14:20] USMLE Step 1 Scores

[16:00] Medscape Lifestyle and Physician Compensation Reports

[18:20] Final Thoughts

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