Specialty Stories

Dr. Polotsky, REI specialist and infertility fellowship director, feels very fortunate to provide fertility care for women and families. Listen to find out why!

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

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The Premed Years Podcast 

The MCAT Podcast

The MCAT CARS Podcast

Board Rounds

Where will you see the most variety of patients? Internal Medicine, of course! Dr. Hilary Ryder gives us a peek into subspecialties and the IM lifestyle.

Hilary is the Internal Medicine program director at Dartmouth-Hitchcock Medical Center. She shares her internal medicine residency experience, how to pick a program, and how to stand out in your applications and rotations.

If you haven’t yet, please do check out our other resources on Meded Media.

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

Hilary was initially unable to make a decision about what specialty she wanted to go into. Into her fourth year, she thought she wanted to be a dermatologist. What drew her to it was the lifestyle having no nights and weekends. It felt like a lifestyle specialty that she could get into.

During her third year clerkship in medicine, she really loved what she was seeing but she wasn't sure if she could handle the 30-hour shifts they were doing. Eventually, she did a medicine sub-internship in hospital medicine that didn't have any overnight shifts.

She ended up falling in love with her team and with how diverse the cases she was managing. She started to take on more ownership of patients. She found it so rewarding that she found the 30-hour shifts to be all worth it.

The'res this idea of spending of 6-12 weeks on Internal Medicine doing some hospital medicine work, ambulatory care work, etc. Then you're going to figure out this is what you're going to do.

And so a lot of people choose IM since they haven't really made their decision. But then when you're in your residency, you're stuck making another decision because there are so many different ways to be an internist. You have the breadth of opportunities all over again within internal medicine.

[Related episode: What is Private Practice Internal Medicine-Pediatrics?]

Hilary explains that the types of cases an internist might manage basically depend on your geographic location. She's from New England and a lot of their primary care doctors are internists.

If you travel more to the midwestern states, you're going to find that most of the primary care doctors are family medicine doctors. So you go into internal medicine planning to subspecialize.

You can do an internal medicine residency and go into Sports Medicine, Allergy, Interventional Gastroenterology, Interventional Cardiology, Geriatrics, or Critical Care.

If you go into Anesthesia or Psychiatry, you're going to do just a couple of months of medicine. If you're going into Neurology or Radiology, you're going to do a year of internal medicine. If you want to be an Endocrinologist, you're going to do a three-year IM residency. And then spend some more time in a fellowship subspecializing even more in terms of the types of patients you're going to take care of.

Many of the mentors you're going to see in your second year are internists. In your preclinical years, a lot of the physiology and the pathophysiology are going to be taught by internists.

In Nephrology, you're going to learn your acid-base. And you're going to learn your electrolyte disturbances from internist. They completed their three years of internal medicine and they went on to a Nephrology fellowship.

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

Their internal medicine residents rotate through a variety of different specialties within internal medicine. A third-year clerkship student rotates through a variety of different departments.

In their program, they have residents in the intensive care unit for a month. They have residents on the interventional cardiology service. They have those taking care of bone marrow transplant patients. They have residents in clinic and residents doing home visits.

In general, students know what the inpatient experience is, the interims of pre-rounding, then the rounding with the residents and seeing patients. What they may not see are some of the other work residents are doing.

Their residents do homecare visits with geriatric populations on their mandatory geriatrics rotation in the second year. 

They have dedicated rotations on medical education to try and make their residents better teachers. Because they're an academic program, they want residents to be able to teach medical students. So they spend some time on medical education.

In medicine, they work in teams. So residents are going to have to go through a lot of teamwork and leadership. They expect residents to not only provide medical care but also, to teach others and lead teams that provide medical care. 

The resident is going to need to learn how to interface with the social worker, the discharge coordinator, the primary care physician, and the student and the nurse. They have to keep those balls in the air and keep the team moving forward. They need to make sure there's a great plan of care for the patient and the patient's plan of care is being moved forward.

[Related episode: Resident Duty Hours and the Ripple Effect]

Taking calls is different depending on where you practice. In general, call for people who haven't done a lot of clinical exposure would be this long-term, multi-day experiences. You live in the hospital and you admit a lot of patients that you cared for longitudinally.

Some programs are have gotten away from the 24-hour calls. This means you're in the hospital admitting for 24 hours. You can be in the hospital for up to 4-6 hours after that cleaning up before you go home the next day.

Other programs like the night programs have gone to shift-based work where there is no long-term call. Residents will stay in the hospital and admit patients for a certain amount of time. They sign out to an overnight team who comes in to cover the patients and do the admissions overnight.

There are medical students who have no idea of what they want to do coming into their IM residency. 

There are also those who are pretty sure and they're right. They end up doing what they think they wanted to do in the first place.

Then there are medical students who are pretty sure and they're wrong. They try something out and realize it's not for them. Some of the disease processes you learned about as a medical student may be intriguing. But the most common diseases in a specialty, you might not find all that appealing.

Figure out where you think your career is going. If the residency program you think you want to go to has never sent anyone to an Allergy-Immunology Fellowship and you're determined to be an allergist, you really need to think if that's going to be the right place or you.

Consider what your experience is going to be like. Are you going to be with like-minded individuals? Are you going to have the clinical experiences and support you want?

Is it going to get you where you want to go? The best way to determine that is if there's a track record of other people going there. Look at the schedule and who the leadership is. Look at where people went after residency.

[Related episode: The Nontraditional Medical Student: A Different Path to Med School]

After Hilary finished medical school, she went into residency. She was undecided and she was one of the students who loved everything in medical school and thought she wanted to do everything. So she had difficulty choosing.

You spend 36 months in your residency program. You should get exposed to a wide variety of different specialties. If you choose not to go into fellowship, you're ready to practice.

You can then practice as internist without further training either in primary care or hospital medicine. But even these two are broader than you think. A hospital medicine doctor is going to practice exclusively in the inpatient realm of things.

[Related episode: The Role of Residency Training For Physicians]

Looking at the 2019 match data, 97% of internal medicine spots filled and only 42% are filled by U.S. Seniors from allopathic medical schools. There are a lot of DO students entering IM as well as international medical graduates.

To be most competitive, as with other specialties, they look at the internal medicine grades. Often, there's an IM clerkship, a primary care clerkship, and at least a sub-I in either medicine or one of the subspecialties. They also look at the surgery grade. 

Hilary believes in the holistic review of the application. They look at the Step scores as a marker of someone's ability to pass the boards. They're also looking at experiences. It doesn't have to be a lot of research.

Some students worry that they're in an institution that focuses more on clinical excellence or QI than basic science research. But what they're really looking for is curiosity, leadership, and desire to learn. 

They want someone who has done research in GI and inflammatory bowel disease and can talk passionately about that. Or someone who has been involved in medical education, curriculum design, volunteer work.

Other traits to be competitive include enthusiasm, eagerness, and a desire to make the world a better place.

They also look at the letters and they want to see whether the person is a team player. Is the person able to carry a decent patient load? They look at the medical knowledge and clinical decision-making. And the letters or the Dean's letters are often the best way for them to see this.

You may not match into neurosurgery or orthopedics so you need a backup. However, more than anything else, they want eager residents who want to be at their program.

They can help you with things like if you have less exposure to a certain patient population or certain disease. But if you'd really rather be somewhere else, there's not a whole lot they can do about that.

They look at any significant evidence that this student actually wants to be in a different specialty. And sometimes, this can be a bit subtle.

[Related episode: 9 Med School Application Tips That Will Give You an Edge]

There are some specialties that you need to do away rotations for you to demonstrate that you're passionate about it. But you don't need to do this for internal medicine. In fact, an away rotation can even backfire. 

That being said, Hilary thinks that an away rotation as an audition rotation makes a lot of sense. You just have to be careful and recognize that you're signaling to all the programs you're applying to that you have that interest.

When it comes to sub-internships, the biggest mistake is not bringing in your enthusiastic game with you. It's a hard month. And if you only the minimum that's asked of you, the sub-I is the opportunity to do more.

Hence, you need to bring your A-game. Bring in your enthusiasm. Do more than what's expected of you. Be a team player. If an attending asks you a question, make sure you're researched that and you can answer that the next day.

Be the A-plus version of yourself independent of how tired you are and what else is going on in your life.

Internal Medicine is a team sport. They're working in teams, not just teams of physicians but also multidisciplinary teams.

When they say bring your A-game, it's not the student who's jumping over the other student to answer questions. But it's someone who is assertive and willing to help out other people in the team.

They want to see that you care about the patients, about your team members, and also, you care about yourself.

They're going to notice a student trying to get early everyday so they can study for their Shelf. Compared to someone who makes sure the patient is updated and see if there's anything else they can help with.

One thing Hilary observes that students are doing is panicking. If you're planning to match in Internal Medicine and you have good mentorship, you're going to be okay. But students tend to over-apply.

Personally, Hilary would see applications for people who she really doesn't think would be happy at their program.

Hence, think about what you want in a residency program. Look and ask your mentor how competitive you are. Think of whether there are geographic restrictions. Or there's a certain population type that you want to take care of.

Make sure that the residency programs you are applying to and interviewing at are going to give you that.

Get as much information as you can. You don't want to be applying at programs you wouldn't actually be happy at. Stick to the ones you think are going to give you the experience that you want.

Hilary doesn't think medicine is as impacted by the USMLE pass/fail. And that this system will help the people who are extremely dedicated but may not be great test-takers.

What she worries about more is the trend of withholding all information from residency programs.

More and more medical schools are going pass/fail in their clinical years. But if you don't have grades, it would be hard for them to tell whether you're going to do well in their program.

Be your authentic self. Be eager, enthusiastic, engaged, and a hard worker. Find a mentor. Wake up everyday thinking about what you can learn and how you can make the world a better place.

Look for ways to engage and participate. And the path will become clear to you. Surround yourself with like-minded individuals.

Seek your joy. Find out what diseases make you happy and what patients make you happy and what other providers you want to be with. Then you will figure out what the right place is for you.

Meded Media

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

Residency director and pathologist Michelle Dolan, MD joins me to talk about how to get the most out of your residency and what it means to slap glass.

Specialty Stories is part of Meded Media. If you haven’t yet, please do check out all our other podcasts geared towards helping premeds, medical students, and residents along their path to medicine.

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

Michelle initially didn't know what to do back in medical school until during her second-year pathology course. One of their lecturers encouraged them to do a pathology rotation. So she did and she loved it.

She had to choose between Internal Medicine and Pathology. What drew her to Internal Medicine was hands-on patient care. But there were also some things that she didn't like.

One of those five years could be a clinical intern year. So she decided to do an internship in internal medicine and she realized she really likes hospital care. This was before the advent of the hospitalist. She didn't like the clinical aspect but she liked the slower pace of pathology.

The ability to focus is an important trait to have in order to be a good pathologist. For instance, you need to be able to sit in one place for an extended period of time at the microscope or the computer screen.

If you're going into anatomic physiology, a good chunk of your day is going to be spent "slapping glasses" where you just sit at the microscope and look at a lot of different cases. But not every field in Pathology is like that.

One of the things that she likes about the field is how varied it is. You just have to be able to find that good fit for yourself.

Because pathology is so varied, there are people who are very visual and love learning by seeing. There are also other parts where it's much more conceptual where you learn a lot by reading and thinking. There are other areas where you can learn by doing. To help you figure out which area to go into is to know yourself.

[Related episode: The Pathologist as Medical Detective]

There are not many trained pathologists that are cytogeneticists. One of the benefits of the Pathology residency is the exposure to every area within pathology. You can see what you like and you don't like, or what's a good fit and what isn't. Then you can plan your career from there.

Pathology is a broad field in that they can look at a variety of patients from prenatal through geriatrics patients. They look at the entire lifespan.

Moreover, pathologists get to know clinicians from a huge number of different fields. Michelle is also boarded in Molecular Pathology, which now goes hand in hand with Cytogenetics. There are so many tests now coming on board for molecular testing, most of which are housed in Pathology laboratories. Those connections among the different fields of medicine are only going to grow.

All those being said, Pathology is not a required rotation in medical schools. This is a huge challenge because there's a striking decrease in the number of U.S. medical school graduates choosing Pathology.

There's so much curriculum change in medical schools now that Pathology is getting shorted on some face time so it's difficult to engage students.

To overcome this challenge, they try to be creative in coming up with ways to engage students. One of which is through a Pathology interest group.

They also offer a Post-Sophomore Fellowship (PSF). It's an entire year spent between the first two basic science years and years 3 and 4. It's sort of a hiatus year where the PSF works like a Pathology resident.

While a number of people who have done their PSF program have gone on into Pathology, there's also a good number of those who have gone into different paths. 

It's a great year to learn your clinical medicine because Pathology requires a lot of knowledge of clinical medicine. Because they test a pretty broad patient spectrum, it's very helpful for people going into other fields to have a firm understanding of Pathology.

There could also be this ego among students where they go into medicine thinking they want to save people's lives. So why go into something they "assume" can't have a big impact on people's lives.

There is this weird stereotype around Pathology where people think they're sociopaths. And Michelle admits to still hearing interviewees for residency being questioned by other specialties on choosing Pathology when they're so good with people.

This is a big point of contention for a lot of them in Pathology. So much of their jobs require interaction with clinicians.

There's a very strong drive now in Pathology to be out there more interacting with patients. 

They have initiatives like the "see, diagnose, and treat" put forth by the College of American Pathologists. Women from underserved areas would be able to come in and have a pap smear done. They'd be able to see those cells underneath the microscope. A diagnosis would be made at that time and interaction with the pathologist to be able to help them move forward with their care.

Most pathologists don't have day-to-day interaction with patients. This was even hard for Michelle initially since she liked working with patients.

That being said, there are also some downsides. You can't romanticize the daily work involved in dealing with patients. 

Michelle admits she's being protected from this being in academia since they take care of billing for her.

However, insurance companies don't reimburse well for some of the more complex testing that they want to do have. So they try to subsidize these by the bread and butter stuff so they can generate funding that will support some of the more esoteric testing.

Pathology has a very large professional footprint in the College of American Pathologists that they have a very strong advocacy role in Washington. They've pushed very strongly for better reimbursement for pathologists.

A lot of their resident applicants actually found themselves being less interested in the surgery, procedure, or direct patient care than they were about seeing what happened to that specimen they took. They were curious about what those cells were in the fluid.

Typically, attendings on those other rotations are quite supportive when they realize someone has an interest in Pathology. They actually encourage them to follow it up in the Pathology lab.

Michelle recommends that third and fourth-year medical students on rotation should familiarize themselves with their hospital laboratory.

You have to understand how tests are properly validated. Know the strengths and limitations of those tests as well as the positive predictive values and negative predictive values. These things seem esoteric but they're very important to know.

Much that goes into laboratory medicine is knowing the backstory of those results. A lot of test results are automated results. But you can't just buy any instrument out there. There are extensive validations needed. 

You need to understand false positives, false negatives, sensitivity, specificity, etc. How low can you go to detect someone with minimal residual leukemia? How confident are you in saying that there's no disease or there's a little bit of disease?

These are all important things that are easy when you're on the wards, you say all those numbers. But there's a lot that goes into it. The more that you know about that, the better off you and your patients will be.

A typical day of a pathologist primarily depends on their type of rotations. They offer both anatomic and clinical pathology. The anatomic pathologists look at tissues coming from patient in surgery.

Clinical pathologists are involved in hematopathology. They look at bone marrow biopsies. They are the clinical chemists, cytogeneticists, molecular diagnosticians, immunologists, and blood bankers.

So it depends on what rotation the resident is on. If they're on anatomic pathology rotation, they are looking at slides most of the day.

They may be grossing in specimens. This means they're processing specimens so they can cut them and get them onto the slides. Then they look at them under the microscope.

They may be doing frozen sections running back and forth between the O.R. and the grossing room where they do immediate evaluations of tissues.

In cytopathology, they may be out doing a fine-needle aspiration or an adequacy assessment if someone is having a procedure done under ultrasound or interventional radiology guidance.

In a clinical pathology rotation, they're on blood bank. They may be out doing transfusion reaction workups. They may be consulting on apheresis patients.

If they're a hematopathologist, they may be out doing a bone marrow biopsy or evaluation bone marrows under the microscope.

Michelle clarifies that although they're not directly involved in patient care, they still want to help patients. They're helping patients by looking at and processing all of these specimens properly.

Some of their applicants will almost do a mini-residency where every one of their rotations has been skewed towards pathology.

This is not a bad thing actually. But she tells them that they have four years to become a pathologist. What she really likes them to learn well is clinical medicine. So really do good, focused clinical rotations. They will help you become a pathologist.

Of course, you should do a basic pathology rotation. This will allow you to figure out if you're a good fit. And also, this will help you develop a good working relationship with a mentor who might be able to give you a good letter of recommendation.

It is helpful for program directors to know that the applicant actually knows what pathology is all about. So they don't come into it thinking it's all just forensics or autopsies. Again, know clinical medicine as best as you can.

Moreover, pathology has the aura that your answer to a given specimen is the only answer. But this is not true. They consult themselves a lot. There's not just one answer to things. There's often not a definite answer that people are expecting.

Michelle says that they've never seen any bias towards DOs. In fact, a lot of DOs come through their program. They have a lot of applicants who are DOs. One of their strongest residents was a DO who just left for a cytopathology fellowship.

So she gives the same advice to interested DO applicants to know clinical medicine. That being said, she has never come across any bias towards DOs.

No matter what field of medicine you're in, you will get out of residency what you put into it. 

So they want to see someone who's really interested in Pathology. One has to have the drive and they want to see things, participate, and actively do things.

A resident can't be exposed to every entity that's in pathology textbooks. They're going to have to do a lot of independent learning and reading. They have to look at the great images that are now available online.

They want to see some of that initiative. Get early, stay late. Participate in as many as different conferences as possible. Ask questions.

Moreover, they've had people who would seem they'd struggle if it were just based on paper. But they've overcome that. They're stronger for it.

Michelle explains that they are liberal in the sense of not judging people on paper. They're willing to give people a second chance. 

Another misplaced emphasis is trying to do a mini-path residency as explained earlier. You have multiple areas you've done rotations in instead of just focusing on your clinical knowledge. 

Michelle would probably tell her younger self that just because you're looking for the perfect fit, don't worry, you will find that square hole eventually.

Keep an open mind. For instance, Michelle kept her forensics rotation to the very end thinking she was going to hate it. But she loved it! Had she just had an open mind and done it a bit earlier, her whole career might be very different since she was already doing her fellowship at that point.

Be patient with yourself. They met a number of applicants every year that didn't find anything that really clicked until they did their pathology rotation.

Michelle loves interacting with clinicians. She finds it very rewarding as she's able to get a sense from them as to what their struggles are. This way, they'd be able to determine what is needed for them to make a diagnosis and how to help them.

They've made some calls that have literally been life-saving. Those may not happen everyday, but they do happen frequently.

On the flip side, what she likes the least is the feeling that there is so much in pathology that you can't master. There's just so much to know. And it's becoming more subspecialized.

They also have to realize the fact that they're not immune to making mistakes or misses that have significant negative ramifications on patient care. It can be a difficult, almost paralyzing fear that you can develop. You just have to make the best decision and best diagnosis you can and move forward.

Michelle thinks that all of the major advances in genetics and genomics is huge. Most of these targeted drug therapies are driven by molecular diagnostics. It's a specialty field you can do a fellowship in Pathology.

Personalized medicine and informatics are two other huge areas. Particularly, computational pathology is tied into informatics.

Pathologists constantly encourage students to be interested in pathology. They're saddened by why U.S. grads are not turning to pathology as both a great career choice and a great lifestyle choice as well.

They have many switchers to Pathology. So just try to get to know a pathologist. Call the lab director. Call the hematopathologist and ask if you can review the slides with them. There are insights that you can get that you cannot get just from reading a report. 

Understand what it is that you're seeing so you can understand the patterns. So when you're on a medicine rotation or a peds rotation, you can understand these things without necessarily going into Path.

Meded Media

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

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

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

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

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

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

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

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

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

[Related episode: The Possibilities in Pediatric Orthopedic Surgery]

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

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

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

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

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

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

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

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

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

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

[Related episode: 6 Tips For Improving Patient Communication]

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

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

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

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

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

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

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

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

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

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

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

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

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

[Related episode: Orthopedic Surgery Match Data Deep Dive]

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

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

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

How do you begin that relationship?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Meded Media

Do you know what Occupational Medicine is? Although the specialty has been around for a long time, it’s not very well-known. If you like variety and a detective type of work in exploring what could be causing someone to be ill, Occupational Medicine is an amazing specialty you should check out.

Dr. Jacqueline Moline is an Occupational Medicine specialist in an academic setting. She’s here today to help us understand what they do, why such specialty is very important, as well as the ins and outs of the specialty.

If you’re a premed student, please do check out all of our other podcasts on the Meded Media.

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

Jacqueline didn't know about Occupational Medicine when she was in medical school. She first got interested in the specialty during her Internal Medicine residency program. She had the opportunity to rotate through and meet with faculty. At that point, she thought it was the career choice that appealed to her.

Occupational Medicine is a discipline that deals with how the work environment can affect health. It's a global type of specialty in the sense that you have to have an understanding of what the person does, workplace hazards, and how the body is going to be affected.

Jacqueline explains that occupational medicine involves not only treating the "what's" but also the why's." They can treat your "what" but they also need to understand "why" you have this. What can they do to identify what might be causing it?

For instance, an adult presents to you with new-onset or a sudden exacerbation of their childhood asthma. The first question they would ask is what are you exposed to know that you weren't exposed to before? So they can treat your asthma and give you the appropriate inhalers or whatever medications needed. But they're also concerned with identifying why you have it.

If they can identify why you have it and work in a way to avoid that exposure then you don't have asthma anymore. 

Just a little backstory here. I used to work as a flight surgeon in the Air Force and we deal with Occupational Medicine all the time. We evaluate the mechanics working on planes and the paint shops where they're dealing with all these chemicals.

Occupational Medicine is a specialty within Preventive Medicine. If you can identify the hazard, you can prevent it.

[Related episode: What is Preventive Medicine? A Look at Academic Prev Med]

Occupational Medicine is a residency/fellowship. It's called a residency because technically you only need to do an internship and then join the two-year training program. Or it can be called a fellowship if you have done three years of training in Internal Medicine or Family Medicine.

She wanted to get the additional training because she wanted to learn more about the things she didn't know about like toxicology, epidemiology, etc.

You could actually play several roles as an Occupational Medicine specialist. You could have a policy role or work to help foster new policies in the federal or state government. You could work for a large corporation or be in academia. You could work in a clinical practice and do clinical Occupational Medicine all the time.

Moreover, Jacqueline wanted to know how to take an occupational history and practice it because this wasn't something they had time for in internal medicine due to time demands.

Curiosity is important. Try to figure out what's going on. Often, you're like a detective. It's going back to being really curious and just asking questions and having an open mind.

Jacqueline works in an academic setting and has a more specialized practice. She sees patients who've had asbestos exposure or patients were exposed 30-60 years prior. Then they've developed an asbestos-related disease. Or they've had the exposure and they monitor their health to make sure they don't develop diseases.

She covers a range of patients from those with asthma to manufacturing people exposed to various chemicals. She takes care of painters who might be exposed to solvents. She had also looked at folks who've had exposures to mold, heavy metals, or molten lead.

Based in New York City for many years, she had a uniquely New York type of exposure. They did a study on the health effects of theatrical smoke on actors on Broadway to see if that was impacting their voice. They also looked at any health effects related to the special effects used on stage.

They looked at whether wood preservatives can cause cancer. They've done studies on firefighters looking to see at increased rates of cancer. One of the things she has been doing for the last 18 years is monitoring the health of folks exposed after 9/11 at the World Trade Center site.

Some people in her field see more ER-type, urgent care stuff where they may see people with slips, trips, and falls at work. Jacqueline had taken care of folks with repetitive strain injury from overuse of the computer. It could also be something they developed as court stenographers or those who had to punch tickets on the train where they had to use their hand repetitively and developed thumb problems.

What she loves about her specialty is that she never knows what kind of exposure she's going to encounter through her patients.

[Related episode: 6 Tips For Improving Patient Communication]

Jacqueline explains the difference between Internal Medicine physicians and Occupational Medicine specialists treating specific occupational-related cases.

As an Internal Medicine physician, you're not going to be necessarily well-versed in the regulations that are going to be the underpinnings. 

How often should you be monitoring someone who has been exposed to lead? Do you know when they can go back to work? What does their lead level need to be?

If they're exposed to asbestos, do you know what you should be looking out for on a regular basis and how you should be screening?

Are there any regulatory requirements depending on their job that you have to fulfill? So they have worker's compensation and are you treating them according to the guidelines that might be present in your state?

Do you have time to take the full history to figure out what's going on in someone who's presenting rather than just treating them?  Jacqueline spends about 80% of her time or more, talking to the patient to figure out what's going on with them. The exam part is usually much shorter as well as the test-ordering and results.

Every discipline has its acronyms. There have even been primary care physicians who came to her and didn't know how to begin to do it. And she'd be happy to work in tandem with them.

Jacqueline underlines the importance of thinking in terms of what the person is doing for a living or what their hobbies are. 

The exposure might be the same, and it's just the location is different. If it's in your home, it's considered environmental exposure. If it's at the workplace, it's called occupational exposure. But it's really a continuum which is why the specialty is usually called Occupational and Environmental Medicine.

One of the beauties of this specialty, Jacqueline expressed, is that there is so much appreciation from your patients that you're having a conversation with them. It's not only transactional. It's not just clicking a bunch of boxes but actually having a conversation about your life.

People might be asked about their family history but, for instance, it's usually whether their dad died of heart disease, diabetes, or cancer. It's never like asking what their dad does for a living. Because if your dad was a shipyard worker then they need to know that because then they would know you're at risk for asbestos-related diseases.

Currently, Jacqueline is the department chair so she has more meeting time than the normal person, plus she's in academic medicine. Part of her time is spent doing research projects and research protocols and working on getting the date and the results. Then she'd have to write the stuff up.

She also runs large clinical programs so she has to make sure the staff is doing the right things and make sure everything is running appropriately.

Her favorite part of the week is seeing patients. She gets to do what she had always wanted to do in medical school. She loves taking care of the patients and meeting up with them.

She also mentors both her faculty and other doctors. They're trying to cascade where they're trying to begin to mentor other people to have opportunities that will allow them to grow.

Jacqueline initially thought she'd be more hospital-based. She actually went to the University of Chicago, which is very academic-based, and she did her Internal Medicine residency at Yale. At the former, you’re considered a faculty member when you’re seeing patients there. While at Yale, there were both private physicians and Yale physicians, more of a mixed model.

She had always thought of staying in academic medicine. She likes the idea of doing clinical research. So she didn't think she would necessarily want to see patients five days a week. She wants to mix it up and do some other things to feed her curiosity.

The field has allowed her to do all sorts of different things in her career from lead exposure to projects looking at bone lead turnover. She was looking at actors, firefighters, and 9/11-related stuff to working with asbestos-exposed individuals.

On the corporate side of things, one can work as a corporate medical director or a company staff physician. Some physicians also get involved with travel medicine and government roles.

Jacqueline found academics to be the right fit because it allowed her balance between patients and research. Plus, she gets to do policy and influencing along the way.

Jacqueline doesn't take calls and she has not really done it since her Internal Medicine days. She considers the specialty as having a nice lifestyle. It's more of an 8-6, 9-5, or manageable shifts. It's very much an outpatient specialty.

Occupational Medicine is a 2-year training program. During this time, you also get a Master of Public Health or its equivalent. So you will be doing MPH work and studying with other students. You will be taking courses in the core requirements.

Then you begin to see patients as you would with an attending physician in the specialty. You have supervised patients that you see and you begin to work on various research projects. 

In Jacqueline's case, she did a variety of projects with a mentor. One of which gave her early exposure to working with pesticides. This allowed her to learn about pesticides and their health effects.

In some programs, you need to do a thesis. Other programs require a capstone project. It's a multidisciplinary project. Not only do you need to interact with your medical team, but you also have to be well-versed in industrial hygiene. So when you get a report, you would understand it.

For example, you may do a worksite visit to understand how people can get exposed. You might work with a safety engineer and figure out what processes could be improved to make it a safer environment.

You will be working with occupational health nurses as well. So you need to think about it in terms of multidisciplinary and interdisciplinary.

Do a primary care specialty first. This provides you with the foundation that it's hard to gather without having those years. Ideally, this would take three years, but if you can't, do two years to just get more experience. Then you transition over to Occupational Medicine.

Jacqueline used to be a residency director and says they've had some amazing trainees who came from different fields. Some came from Radiation Oncology where they didn't feel it was the specialty they wanted so they transitioned over to Occupational Medicine.

Try to find folks around the country who would be willing to work with you and maybe you can do a project form afar while you're a medical student. And if you just want to do an internship and go to Occupational Medicine, that works as well.

[Related episode: How to Think About Choosing a Residency & Specialty]

Jacqueline wished primary care physicians knew they could work together better to identify what's going on with their patients. They should think about the external factors that might be affecting health. But they don't have a lot of times as their days are so busy.

Jacqueline encourages primary care physicians to use them so they can better care for their patients. Let them at least take that long history and identify if they can find a reason why their asthma, for instance, isn't getting better, or potentially cure it.

If someone comes with a new-onset unusual condition and they just switched jobs, send the patient to them. This way, they can do an inventory of what they might be newly exposed to in the workplace that might explain why their blood count is unusual.

If a patient is a member of the union, often the union can help and assist. But by law, the workplace has to provide the information. But you can also work with your patients.

You can find what is called MSDS's (Material Safety Data Sheets) online to get a sense of what they're exposed to.

Sometimes, they will lean into what is actually in that particular substance as it may have proprietary secrets. You can call the company and they have to tell you as a health care provider what it is if it could be causing adverse health effects.

This can be time-consuming and this is one of the challenges they have. But that's part of identifying the mystery of why someone might be sick. If they're using a substance, they have to have it available to all their employees and that's the law.

Jacqueline deals with pulmonologists a lot as well as ENT and GI. They also deal with mental health as some exposures have led to mental health issues such as PTSD, anxiety, stress, or burnout.

Other specialties they work with include thoracic surgeons, dermatologists for rashes in the workplace, and orthopedics and physiatrists for ergonomic issues.

There are government roles you can do whether on a state, federal, or local level. There are corporations looking to hire doctors. There are always tons of job opportunities available in Occupational Medicine.

There are also corporate medical director positions available. There's also the academic setting.

No one knows what Occupational Medicine was and she wished she knew about it going into medicine. When she went to Yale and there was Occupational Medicine, she felt it was the natural fit for her.

Over the years, she has found it to be a challenge that she would always have to describe what she does. Part of the reason is that they're not a specialty that's direct from medical school. It means that people choose something else first before they go into Occupational Medicine.

Jacqueline encourages people to contemplate on the curiosity and thinking outside of the box. Think about what might be causing things and not just taking it at face value and treating what's causing things. 

What Jacqueline likes the most about Occupational Medicine is its variety. She never gets bored. Things are always different even if she's reviewing the same type of case, she can always learn something new everyday.

On the other hand, what she likes the least is paperwork and dealing with archaic systems including worker's comp or delays of trying to get patient care.

One thing that would stay the same for Occupational Medicine is figuring out what someone does and this is a constant. That said, there will be changes in technology and new types of jobs that people have. We have to morph and adapt to whatever those jobs would be to understand the risks associated with them.

If she had to do this all over again, she would still have chosen the same field. It affords her a great lifestyle as well as an opportunity to have curiosity and learn something new everyday.

If this specialty is something you're interested in, reach out to someone in your region. There are education and research centers located across the country.

Reach out to the medical directors of a residency program and see if there's someone interested in having a medical student work with them. Learn more about the field as it has so many opportunities.

Meded Media

Dr. Aaron Leetch one of the program directors at the University of Arizona for a combined residency in pediatrics and emergency medicine. It's actually a very rare residency program with only four programs in the country that offer this. Find out more about this, how it's different and much more!

Dr. Leetch is the host of the Arizona EMCast. Also, check out all our other podcasts on Meded Media.

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

Aaron has always been certain he was going to be a pediatrician as he loves working with kids. He also liked the compassion of it. It was when he started working at one of the local ERs as a scribe that he felt torn between pediatrics and emergency medicine. He loved the acuity and multitasking aspects of emergency medicine. In fact, he likens it to waiting tables which he used to do.

Then he met the program director at the University of Arizona who trained at the combined emergency medicine and pediatrics program in Baltimore and started the program there. He asked Aaron why he wanted to do both and thought it was everything he had wanted to do.

After five years of doing the training program, he still loved every minute of it and knew it was the kind of thing he wanted to do for the rest of his life.

Aaron has always been amazed at people being torn between two specialties that are very dissimilar. For some people, pediatrics and emergency medicine are not the same. But he explains that there are aspects of both sides that he really liked.

Aaron later realized that his pediatric training would be applicable when he sees children in the emergency department. To help them navigate that system in the ED is incredibly helpful to the patient. 

[Related episode: What Does the Pediatric Residency Match Data Look Like?]

You have to be patient considering that it's a five-year training. Be sure that you're willing to do five years since you can just do emergency medicine and still trained to see children.

The first thing he looks for in applicants is why they want to do both programs. He also wants to know people have considered what they want to do after they're done with training. There are lots of EDs that can't afford to hire somebody who's only certified to see children and they need to see both.

[Related episode: Advice From an Emergency Medicine Residency Director]

Considering that there are only currently four programs doing this kind of training in the country, they're hoping to gain visibility through doing medical student podcasts. Plus, they also get the opportunity to talk to people about this.

The most common for pediatric/emergency medicine is doing a peds or emergency medicine residency and then doing a fellowship. This is great as long as this is what fits with what you want to do.

However, if you want to be a rural doctor and you want the general pediatrics knowledge or the subspecialty time with pediatric nephrology or neonatal ICU, you wouldn't be able to get this by just doing an emergency residency and the pediatric fellowship for two years.

It would not give you the same level of intensity if you want to be a broader trained person rather than narrowing and being a specialist.

The types of patients you see depends on where you go. In Aaron's case, he does 60% peds and 40% adults.

You have the potential to work in any emergency medicine department across the country. If you want to work in a pediatric-specific emergency department, that depends on the needs of that emergency department.

You could open up your own clinic if you wanted to or work in places that need a general pediatric physician as a hospitalist. You can do a fellowship on the emergency side or on the pediatric side. Or you can do both.

In their program, they've had people who did fellowships in pediatric critical care, simulation and medical education, toxicology, sports medicine, and some other ones.

You've got a lot of opportunities when you're done assuming you keep your options opened for geography. Make sure you've got a good idea of where you're headed.

As fellowships are becoming more common after residency training, you need to be able to stand out. However, you don't want to do this just to stand out because it's a long chunk of your life to spend. There are better things you can do. But it does help and it gives you a different philosophy for how you're approaching things.

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

If you have an idea of where to go, then you need to email that institution and ask what you need to do to get the job. That said, there are plenty of places that are still clamoring to get somebody who is a specialist and wants to take ownership of pediatrics.

There's a lot of literature suggesting that people who have done the pediatric EM fellowship stay in large academic centers. They don't go out into the community and work as they had hoped. In fact, many have now questioned whether centralizing everything at the children's hospital is still the best way to go.

Aaron feels that if you've got extra training, you feel more comfortable seeing children. You feel more prepared to see a really sick kid out there because that's where the majority of these kids are going to end up going.

For their program, Aaron explains you have to have the pediatric experience. You've seen kids, especially the really chronically ill kids, and the tech-dependent kids. You've seen them in the clinic. You've seen them at the subspecialist's office. You've seen them when they're really sick in the ICU. You've got a background on how to take care of children that you can pull from.

And then you've got procedural competency and that critical care emergent time-management mindset from emergency medicine. The other five years of training just becomes a part of you.

If you can get any experience during medical school, you will decide very quickly whether you love procedures or you don't. There are a handful of environments where residents and attendings tell you how they've walked into X environment and they knew they're home. For some people, that's the O.R. For some, that's the clinic or the ICU or the ED.

If you have the opportunity to do any kind of three-week elective or some experience ahead of time, do it. Email a physician and ask if you can shadow them even just for one shift or overnight or for one time that will allow you to get the best exposure.

A lot of what they do in pediatric emergency medicine is to convince their kids are going to be okay as well as a lot of return precautions. If you don't like doing this then pediatric emergency medicine is probably not great for you. You're not constantly having critical children coming in. 

Regardless of what you're considering, try to get some experience early and that will help you make your decision.

Aaron still gets to have a life outside of the hospital. But he believes you have to make time for it. He makes it a point to take time out apart from doing anything related to work to recuperate and refresh.

With shift work, you've got to work 365 and somebody's got to work the holidays. Somebody's got to work the overnights. So you adjust to it. And if you're considering emergency medicine of any kind, you have to determine whether you can function at 2 am. And are you somebody that someone wants to be around at 2 am? Or do you turn into a werewolf that nobody wants to work with?

You have to make it a point to do something that is not medical after work in order to restore yourself.

At their program, they've got a handful of people that just do nights. They're offered a pay differential so you can make a little more. But they would usually split between mornings and evenings.

The morning shift can start as early as 6 am. They work 9-hour shifts. And it can start as late as 5 pm and you get off at 2 am. But in an emergency, you get off when everything is done, especially as a resident when you're still trying to learn your flow and your management. But you will get better over time and things will get tolerable.

As a resident, everybody rotates through in a circadian fashion so that you do as much as you can. But you do a lot more evening shifts because that's when the patients come in. Even if your sign out is done is at 4 and your relief comes in at 4, then you're not done for another 30 minutes so that the transition of care is appropriate. And this is expected.

Aaron gets off when he's supposed to probably 60% of the time. Especially in pediatrics, most of the kids they see are not critically sick. So when he works his adult shifts, he always buffers knowing that a lot more adults are going to be critically sick and they're going to need his time. But you're never really prepared for that stuff.

[Related episode: Balancing Family Life with Being a Premed and Medical Student]

If you want to do pediatric emergency medicine, you can do a three-year pediatric residency and the three-year pediatric emergency medicine fellowship. You can do a three or a four-year emergency medicine residency. Then another two or three years in pediatric emergency medicine fellowship.

At their school, they have a five-year program where you have to fulfill all of the requirements for emergency medicine and all of the requirements for general pediatrics. They're doing this concurrently.

They do somewhere between 2 and 6 months in the emergency department doing trauma surgery, ICU at the VA, emergency medicine, anesthesia. Then you'll flip and do 2-6 months of general pediatrics, neonatal ICU, pediatric pulmonology, inpatient wards, clinic. Then you keep flip-flop back and forth until you reach your five years.

Aaron likens their training to children growing up in a bilingual household. They don't necessarily keep the same verbal milestones compared to a kid growing up in a single language household. They're learning two different words, two different idioms, and two different ways to say the same thing. But once they do, they catch up pretty quickly and they speak two languages.

With their program, they're going to teach you how to speak pediatrician and how to speak emergency physician. Although, it takes a little bit longer. 

It's a different growth curve of how you're going to progress along in your understanding of both specialties. But once you do, you're going to catch up. You may even surpass some of the residents from either the emergency medicine or the pediatrics program itself because you now speak two languages.

The four programs that offer the combined residency include the University of Arizona, University of Maryland in Baltimore, Indiana University in Indianapolis, and LSU in Louisiana.

There are only 8 or 9 spots in country. Aaron says that you have to consider if you're crazy enough to do five years. You have to love this enough that you want to do five years

To make yourself competitive, have a backup either in pediatrics or emergency medicine. Some people choose both.

And even if you don't match into one of these spots, you can still do emergency medicine and a fellowship or pediatrics and a fellowship. They've even had several residents that graduated from one program and then re-entered the match and did the other ones. So they did six years to do the same. Well, it's not quite the same because you're taking it in chunks instead of intermingling it.

Aarons recommends that you strengthen your application packet towards whichever is going to be your backup. So if your backup is emergency medicine, then strengthen your packet towards emergency medicine. Show that you're going to be a good emergency medicine resident.

Doing away rotations is great as well as interview rotations to have a good idea of what's there. 

Do pediatric emergency medicine or pediatric ICU as they're going to be helpful whether you do the combined EM/peds program, EM on its own, or pediatrics on its own. Both are going to intersect with peds/EM and peds-ICU. This will help strengthen your packet for the combined program and for whatever your backup is going to be.

Two of their residents at their program are osteopaths and they're fantastic. If you're applying to a place that already has unfavorable opinions set on osteopaths, go for it if you want to be the trailblazer and try to rotate there. Otherwise, consider if it's really the best place for you if you're not going to be viewed as an equal with the other residents.

Aaron adds that you can strengthen your application just as you would for any other place. But if you feel like that may be a hindrance for you, doing an audition rotation is a great way to show how good you are.

To stand out at these rotations, you have to show initiative and that you can work well with a team. They want to see that you've done some of the work on your own. There's also the 2 am test. Are you somebody they want to be working with at 2 am? You have to be reliable.

A fit in personality is also important to consider. Their program wants to see that you fit well. So you have to consider whether you're a good fit at a certain program and determine if you like them.

[Related episode: The One Thing You Need to do to Stand Out as a Premed]

Aaron wished he had done a much better job with self-care and making sure that he took time (that he now takes) for family, for friends, for hobbies, and for things that help maintain his sanity.

Although residency is not as a brain-drain that medical school can be where you feel like you're drinking from the firehose, it is time and energy-taxing.

You have to put effort into the things that you want to be around when residency is around like family and friends. Because you can't just push pause and come back in 3 to 5 years and feel like everything is still going to be the same.

What Aaron likes the most about the combined residency is that they are people who like to have fun and have a broad perspective of medicine.

What he likes the least about the pediatric emergency medicine is that when it's bad, it's really bad. They deal with cases like child abuse, pediatric sexual assault, drownings, SIDS, and cancer diagnosis. Often, those will happen in the ED.

What he realized that really affected him is that they can't help everyone. They want to take care of everybody that's there. They want to try to help every person that comes into the emergency department. But there are so many people that come in with complaints that they can't help.

He tries to provide hope for people in a hopeless situation when they come in at midnight on a Saturday. For him, this is frustrating when you can't offer what they want.

Especially during residency, you spend a lot of time in the clinics and on the wards. They even joke around that kids are not little adults but adults really are just big kids.

Aaron says he can do a lot of the same things that he does with children. He's able to apply some of that to adults especially among the 20-year-old's where the overlap is not quite there yet.

In pediatrics, one of the first questions they ask themselves is whether the patient needs an IV. In adults, before they even get their chief complaint, they've already gotten an IV. They're getting a dose of antibiotics and they're on their way to the CT scanner. All those being said, he gets to have a different perspective.

If he had to do it all over again, he'd still be a combined EM pediatric physician. And even his wife just recently told him that if he had to do it all over again, she would still support him all the way through.

To those interested in getting into this specialty, try to get experience in both emergency medicine and pediatrics because they want to train people in both. They want you to be a pediatrician. They want you to be an emergency physician. Then they're going to train you on how to be a pediatric emergency physician.

Make sure you really want to do both because the last thing they want for somebody is to be halfway through and say they hate this. They want you to go in with eyes wide open.

Meded Media

Arizona EMCast

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

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

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

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

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

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

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

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

[Related episode: What Does the Pediatric Residency Match Data Look Like?]

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

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

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

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

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

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

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

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

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

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

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

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

[Related episode: Balancing Family Life with Being a Premed and Medical Student]

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The Premed Years

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