Specialty Stories

Geriatric medicine is both stimulating and satisfying for Dr. Shannon Tapia. We’ll talk about housecalls, mortality, and the importance of having a sense of humor.

Meanwhile, be sure to check out all our other resources on Meded Media for more help as you journey along this awesome field of medicine!

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

Having a father who's a geriatrician was Shannon's first exposure to medicine. Growing up, medicine was different back then but she got to witness how it was being a physician.

She liked the cognitive aspects of medicine. She could do procedures but she just never really got stoked about it. Being exposed to it early on and realizing how cognitively challenging geriatrics is, she was essentially drawn to it.

Shannon compares geriatrics with being the Sherlock Holmes of doctors. Aside from a huge kinetic variability if they live long enough, they also have a lifetime of choices.

With geriatric patients, many of them could be suffering from dementia and other cognitive issues, making it difficult for them to express how they feel. So geriatricians have to get a collaborative history from their family and know the environment. 

Shannon finds this to be very interesting, challenging, and satisfying. Half the time, it's med side effects from the specialists. They throw a med at them which they should never have been on.

You will also realize there's not an answer so you need to be working with the patient and their family. It basically covers all aspects of medicine. You have to be constantly thinking of options and navigate it with your patients and their families.

The majority of 30-50-year-olds are rare diagnoses but most of them present pretty similar cases. They come in and the doctor asks appropriate questions and they give an accurate history for the most part. This excludes people who are actively psychotic.

In the older population, you have to expand your differential in what they say because a lot of things present differently. They have dampened immune systems. They have neuropathy and they don't feel pain in the same way.

Until you spend a lot of time with your geriatric patients, it's hard to truly describe the extent of how different it is. You're essentially dealing with a variety of factors when you're trying to approach a problem. Then there are a lot more limitations on what the achievable goals are. So you have to reconcile those to arrive at a realistic outcome and that people can be comfortable with.

Shannon says that having a healthy sense of humor is good. You have to be patient and not afraid to get into the thick of things. You never know what you're going to walk into half of the time.

Don't take things too seriously otherwise you're going to end up missing what the patient really needs and that of their family.

Being empathic and being comfortable with mortality are two other important traits of a good geriatrician. Shannon believes that if you're not someone who can stop doing things to people, you should not be a geriatrician.

There's this mentality in medicine where doctors intervene when there's a problem and they're going to fix it.

As patients get older, the only truth is we all die. There's always more we could do but you have to be able to step back. Think about the quality of life and prognosis for the patient if you did it. How would it look like not only after they recover but also in two years down the road?

Essentially, you have to take it one patient at a time and take their goals and preferences at a time. Have your opinions but separate yourself from that.

Moreover, there's a lot of misinformation even for geriatric patients and their families as to what's achievable in medicine. You have to get to know both the patient and their family. Be honest with them about what you think and whatever intervention they're considering.

If it's a treatment situation, you have to be able to take their goals and translate what the realistic prognosis would be for them, knowing what their wishes are. That's not easy always because there's a lot of misinformation about what the medical community can achieve at a certain point."

Shannon explains how geriatrics is struggling in terms of how they're under Medicare plans. But it's a cognitive field. It's not a procedure that they can always do and can rack up reimbursement for. 

Especially if you're in private practice, it's really hard to pay off your student loans and do it well. 

Unfortunately, there are very few private practice geriatricians anymore because it's tough and the pressures in the private practice world are hard. Not to mention that there are only a few great academic institutions that have great geriatric support programs. 

Shannon describes her typical day as being different from an academician. It's basically different depending on what realm you practice in. If you're in academic geriatrics, you're going to do a mixture of geriatric consult service at a hospital you're affiliated with. You will be on service with heavy clinic and lots of didactics.

It's hard for academic institutions to do long-term care providing. It's a whole different set of private regulations that tend to be challenging in an academic setting.

As a private practice geriatrician, your day is variable depending on whether you're clinic-based or when you're doing house-based care.

When Shannon's new job starts, her practice will be in one geographic area with the goal to see 10 patients a day. Four will be in one assisted living facility and the other four from another assisted living facility, and then two independent homes within the same geographic region.

Moreover, Shannon has done some expert witness and chart reviews. There is so much chat vomit in terms of what they're required to put in the medical records. So much of it is just completely useless information.

Before Shannon moved to Denver, she used to do direct primary care house calls. She was fortunate in her geriatrics fellowship to get good exposure to it. The problem with geriatric fellowships is they're hugely variable. Some are more research-focused, some are more clinical. Shannon did it for a year but it was clinically focused on every level. 

While Shannon loved her fellowship training, she also saw how bad what you walk into could get. But part of why she loves doing this is that because of the patient population they serve. Just because you're Medicare age does not mean you need a geriatrician. It's really based on your physiology and the individual patients.

Shannon explains that doing house calls could be best for the majority of the patients. This way, you also get to figure out what's going on with them. Whether it's physical debility or even a mile cognitive debility, getting them to the doctor is a huge deal. This also gives Shannon as their physician so much more information.

Plus, the relationship you're able to build with them goes to another higher level. Being invited to their home, you kind of become part of their family. There is a much more intimate relationship with your patients. There is a lot more trust involved.

Whereas just receiving patients in your clinic and you only have to go on the face with what they say that they're taking their medicines or they're eating. But it's different when you walk into their homes and see how they're taking their medications. So you get this unique perspective when you get to go to their home.

Shannon says there's a potential to have a very good work-life balance as a geriatrician but it depends on how much money you need for your life balance. Again, it's a low-reimbursement field. So if you are one of those people that wants to take extravagant vacations, it is not for you.

As a single mom and not having to be tied to an office, Shannon says this is really huge for her. When you're doing house calls or going to a long term care facility or nursing home, there's a timeframe. There's that flexibility of time that comes with having children but still being able to go out and do clinical work.

The only challenge is the documentation requirements that put a lot of pressure on you so you end up taking more work home.

Medicare sets the fees even for private insurances. So everything in medicine is all based on trying to figure out how much they're going to pay you and how many RVUs (relative value unit) you've got for a visit. The way the system works out is that time gets very few RVUs unless you do a ton of volume. But procedures get a ton.

It's inherent that it's highly cognitive and diagnostic but it's not like you should be ordering tons of tests because usually, those tests are bad for the patients.

People who do nursing home care sometimes do pretty well because they can do high volume as they're able to see a ton of people in one place.  Also, the reimbursement system is different in nursing homes than in an assisted living or even in house calls.

In nursing home care, how reimbursement works is that it's not just face-to-face visits but it works like at a hospital where it's billed for all the time you spent on the patient. If you're in an outpatient clinic or in a house call, your time is all face-to-face time with them. 

You can either do internal medicine or family practice to become a geriatrician. She was originally going to do internal medicine. Then she had great mentors in family medicine that told her that geriatrics is really an outpatient field and that if your patients are in the hospital, it's not good. Because of this, Shannon wanted to go to a field that emphasizes outpatient and she got a sense in medical school that family medicine did this. So she decided to do family medicine the last minute.

After residency, you have to go through either a one or two-year fellowship thereafter. Whichever one you choose, you have to take both boards. 

Since she did family medicine, she would have to take a family medicine board every ten years and the geriatrics board. She also has to do a ton of things that family medicine requires that are focused on peds and women's health, which are not related to what she's currently doing.

In terms of subspecialty, there really isn't that much. You can do geriatrics/psychiatry but you would have to also go into psychiatry residency.

There is apparently no bias against DOs. Geriatricians are badly needed. Unfortunately, there are people who do fellowships just for filler because they can but they don't really have intention of really practicing the specialty.

Shannon wishes to say to internal medicine and family medicine physicians that geriatrics is a specialty. This has been her biggest frustration with some family doctors. There are some that think that they've got it all and they don't need help from geriatricians. But they are trained to recognize a lot of things that can help their patients out.

Geriatricians are very good at recognizing and helping treat dementia, Alzheimer's, and most vascular dementias. 

They're actually better suited to treat it than neurologists because they are also generalists in the whole area. They're able to take a more big-picture approach. They can stay involved with the families and get them connected to the resources they need, more than just do a cognitive evaluation once a year and give them medicine.

For family medicine or internal medicine physicians that have patients that are of the geriatric population or have geriatric syndromes such as Parkinson's disease and certain types of early-onset dementia, you would benefit from a geriatrician.

Other specialties they work the closest with include cardiology, ophthalmology, and neurology, and gastroenterology. She also works with nephrology but not as much.

They also work closely with trauma surgeons because so much of the geriatric trauma are related to unrecognized geriatric syndromes. Getting a geriatrician involved can medicate delirium and help the patients get on the right track.

One opportunity is being an expert witness. Shannon only does defense. There's a lot of physicians, especially academic physicians that are on the plaintiff side.

For instance, if a geriatric person had a fall in a nursing home and a bad outcome, the family goes and sues. So she does the defense and expert witness if she's asked to.

What Shannon wished she knew about the specialty that she knows now is that the system is not great for geriatric patients. And Shannon thinks it's even gotten a lot worse. If she had to do it all over again, she would still have gone into geriatrics.

She just wished she had known how things would change in the system for the worse. 

For her, it would have been easier to accept things if she knew about it going in, sort of like an informed consent process.

Just like when she didn't know she had to take the family medicine boards every ten years that doesn't even apply to geriatric patients. So she was really frustrated about it. And had she known it, it would have been a different story.

There's a disconnect between the general population's understanding of how the medical system works and how the system actually works.

What she likes the most about being a geriatrician is the patient population. It's fun to be dealing with people. You get to know them and their families. She likes how these people have a lot of wisdom. If you go into it with a sense of humor, you can have a lot of fun with it.

On the flip side, what she likes the least about her specialty is the system. She really believes how detrimental the system is to the patient population. It's a growing population and it's costly. 

Eventually, she wants to get involved in advocacy for changing the system because she really doesn't think we can sustain the way we do things now.

Shannon admits that she stopped subscribing to the Journal of American Geriatrics Society as she didn't see it necessary. She doesn't think there are major changes in the field but she hopes that there will be changes in terms of the system and Medicare. 

On a side note, Shannon also does hospice, which a lot of geriatricians do because of a similar mentality. And she really hopes politics will recognize the need for qualified geriatricians.

It's one of the most fascinating medical fields you can go into. You have to constantly use your mind and be an expert at pharmacology and psychiatry in some ways. The physiology is fascinating as well as the pathophysiology. So if you love to think and you love relationships, it's a great field for you. 

But be aware that everybody is different in terms of their student debt burden and the kind of support systems. That being said, it's not the field that's going to make you the most money the fastest.

Meded Media

What is pathology like? Dr. Uthman debunks some myths and tells us why he needs more than just a tissue sample to arrive at the right diagnosis.

Pediatric GI was a natural fit for Dr. Jason Shapiro, who was interested in diverse pathologies, performing procedures, and developing relationships with patients.

Also, please check out all our podcasts on Meded Media for more resources to help you along your premed and medical school journey!

Jason is a pediatric gastroenterologist at Brown. He initially got interested in GI during the first month of his intern year. He likes the diversity of the field. It has a lot of procedures involved as well as research, immunology, microbiome, medication, and optimizing medication effects.

Most of Jason's clinical time is dealing with kids with Crohn's disease and ulcerative colitis, which are impactful conditions. You want to have as minimal effect on the child's daily life as possible. So you need to be empathetic, compassionate, and a hard worker.

Most kids with IBD (inflammatory bowel disease) present themselves during early adolescence. But there's an uptake of very early onset IBD where kids less than 5 years old come in with it. For the most part though, new diagnoses are in early teens although it can run the spectrum.

Their bread and butter cases for Pediatric GI include infants with gastroesophageal reflux, milk protein allergy, constipation, Coeliac disease, and functional abdominal pains. They're also seeing a huge increase in an allergic condition called eosinophilic esophagitis.

At Brown, they work with a team of GI psychologists who help them manage some of those more complicated cases.

Most of the referrals they get from a blank canvas. The majority of their new patient referrals from a general pediatrician have not had too extensive of a workup just yet. So there's a degree of diagnostic work that needs to be done.

There isn't a huge amount of patients that they do procedures on. Although they're generally non-invasive, there are procedures that need general anesthesia. And this is something they don't just do without a good reason to do it.

Out of the total numbers they see in clinic, Jason estimates 10% of them would be procedure-related. His typical week would involve doing endoscopies. When on call, they're probably doing more procedures than they like. So there's no lack.

For Jason, research is a very important part of his career. Even in residency, he was involved in an Ivy League research that he did all through fellowship and up until he was already an attending physician.

As a PGI across the country, you need access to pediatric anesthesia, which means you need to be in an academic center. In New England, there's not much practice in pediatric GI so most of them are affiliated with an academic institution. 

Jason takes calls between 8-10 weeks a year. Calls are variable. Their fellows take the first call from the ER or the community doctors.

The calls may vary from a couple of calls overnight to a week of procedures, most of which are esophageal foreign bodies, mostly coins. Every now and then, they do a few GI bleeds and variceal bleeds.

Jason believes work-life balance is an acquired skill in terms of working on time management and trying to get as much done. Since having his kid over two years ago, he had adjusted his work schedule accordingly.

At every phase of the medical career, it's a hard adjustment. But having been in faculty for several years now, Jason has learned to set priorities and make the necessary adjustments.

The path to becoming a ped-GI doctor requires three years of general pediatrics. On your second year, you apply for fellowship and then you get into three more years of pediatric GI fellowship.

Currently, some people are doing extra years within ped-GI. So there are advance fellowships in transplant hepatology, motility, and IBD.

Competitiveness-wise, Jason thinks the subspecialty is generally competitive from a pediatrics field standpoint. Therefore, you want to have good letters of recommendation and good board scores.

They recently graduated a DO fellow whom they think was one of the best fellows they've ever trained. For osteopathic students, just like any other traditional MD student, you have to have good letters and good scores. That said, he claims he doesn't see a huge stigma against DO as much as it used to be. If you're a good doctor, you're going to be good doctor regardless.

What they wished primary care physicians knew was that they were able to spend more time and counsel some of the more basic stuff. He believes some of those cases could already be managed by a general pediatrician.

But he's also aware that the primary care setting deals with a ton of patients to keep up with the demands.

Major stuff they could be counseling on would be constipation or functional abdominal pain. But can be difficult to get the message across to families so it takes time. And sometimes, hearing it from a subspecialist is important. 

Jason adds that there is an art to treating constipation. And explaining this to a family can take time. Investing time and energy early on is therefore important in terms of keeping the kid feeling well and helping the family understand the plan.

Jason works closely with pediatric surgery, pediatric psychology (specific to Brown), pathology, radiology, and hospitalists. For Crohn's, he works closely with dermatology and neurology.

There are a lot of opportunities in pharma. He knows a few people who practiced the subspecialty for a few years and ended up working at various pharmaceutical companies. Jobs in pharma can be widely varied. You can work on clinical trials or drug design, depending on your background and interest.

There is a need within the bigger pharma companies to have input from physicians with clinical experience treating these diseases.

With everything that he knows now, Jason would tell his old self not to be too distracted by the salary discrepancies within different fields of medicine. No matter how much money you make, if you're not doing something you love, you're not going to be happy. Money isn't everything and it doesn't buy happiness.

Still, Jason would still have chosen the same field, if he had to do it all over again. He loves the patients and their families. It's something he enjoys. He loves the science and the research aspects of the field. He loves the procedures.

What he likes the most about his subspecialty is the ability to develop relationships with his patients and families. He finds it very rewarding.

Jason has been in the same institution for 14 years in total now. He has seen kids from being small to graduating high school. He also likes the relationships he has built with colleagues and support staff.

On the flip side, what he likes the least is the EMR. He does think that the business side of medicine is necessary but it can be ugly. There is this sense that you need to bring more money and you need to do more and it's tough.

He is lucky though for being a part of a department that's really supportive and truly cares about child health.

Work hard. Find a good mentor. For Jason, having great mentors has been so important to him. Have somebody to guide you no matter what phase of career you're in. Find somebody you trust and who cares about you and your career. Your mentor doesn't have to be in your subspecialty.

Be honest. Always treat everybody with kindness – your colleagues, junior and senior people, nurses, secretaries. You can't do your job if other people aren't doing theirs. You're a part of a team and it's important for you to understand that.

I just would like to point out to this discussion around how DOs are not respected. It's not true. There are some programs out there that disrespect DOs but there's a lot of disrespect happening in general. So it's not a broad idea that if you're a DO, you're “lesser than.”

As mentioned by Dr. Shapiro, they have had DOs graduating from Brown and DO attending at Brown. So if you're a DO interested in Pedia GI, there is hope for you. Just do your best.

Meded Media

Emergency medicine residency training requires lots of interpersonal skills. Dr. David Snow has been out of training for 6 years now. Today, he tells us more about the acuity, variety, and steep learning curve in EM.

Meanwhile, be sure to check out all our other resources on Meded Media.

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

Coming to the end of the third year in medical school, David was choosing between surgery, psychiatry, and emergency medicine. Ultimately, there were things about EM that appealed to him.

[Related episode: What is Emergency Medicine?]

When you get to a shift, it can get as busy as any other time during any other shifts in their life. They sometimes work at 5 am and 11 pm and it doesn't matter what comes before that. They just have to be ready as they walk in the door. This is not unique to EM at all, but it is unique across all the fields of EM. As an EM doctor, you have to understand the unpredictable nature of the specialty. 

Additionally, interpersonal skills are important as you could be speaking to patients from all walks of life.

Alongside, you'd also be networking with clerks, nurses, medical students, and division chairmen. You have to be able to work with the challenges of that environment and do so with a smile on your face.

David has been evaluating residency applications for 7 years now. A few years ago, they added a new piece to the application for emergency medicine called the Standardized Letter of Evaluation. In any of the rotations you do, you will have one of these letters written for you.

This is a movement away from the Letter of Recommendation that students ask from an EM physician. It compares you to applicants from the current cycle and the previous year. The letter also lists a set of attributes that talk about your success within those attributes as well as your work ethic, professionalism, etc.

There are also specific pretext parts to the document where people speak very candidly about the applicant. Emergency physicians are looking for the same things. They somewhat know what to write. 

[Related episode: Looking at Emergency Medicine Match Data and Surveys]

David thinks there are so many facets to a pass-fail system. He believes it could be hard from the student's standpoint as a sub-average USMLE Step 1 score can be very detrimental to an applicant.

Programs can use filters based on USMLE or COMLEX scores and that one score can be very hard for them to move past to ensure the reviewer doesn't get stuck on that. There's no recommendation an applicant needs to have taken Step 2. But if the Step 1 score is below the mean, it's encouraged that they take Step 2 so they can work past that. This being said, it adds a lot of pressure to all of it.

[Related episode: What Step 1 Score or Level 1 Score Should I Try to Get?]

David recommends getting in touch with EM faculty and to start interacting with them as early as possible so they can start asking questions. Most medical schools that have EM departments have some way to get shadow shifts with EM faculty.

Nevertheless, he doesn't think there should be pressure for students to get in front of PD during their second or third year. You just have to do what has to be done to figure out that EM is for you. If meeting with a program is the way to do that then fine. But don't feel like you need to do that in order to bolster your application.

Ultimately, just enjoy your rotations during third year as your learnings are all going to be very useful for your future training.

Donald underlines understanding the key attributes of an EM physician. They are hardworking. They don't complain about the work before them. They try to enjoy as much as they can. It's important to have that positive outlook and the desire to come in and take care of patients.

Be able to come in wiith those attributes without trying to be held back by your nerves. Understand you're still a student and not a resident yet so your level of knowledge is obviously below the residents.

Donald notices how many students come in during rotations where they feel this need to prove they know what they're doing. He advises students to step back from this. ED is challenging itself. Just find your team and enjoy your time.

Anything you can do to help out a resident would be golden. They would thank you and love you for that.

Try not to think about the importance of the rotation and just be yourself. Be that motivated and driven medical student on the rotation who's there to learn and work. Being so focused on proving and performing would only limit yourself from feeling what it might be like to be that person in the field.

Many students are drawn into EM by trauma and acute resuscitation. Although this is a huge part of what they do, it's far from being a true EM clinical life. It's a big part but it's not a huge part of an EM physician's life.

Another misconception about Emergency Medicine is the idea of burnout. David believes that so much of this is born out of the habits formed during residency. You might do all of that right and end up in a job that makes you very unhappy but then you must change jobs because if you don't, you'll fit in that burnout spectrum.

David clarifies it's not a false label as this is what's being shown on the survey. But he doesn't think this should preclude you or stop you from going into a career in emergency medicine.

What differentiates EM from other programs is that by Day 1, you may have the sickest patients of your residency training.

In most programs, the system is set up to where you might not be going to an operating room or ICU during your first year. They would still build up your knowledge and experience before you're exposed to that.

In emergency medicine, the learning curve is steep. It can be truly overwhelming in terms of the knowledge needed and every patient encounter you have for the first several months. But there will be an attending physician with them throughout the process.

You will also be doing 5-7 off-service rotations during the first year. You will go to ICU's and do orthopedics, anesthesia, and obstetrics.

On your second and third year, it will progress to increased patient care responsibilities. You will start to lead teams. There will be teaching and mentoring aspect to that.

When you get to your third year, you will start to lead the areas you're working in. And when you're done with your training, you need to be able to handle whatever comes through those doors at any point of the day.

David thinks the program has become so competitive that there's no standardized way of mentoring an applicant as no two applicants are the same. That said, the applicants themselves don't know where they stand on the bigger scale of applicants.

Because of the varying degrees of mentoring, students are picking up a lot of interview spots early when they probably don't need to. Then they cancel a lot. So there's a whole bigger issue here.

David recommends that students seek someone who has experience in reviewing applications. They can look at your file and compare you to other applicants to give you a clear sense of what's important and where you might fall on that spectrum. This way, you can start thinking about how many applications you should be submitting.

Ultimately, David outlines two things to know if this is something for you. First is to get into EM if you really think that EM is right for you.

Second, experience at least two different types of EM programs. This could be an affiliate with the college of medicine. Or there could be close ties between the medical school and the ER department. There's also a community program that doesn't have a medical school in the area. There are also hybrid models that exist.

At the end of the day, see if the message of the chair is something you would put your faith in. Pay attention when they're speaking. Then try to see if you like the residents and you fit in.

David doesn't think there is any negativity that needs to be overcome. He believes allopathic and osteopathic students are viewed in the same way. However, he feels there may be still some programs that will require a USMLE score.

Because of this, it could be hard for them to mentor an osteopathic student and tell them they need a USMLE score. He hopes there is some way to measure this going forward where programs are moving away from requiring USMLE scores.

[Related episode: 6 Myths of Osteopathic Medical School]

Don't be afraid to reach out to people and residency leadership to ask for advice. They want to find people that can do the work that's put before them. Most importantly, just be yourself and enjoy the time in the clinical setting. He assures you will get way more out of this.

Meded Media

Pediatric rheumatology is for doctors who are good at teamwork, problem-solving and becoming experts in nebulous problems. Dr. Jay Mehta joins me to explain. Jay is actually the fellowship director at Children's Hospital of Philadelphia (CHOP) for pediatric rheumatology and out of training now for 10 years.

Jay actually didn't know about this specialty until he rotated during residency. This is exactly the goal of this podcast is to expose you to specialties out there that you may or may not know about. So listen every week and take some notes. Figure out what you want to be

Meanwhile, check out all our resources on Meded Media as you go along this journey towards becoming a physician.

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

Jay remembers liking every rotation he was on but he just kept coming back to pediatrics. He loves the people he gets to work with both patients and the other residents and faculty.

He went through a small medical school and they didn't have real exposure to pediatric rheumatology. The only exposure he had was at an adult room when he took an elective in medical school. He initially thought it was interesting but didn't have any sense that kids actually got rheumatic diseases.

When Jay started his residency, he wanted to do pediatric hematology-oncology because he loved the elective for this subspecialty that he also did back in medical school. Particularly, he loved the diagnostic aspect of it. 

So he assumed he would like Pediatric Oncology because the diseases are interesting, the kids are sick, and you get to create great relationships with families. He thought it was something he would enjoy.

Then after doing an oncology rotation on his second year of residency, he realized he didn't love the practice of oncology for various reasons. 

A lot of the biopsies were made through biopsies or imaging. The oncologists themselves weren't making the diagnosis and the treatments were protocolized. This is great since the mortality from childhood cancers dropped incredibly since treatments have become protocolized.

As an oncologist, you're not making a lot of decisions about treatments. So he decided this wasn't what he wanted to do.

Meanwhile, Jay had a couple of interesting patients who were kids with autoimmune disease. He loved the problem-solving aspect of rheumatology. This was also when the biologic era was starting in the mid-2000s when biologics were coming into the scene.

[Related episode: Discussing Pediatric Oncology with an Academic Doc]

Collegiality is one of the biggest things. Just by the very nature of autoimmune diseases, all organs can be affected. So they end up working with every specialist in the hospital.

You must want to think about your patients. There are a lot of things they see in a day that they're able to put a name on in terms of the specific diagnosis. 

So you have to reach back to your knowledge of immunology to think about what might be going on in the disease. Then you use that to try and come up with targeted treatments.

You must love to form relationships with families. Jay has been seeing patients for years and watching them grow up. So you have to be that kind of person that wants to have a long-term relationship with families. You need to work with them through a lot of things that are going on because autoimmune diseases are systemic.

"Rheum" is Latin for flex. A lot of these diseases can affect the joints that why a lot of people associate rheumatology with joint diseases. They get referred for a lot of things for kids with musculoskeletal pain or joint pains. But rheumatology deals with the systemic autoimmune diseases, where the immune system goes haywire and starts attacking the body. 

Rheumatologists get to be the experts in a nebulous field. Most patients that come to them don't have a defined diagnosis. Also, several patients that come to see them are also getting referred to infectious diseases and oncology at the same time.

Because these diseases are rare and primary care physicians can miss them, a lot of patients can come to them with benign joint pain but with concern for arthritis. They would then differentiate mechanical joint pain (benign and short-term) from actual inflammatory joint pain which needs to be treated with immunodepressants.

Jay wears different hats. He is involved with the fellowship and residency programs as well as education research. He has an interest in how people make career decisions, specifically how fellows navigate through career transitions through fellowship into attending life.

He does clinic a couple of days of the week and sees about a couple of new patients and 4-6 follow-up patients. The latter patients have been referred to him for things like childhood chronic arthritis. Or he might see patients that are stable on their biologic therapies.

A few weeks in a year, he does inpatient or consult service where he sees patients with established autoimmune disease. Most of the time, these patients have fevers or some multi-system diseases that are being evaluated for biologic causes.

He likes how he's able to work with trainees all day long. They have a pediatric fellowship program so he works with the fellow or students most of the time.

Jay describes procedures in pediatric rheumatology as not being too heavy. But they do joint injections. Ultrasound has been emerging in their field as well either for the purpose of diagnosis or milder response to therapy.

In terms of taking calls, a lot of what they do is taking home calls and working with folks inside the hospital. So it's all home call then they just see the patients in the morning.

All this being said, Jay thinks he has great work-family life balance. His wife is in finance and her schedule is crazy with frequent travels. The good thing about rheumatology is that it's primarily an outpatient field. So when in clinic, he gets done by 530-6pm and goes home and spends time with his kids.

When he's on call for the weekend, he could go in for a couple of hours and spend the rest of the day at home with his family.

Conversely, the one downside he sees is the burden of the EMR. After his kids go to bed, he would have to spend time on the EMR charting.

Pediatrics is three years and fellowship is another three years. Presently, there's a debate on whether the three-year fellowship is necessary. But for now, it's kept at three.

The American Board of Pediatrics requires people to do some scholarly product for your second and third year. 

This can be in the form of an education research project, a basic science project, or a clinical research project. QI (quality improvement) is being increasingly accepted as a scholarly project as well.

Pediatric rheumatology is not a very competitive field. There are about 30-40 fellowship slots a year and about 20 of them get filled. So about 50%-60% of slots get filled every year.

There are lots of different reasons why it's less competitive. One reason is the lack of awareness. There's not a lot of exposure to it.

Also, because it's not a procedure-heavy field and visits take a long time, they don't generate revenue in terms of procedure or volume as much as other fields can. The compensation is not at par with general pediatrics. You will still be comfortable, just that it's not as much as the procedure-heavy fields.

They have a pretty huge program at CHOP. In order to be competitive at these big programs, there are a couple of things that they look for.

There must be evidence of collegiality. What have you done to show you can work well within a team?

One must be able to show a level of intellectual curiosity. You have to improve your knowledge every time.

Lastly, you must have curiosity in the field. What have you done to show you have an interest in the field? Have you spent enough time with a rheumatologist? Be able to show that drive to get things done and know about the field.

The American College of Rheumatology estimates that they need about half of the pediatric rheumatologists in the country to fill the demand. In this regard, they were thinking about reaching out to DO schools.

The practice of osteopathic medicine is very hands-on and embedded with the musculoskeletal system. And in rheumatology, they do a full joint exam on every patient that comes in. They have noticed that fellows who have been trained in osteopathic schools have amazing physical exam skills. So they want to reach out better to osteopathic schools to sell them on the joy of pediatric rheumatology.

[Related episode: Let's Talk About Osteopathic Docs and What You Need to Know]

There are not any official fellowships beyond your three years unless you want to do postdoctoral training in the lab.

But the field is changing now. With more and more diseases now being characterized, there's an increasing area of interest in immune dysregulation syndromes. 

Because of this, there are places dedicated to lupus clinics. You can spend time in those clinics getting more expertise in lupus. There are some opportunities more than an official capacity.

They see a lot of kids who would have joint swelling and get sent to orthopedists who would cast the kid. They take the cast off. The kid's joint is still swollen. Then they'd come to them. But by that time, the kid could already develop some joint damage.

This is happening a lot less now. Primary care providers and orthopedists are now doing a great job at recognizing that kids get arthritis.

That being said, primary care providers must understand that arthritis can happen to kids Know the questions to ask to be able to differentiate arthritis pain from mechanical symptoms. Time of the day is a big predictor of inflammatory vs mechanical pain. Inflammatory pain tends to happen in the morning.

There is a screening test for arthritis in kids and most of them don't have abnormal labs. Don't rely on negative labs to make the diagnose for arthritis.

In the evaluation process, when the kids are developing their systems, they have this immune dysregulation team that consists of rheumatologist, oncologist, immunologist, and infectious disease.

The team will often get consulted when a patient comes in with an unknown disease. And they all work closely together to develop an evaluation and management plan.

The biologic era was starting when Jay came into rheumatology. Back then, there were only three drugs for the treatment of autoimmune disease. Now, there are about 20-25 different biologic drugs that he might prescribe in any given month. 

The pathways are getting more and more specific so there are lots of opportunity within the industry.

There are lots of opportunities for teaching within residencies and medical schools. As diagnosticians, they're often asked to help teach the physical exams to medical students and residents.

What he likes the most about his specialty is a tie between his colleagues and their patients. They have a large relatively large group with 9 attendings and 6 fellows. He describes his colleagues as really nice, smart, hardworking, and love to take care of patients. He is constantly learning from them.

Additionally, he gets to see kids from close to birth until they graduate from college. He loves seeing each stage of their childhood. Plus, the families are very appreciative and great people.

Conversely, what he likes the least about the field is the EMR burn. Their evaluations are so complex. They're doing full exams and complicated assessments, balancing large amounts of data. It's fun initially, but only until you put that into the computer as it takes a really long time. Currently, they might explore the assistance of scribes in the future.

More and more ultrasound is being utilized so more and more people are getting trained. The drug development pipeline is going to be amazing in the next few years. He has also heard rumors of a move towards compensating cognitive fields with cognitive diagnosis codes.

If he had to do it all over again, he would still have chosen the same. He loves to tell people about how much he loves what he does.

If you love to be around nice people and think about interesting diseases and make great relationships with patients, Jay says this is a fantastic field. And it's going to continue to get better.

Seek out opportunities. If you have one at your institution, spend an afternoon shadowing them and spending time at their clinic. The American College of Rheumatology has great opportunities to get paid for and travel to annual meetings.

Meded Media

American College of Rheumatology

There are no typical days in radiology. Dr. Anjali Malik joins me to talk about breast imaging, guided biopsy, and what it means to develop a diagnostic “eye.”

For more resources, check out all our other great podcasts on Meded Media.

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

Anjali's interest in Radiology and Breast Imaging Radiology happened at the same time during her internal medicine rotation. After reading the book, Felson's Primer for Chest Radiology, this made her realize that the whole science of imaging was far more interesting than she knew it could be.

Immediately after internal medicine rotation, she worked with a breast surgeon in a community setting, particularly in New Orleans (prior to Hurricane Katrina). Post-Hurricane Katrina, he came to Tulane University and tried to recreate the heavy breast surgery practice. She had seen a lot more breast surgeries than an average surgery medical student did.

That being said, she was exposed to the breast surgery population. She likes the pathology, the patients, and procedures. However, she didn't want surgery or do 5 years of general surgery to go on to breast surgery. So her mentor pointed her to the direction of breast imaging radiology at Tulane.

Anjali also has a background in public health and did her BA in Public Health at Johns Hopkins. She feels every part of the field spoke to her.

[Related episode: Interventional Radiology: Community Doc Shares Story]

Anjali points out that to be a good breast imaging radiologist, you have to be cerebral and have problem-solving skills and spatial awareness. You have to be patient and observant. Having a good eye is also helpful.

As much as pattern recognition is important, you should also be patient, thorough, and be able to direct a surgeon on they should approach the case.

[Related episode: Community Breast Oncologist and Researcher Shares Her Career]

In breast imaging radiology, you're screening for breast cancer. Possible cases include invasive, ductal or ductal carcinoma in situ, or lobular carcinoma, papillary carcinoma, and the occasional medullary or mucinous carcinoma.

They basically diagnose all sorts of system and processes within the breast. They regularly diagnose lymphoma via the axillary lymph nodes seen on screening mammograms.

Sometimes, within the breast, they see an enlarged lymph node and are able to provide a primary diagnosis on something not known.

Other cases they diagnose include tuberculosis, sarcoidosis, and amyloidosis. They also deal with the more benign things that happen within the breast like fibroadenomas in young, reproductive-aged females. Lactating females can get lactational adenomas, galactocoele, mastitis, etc.

Outside of being breast imaging radiologist, Anjali practices general radiology.  She's doing body ultrasound on a daily basis. Some cases she sees are nodules, ovarian cysts, fibroids, and cancer of all of the above organs.

For her, being able to use imaging as a tool has shaped medicine and she's excited to see more of what will come.

Anjali describes having no typical day as it varies day-to-day. Even if she does the same thing in theory everyday, every patient presents something new and different.

She could do biopsies or ultrasound and mammogram-guided biopsies of the breast. There are also some days she's doing MRI-guided biopsies or ultrasound-guided fine-needle aspirations of the thyroid or lymph nodes. She may also be reading screening mammograms and 3-D mammography.

In between, she does radiographs and bone densities. She could be calling patients with results or calling doctors with findings. There are also days when she does diagnostic mammography. This covers any woman that has been called back from a screening examination.

There are also some women that come to her with clinical concerns of their own. For instance, they're feeling a lump or breast pain, or noticing changes to the skin or nipple discharge.

Women who have a personal history of breast cancer or have a particularly strong family history or a known genetic mutation, those women are seen on diagnostic thoughts. There are breast MRI slots as well.

On an ultrasound day, it can vary from doing fibroid fine-needle aspirations to ultrasounds of the thyroid, carotid, liver, pelvis, etc. Anything and everything can come in on an ultrasound day.

For students out there thinking about this field, Anjali explains that there's an entirely separate track. Classically, you would do one year of internship and four years of radiology. Then you'd do one to two years of fellowship in interventional radiology.

Today, there are completely separate training pathways. There are still some programs with the classic spots reserved. But medical students now have the opportunity to apply to programs where they are completely integrated from the start. For example, there's diagnostic radiology/interventional radiology and those spots can be competitive.

Anjali did breast imaging where they do a lot of procedures.  Her practice is completely outpatient. For those radiologists both diagnostic and interventional who are in inpatient settings, they can expect to be exposed to a lot of procedures.

Anjali doesn't take calls now as she is doing outpatient care. But she has had her own share of taking calls during her first private practice and throughout the residency.

Anjali describes the call for radiologists is brutal. It is non-stop. Unlike some of their clinical colleagues that get home calls and get called multiple times a night, radiology call is the entire shift. Sometimes, you do not leave your seat or call room.

When she was in private practice, she did eight-hour shifts two times a weekend. She was reading around 180 to 200 studies. This is a combination of plain film, ultrasounds, fluoroscopy, CT. It was non-stop.

She had a similar experience during residency where she got to cover interventional as a senior resident. She trained at a level 1 trauma center where she dealt with gunshot or vehicle collision victims.

Anjali recommends training for a level 1 training center but it's going to be a very intense experience.

In terms of work-life balance, although it was challenged during residency, she feels like she has it as an outpatient radiologist.  That said, her work isn't easy. She's up at 5:15 am everyday. She comes in at 7:30 am and is out at 5 pm. She goes to bed at 9 pm.

Training for breast imaging radiology involves one year of internship, four years of diagnostic radiology residency, and then one year of breast imaging fellowship.

Breast imaging is a matched fellowship. At the time of her training, one can get a spot outside of the match. In her case, she contacted someone she knew since she had a relationship with that person and did an away rotation with her. There's also the formal match system which happens on your fourth year of being a resident and on your third year of being a radiology resident.

The match is decently competitive. You're obviously competing for spots at the better programs. But she didn't go through the proper and formal match process.

Some radiologists come across breast imaging during their time as radiologists. Usually, they realize it's amenable to an outpatient lifestyle or no calls on the weekend. Plus, they can get a job almost anywhere.

Anjali explains that groups are always looking for radiologists for three reasons. First is the volume. Women are always going to need mammograms.

Second, women get their first screening mammogram and find an imaging center. They then go on to utilize that imaging center heavily. So having a fellowship-trained breast imaging radiologist is a plus for a group.

Thirdly, some diagnostic radiologists don't want to touch mammography. Aside from the fact that it requires full attention to detail that is sometimes difficult to meet, there's also malpractice associated with it.

Right now, there is a huge supply of jobs in radiology and not necessarily a supply of residents. When Anjali was still applying for hobs, it was the other way around. There were very few postings and there were a lot of them looking for jobs. Now is a good time to be looking for a job as a radiologist, specifically as a breast imaging radiologist.

Anjali doesn't think there's anything further than breast imaging. But there are other opportunities pertaining to business, public health, and consulting. There are different ways you could use your breast imaging fellowship to create and mold it to the career that you want. But nothing more specialized for that matter.

Anjali thinks that in order for osteopathic students to be competitive, basically, they would have to do the same.

Have research and be motivated. She sees more and more of residents who have these dual degrees like MPH and MBA. Certainly, these would have a place in any radiology group. That being said, you don't need those for getting a breast imaging fellowship.

Anjali wishes primary care providers know that any woman over the age of 30 has to get a mammogram. A lot of primary care providers and OB/GYN will only do an ultrasound.

But based on the American College of Radiology standards, they image in a certain way. So this is one of the biggest battles she has to fight every day. Someone at the age of 30 with nipple symptom or they feel lumps and they're not expecting to possible get a mammogram.

On another note, Anjali doesn't think patient anxiety is a reason to get less mammograms. Instead, it provides an opportunity for them to work on their education and advocacy. They have to learn how to empower their patients. 

On average, she talks to a lot of primary care providers and OB/GYN. For cancer patients, she talks with breast surgeons, oncologists, radiation oncologists. In her general radiology role, she speaks with endocrinologists, OB/GYN, and primary care physicians.

One of the things she finds most challenging about a breast imager is the emotional burden of patient anxiety, more so the general emotions surrounding breast cancer among women.

She thinks the whole pink ribbon and breast cancer awareness has gone awry. It was meant to create awareness so women can go for screening. But it went from that to pinkwashing everything. This resulted in women getting terrified that they might be getting breast cancer.

When she went into radiology, she just didn't realize she was going to also be like a psychologist or psychiatrist sometimes. In fact, her colleague calls their specialty a "mammochiatry." Because of this, she's actually gauging her patients when it comes to something concerning the breasts.

The same thing with cancer diagnosis where she has to shift her delivery per patient. She has those skill sets now but she admits those took time to acquire. It's a real art as part of breast imaging. 

Anjali enjoys the patient interaction, something she has always liked about medicine. She also likes doing the procedures. She enjoys working with her hands.

On the flip side, what she likes the least is the emotional toll on patients. Even though you're managing the patients' emotions, it can be hard to compartmentalize that. She feels it makes the days longer sometimes.

Anjali says we've had a computer-aided detection for a decade now and she thinks it's terrible. She goes on to say that any academic of fellowship-trained radiologist will tell you that.

That being said, machine learning has advanced and there are several studies showing how it could be useful in mammography.

But she still thinks that at the end of the day, there are a lot of factors you need to take into account. For instance, you have to do callbacks and recommending biopsies. You still need that human touch. Rather, it will only enhance what they do – but not replace them.

If she had to do it all over again, picking the same specialty would be a yes and no for her. She wonders if she could have just gone for breast surgery for two reasons.

First, she likes procedures more than she actually realized. Second is because of where the field of radiology is going right now in terms of corporatization and lack of autonomy. Autonomy is something she would have enjoyed. 

So the only time she would only say she should have gone for breast surgery is when she thinks about two factors.

That said, Anjali is very happy with her current job. But she's just wondering what it would be like to be her own boss.

Radiology plays a big part in medicine today. It's important for medical students to pay their due attention. And you may realize you like it more than you thought. She thought radiology was boring and she was just going to sit in the darkroom, which turned out otherwise.

If you're interested in it, try all of the parts out. Look into interventional radiology as they have a different approach. For breast imaging, have that advocacy, education, and outreach.

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Dr. Bruce Chamberlain tells me why he sees palliative medicine as more of a calling than a specialty. We discuss empathy, communication, and avoiding burnout. Bruce has been out of his training now for 29 years and has been practicing hospice and palliative care medicine all around the country.

In case you may not have come across it yet, please do check out Board Rounds podcast, which I do with BoardVitals, a USMLE/COMLEX Step 1/Level1 test prep company. They offer QBanks for both Step 1 and Level 1. They also have amazing QBanks for your SHELF exams for your clinical years.

Going back to the episode today, palliative and hospice medicine is a specialty that is important. But not a lot of people know about this and not a lot of people actually consult palliative medicine early enough.

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

Bruce got into this specialty without a plan, in fact, he had never heard of it before. He was board-certified in internal medicine and practicing in a clinic doing internal medicine.

Seeing that the majority of his patients were elderly, he began to notice a trend in his patients. They often had a functional limitation as a result of pain, whether they had osteoarthritis or low back pain.

Bruce started self-educating in noninvasive pain management as well as some low-level injections. He partnered with a physical therapist. They started to become more aggressive with pain management and saw great success.

As a result, a fair part of his clinic was devoted to geriatric pain management. Through the course of time, one of his patients ended up in the hospice. The hospice called him and asked to help them with pain management. So during his day off, he'd work at the hospice.

Bruce considers working in hospice or palliative care as more of a calling than a job. You just feel like this is where you belong and what you're supposed to be doing. 

And this happened to him. He began looking forward to half-day of the week going to the hospice. It was when he felt it was being the kind of doctor that he wanted to be.

Because of this, he slowly increased his hospice time and decreased his clinic time. Until finally, the clinic asked for his commitment and asked him to fish or cut bait. While at that time, the hospice offered him a full-time position so he cut bait.

From then on, he never looked back. He has done hospice and palliative care full-time or part-time for over 20 years now.

[Related episode: Palliative Care - There is Always Something You Can Provide]

Bruce explains that in hospice, you have to change your mindset in that you have to accept the reality that people die.

Physicians are trained in the combat mode, fighting disease. And they are taking it as a personal and professional failure when a patient dies even though that's going to happen to all of us.

When you accept the reality of death, then success becomes – was the patient comfortable?

Were they able to have closure on outstanding emotional issues? Was the family able to be there? Were they able to die at home as opposed to being plugged into 15 different tubes and monitors in the ICU?

Yes, it's sad that they died. But it's great that they died in a way they wanted to and they were comfortable. 

Moreover, usually at the very end of hospice care, there would be months before death takes places where you just manage their symptoms.

It's about improving their quality of life for the time they have left because they were able to aggressively manage their symptoms. And oftentimes, they get positive feedback before the death as well as after the death with family comes up to thank them.

[Related episode: This Physician Wants to Change The Narrative Around Death]

You have to be patient and have empathy. But you also have to have the ability to draw that fine line between empathy and getting too emotionally involved with what's going on.

You have to be able to relate and have the patients feel like you actually understand them or you're there for them. 

A good hospice and palliative care doctor is very skilled at pain and symptom management. In geriatrics, you would usually review the patient's medication list.

Hospice has been defined by Medicare – a patient with a medical condition that if it continues as anticipated, we expect the patient to die within six months.

Bruce doesn't actually like this definition because nobody is that good at prognostication. But Medicare is looking to change that definition to allow for earlier care.

Bruce defines hospice as the point of the sphere of palliative care which is an aggressive end of life care. Palliative care refers to aggressive quality of life interventions, symptom management, and communication with the patients and their families.

It's important the patient's family knows what's going as you can't have informed consent if you're not informed.

They also ask the hard questions such as the resuscitation status that people are often reluctant to do or do incredibly badly.

Aggressive symptom management includes pain management with patients who are post-op.

Palliative care is a broader spectrum of quality of life interventions and symptom management that includes, but is not limited to, end of life care. Whereas hospice is end-of-life care. It's part of palliative care but palliative care is much more.

Bruce explains that palliative care is not called upon to be expert diagnosticians. Usually, they already know what's happening. And they work in conjunction with other doctors. For instance, the surgeons are still taking care of the surgical issues while Bruce does symptom management.

Bruce is currently working as an inpatient palliative care doctor. He comes in the morning and works with the nurse practitioner and two nurses who are liaisons with the hospice system.

First, they review consults that have come in from yesterday afternoon and after the shop has closed down and through the next morning. Then they make up a list of all their patients for review. They look at the plans and look at whether some other interventions are needed.

They then split up the consults. Bruce would usually attend to the multidisciplinary ICU rounds.

The rest of the day is spent doing new consults and doing follow-up visits. They also educate them on what their discharge options are from facility rehab to long-term care facility to hospice.

They would often have to explain what hospice is as what they have in their minds is the 1960s setting. 

They have to explain that modern hospice involves aggressive management. You could stay on your medications. They will talk to you about risks and benefits but it's your choice. They try to keep you out of the hospital and go through the benefits involved. Most people are very surprised to hear that this is what hospice is.

During family meetings, they would usually discuss the patient's condition, the current treatment plan of care, and then options going forward. Then together they make decisions when the patient is unable to participate in that decision-making process.

What Bruce loves about being a palliative care doctor is having enough time. As a hospitalist, you're in and out. You have to see all these patients. You get them admitted and discharged. It's a constant rush.

In palliative care, he just spends an hour and a half in a family meeting with a patient in the ICU. There was no rush. He was able to spend all the time that the family needed to answer the questions and give them the information and help them come to a decision. Bruce says there's nobody else in the hospital that can do this.

Both in hospice and palliative care, they have a strong emphasis on engaging a multi-disciplinary team. They often bring in a social worker or a chaplain or a spiritual care worker.

As a palliative care doctor, he would assess the needs of the patient and access the other resources. And to be able to relieve that by providing information is incredibly rewarding for Bruce.

In the hospice he's working in, there are only two of them and they provide an 8am-5pm service. They're a very new service to be doing the more aggressive types of interventions they're doing now.

That being said, they still have to prove themselves before they can grow and get JCAHO-certified. (JCAHO stands for Joint Commission Accreditation for Hospice Organizations) And to get certified, you have to have 24/7 coverage, which can't be done as of the moment with only two of them.

When hospice and palliative care became an ACGME one-year fellowship, it had more boards that endorsed it than he believes any other subspecialty has. 

In almost all of the boards you could think of, as you go through your residency, you can then apply for a 12-month fellowship. In short, there are a lot of different paths that you can take to get there.

In line with this, they believe that primary care physicians should have basic knowledge of palliative care. They should have basic pain management skills. They should be able to talk through advanced directives.

They want to see primary care doctors educate themselves enough to get the basics and know when to defer to a palliative care specialist. So they want more of them trained. Part of this is because there is a growing demand for doctors doing palliative care due to the increasing aging population.

Bruce says this is a field in medicine that is in high demand and will continue to be based on just population demographics.

In smaller hospitals, full-time palliative care is somewhat limited that it becomes an extra duty for the hospitalist.

Previously, Bruce implemented inpatient palliative care as part of his hospitalist practice. The hospital paid him a stipend to manage it. However, it doesn't pay for itself in a silo. Instead, they save a lot of money by getting patients out of the ICU sooner and getting them discharged sooner.

In the big picture, every study that has been done has shown that inpatient palliative care saves the hospital money. Unfortunately, hospitals just look at the cost. This becomes challenging for smaller hospitals to want to go out and bring in a full-time palliative care doctor.

In this regard, hospitals are using nurse practitioners in that role. And the issue is they don't make tons of money with what they do.

The first thing Bruce wishes that primary care doctors knew is that they don't have to wait until their patient is actively dying to get palliative care involved. 

If you have an elderly patient with multiple chronic medical problems, those are patients that palliative care can help with. They can help with symptom management. They can take the time that primary care doctors don't have in the clinic. They can provide this service.

Don't wait until end of life and don't let their patients suffer. If they're having trouble managing pain, they can help with this. In fact, this is an increasing problem, with opioids not being prescribed by a lot of doctors anymore because they're so nervous about it.

There a lot of academic opportunities for palliative care doctors. Many of them actually move up into administration. Other opportunities include research and teaching.

On another note, what Bruce likes the least about being a hospice and palliative care doctor is the fact that most people don't understand what they do. They just see him as the "death doctor" without really understanding the broader picture. He also doesn't like the current financial picture.

With the workforce shortage and the aging population, Bruce thinks that there has got to be a change in the Medicare regulations for the hospice benefit.

Hopefully, there's more involvement in palliative care in residencies and medical schools. This way, there's more exposure and a better understanding of what they do.

Ultimately, if he had to do it all over again, Bruce thinks this actually is a hard question. Where he came from, there were very few full-time jobs in hospice and palliative care medicine. So he had multiple job changes and each time, there was significant stress.

All those being said, in terms of his personal path, he wouldn't mind doing something more stable and consistent. But in terms of the work he does, he feels this is more of a ministry. He loves what he does.

If you're a student doing rotation, go spend some elective time. It's a great way to see what they do. Volunteer with a hospice. They always need volunteers. Go shadow a hospice doctor. 

Bruce also draws the difference between inpatient palliative care, outpatient palliative care, and hospice. Each has a very special skill set and special population. So go out there and get exposed to it!

I had a previous interview with Dr. BJ Miller, a triple amputee from an accident he had while in college He went on to medical school and became a hospice and palliative care medicine specialist. He has made it his life's mission to help people die in a better way. Check out that interview on The Premed Years Podcast Episode 301.

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The Premed Years Podcast Episode 301 with Dr. BJ Miller: Near-Death Experience Led This Physician to Help People Die

Dr. Cabrera-Muffly is an ENT residency Program Director. She joins me to discuss the pathologies in otolaryngology, life as a resident, and more!

Dr. Ryan Matika Residency Program Director in Anesthesiology talks about what he's looking for in his applicants. He also shares what his residents look for when students are doing rotations.

Specialty Stories is part of the Meded Media. If you haven’t yet, please check out all the other resources we provide to help premeds, medical students, and residents on their medical journey!

Ryan got interested in anesthesiology when he was in his second year in medical school. They had a program where they were assigned a mentor who happened to be an anesthesiologist. 

He went into medical school not thinking about anesthesiology. In fact, he was leaning into internal medicine. But from his rotations, he eventually got drawn towards anesthesiology. He thought about this halfway through his third year because of his mentor.

Ryan thinks there is a major element in picking your specialty based on the personality and that element of finding your people. There's a certain type of personality that's a better fit for a specialty than others. But that said, he doesn't think any specialty has one personality.

The longer he has done this, the more he thinks that there are more traits to being a good doctor. Those traits pretty much transcend the type of residency. He thinks all residents of different specialties have a lot of things in common.

First is what drives you, what keeps you up in the morning. That type of work ethic and that type of positive drive would make good residents.

For anesthesiology in general, they're meticulous. Although being OCD is not necessary, but you might notice a lot of OCD behaviors evident in anesthesiologists.

They say that the only thing an anesthesiologist does is putting patients to sleep and waking them up after surgery is one of the misconceptions. There are times your services are requested by a surgeon and part of that is keeping patients calm.

But one of the most important things is delivering the anesthetic methods essentially rendering someone in a medically induced coma to tolerate surgery. Also during that time, you're managing the patient's physiology, most importantly the cardio and pulmonary physiology.

They could give medications to make patients very hypotensive. The patients can be put through all kinds of cardiovascular difficulties and you have to manage them through.

The anesthetics would give necessary poisons and the management they do is to offset those poisons in a healthy patient. And this could get even more tricky for patients with chronic, significant or uncompensated diseases.

A lot of the time is focused on physiology and the vitals. While a little bit less time is spent on ensuring that patients are in a medically induced coma as they have to ensure patients are asleep throughout the surgery.

There are two types of programs – the categorical and the advanced programs. Almost everything was advanced in the good old days. Then categorical has gotten more popular. the difference is how you treat that first or intern year.

About 75% of the spots are categorical. When you match with an anesthesiology program, you're doing a four-year program. But the first year is essentially mostly off-service rotations. Its purpose is to meet the qualifications of your intern year which is either a medicine year or a surgery year.

The advanced year is where you match those two years into separate ones. So you have the intern year where you match into a medicine transitional or surgical year. Then you start your formal anesthesiology three-year training afterward.

During those three years, you do the same cases over and over again. You do more simplicity, a lot of airway work. You're getting the basic skills you need for anesthesiology.

During the latter half of your residency, you're doing subspecialties. You deal with much sicker patients such as cardiac cases. Each program has a different way of doing that but essentially, there are more similarities than there are differences.

After four years and you've met all of your requirements, you can then sit for your final written boards.

The most important thing you have to have is your mind. The cerebral side of it is the hard part. In terms of the procedural part, anybody with two hands can be trained to do the procedures as you will be doing it over and over again.

In fact, Ryan has never seen a resident that has not completed training because of a procedural aspect. 90% of the problem with residents would be medical knowledge or professionalism. And 0% with procedures. There are some people who are better sooner than others but everybody will get there.

Generally speaking, one thing that has changed about applicants is the basic exam, which is part of the American Board of Anesthesiology done at the end of your PGY. You need to pass this exam to be able to complete your residency.

So they always look at your USMLE scores. They essentially tell you how good you are in studying and passing an exam. Many programs have a certain average score they're looking at. If you have a lower score than that, then you may have to make up for it with different qualities.

Ryan personally looks a lot at the Dean's letter, your medical school transcripts, the comments made, grades on your clerkships (particularly medicine and surgery).

Most people have positive letters of recommendation. There are various levels of strength on that. So this may be a little bit less important than the other two mentioned above.

Another thing that gets underestimated is the volunteering aspect. They want to see students getting more involved with different activities at their medical school or at their local communities.

They basically want to see what you were doing during your medical school time beyond just studying and getting the best grades possible.

Research is not necessary. But Ryan takes this into account in looking at grades and scores but it doesn't necessarily overcome a bad grade.

Ryan admits that the ability to evaluate students based on the pass/fail system can be more challenging. A large percentage of medical schools has already gone to not give a class rank. The opposite effect is what they were going for. There's only one score to tell you about their academic abilities. 

Making USMLE's into a pass/fail is fine. But now they're going to have to put more emphasis on different factors. They want more information. The board exam process is very difficult. It's not something to be taken lightly.

Ryan has done round table events at their schools and he's one of the few people who think that away rotations aren't much help. He personally thinks that away rotation only helps you at the program you're interviewing at. It doesn't really help much when you're going out on your interviews.

If there's a program you're really interested in or if you have a place to stay with then that's totally fine. But with the medical school debt and the financial concerns in medicine, the cost of it to go somewhere and rotate wouldn't pay the dividends unless you're really set on one location.

The osteopathic medical students have been increasingly been more successful in getting anesthesiology spots over the last 10-15 years. You're now seeing DOs in spots that you won't previously see. 

Ryan says that the DOs at their programs typically have a little bit higher board scores than the allopathic residents in general. But it's only a minor difference.

Ryan explains that they look for qualities like work ethic, personality, and professionalism.

A lot of anesthesiologists are introverts. So you don't have to make small talk or be the most likable person in the world. You must be willing to help, want to know more, and ask questions.

Another important thing is for residents to be able to follow directions. But procedural skills are often emphasized by applicants than they are by their faculty. Hence, you really don't have to worry about the procedural aspect.

If you really don't enjoy the procedures and dread doing it hen it's a nice thing to know that this is not a great fit for you. You should enjoy it but you don't necessarily have to be good at it. 

After reading so many personal statements, you start to see certain trends in personal statements. The most important thing outside of the why and "tell me about yourself" is explaining any kind of deficiency in your application. Ryan needs you to explain what went on in a greater context. This needs to be explained and acknowledged in the personal statement.

Ryan isn't sure if a great personal statement makes up for any trouble on the application. But a bad personal statement could raise a few eyebrows and lose you a few interviews. Bad personal statements are going to be things that are too negative.

When you're on your medical student rotation in anesthesiology, you're already getting a piece of it. The classic anesthesia medical student rotation is you come in early and leave early. 

The residency is not going to be like this. You've got to come in early and you've got to stay late. This means long hours.

As an attending physician, you come in early in the morning. As a resident, give yourself around 20-30 minutes to set up for your case. This means getting your medications, monitors, and equipment ready. If you have morning didactics, you'd have to come in earlier.

Then you'd have to go see your first patient in the morning. You can look up the patient the day before so you can have a plan.

The next morning, you see the patient and ensure they're ready for surgery. You get their IV in (depending on the institution). When it's time to go back, you're going to take that first patient back. If it's a cardiac case, it's going to take longer since there is more pre-evaluation.

Throughout the day, you're going to be doing a variety of cases if you're in the operating room. It's a lot of work to stay vigilant. It's a lot of work to get different cases going.

Just like you're taking off and landing, you're going to be doing that for each patient. You really need to individualize things. If you're at a tertiary care center, you're going to have some very complex patients. Each patient needs a careful evaluation.

As for the resident level, this needs to be done the night before so they have time to prepare, research, and plan out. The simplest part of it is how to keep them asleep. But the most difficult part of it is how to keep them safe throughout the surgery.

Calls vary greatly between residencies. They can be specific to a rotation or they can just be a general pool for different services.

At their program, different rotations have different calls. When you're doing the general emergency cases, usually residents do one to two nights a week and one to two weekend nights a week.

There are a lot of spots for anesthesiology. There are about 1400-1500 spots in the country per year. So your chances aren't bad even if you have some issues with your grades.

In general, applicants with lower board scores have to really focus on their clinical rotations. Make this your priority.

Also, take a month off after your third year is over. Really dedicate yourself to the Step 2 exam. A much higher Step 2 and a low Step 1 is fine with them. But it can be concerning to have two low Step scores.

Ultimately, they need residents that they know are going to pass the boards. If possible, try to get some face time with a program director or someone involved in the selection process.

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Dr. Patrick Myers joins us to talk about what he looks for as a fellowship program director, what makes a good neonatologist, and his own unique journey to this specialty. Out of training for about eight years now, Patrick also shares what they’re looking for in candidates if this is something you’re interested in.

Meanwhile, be sure to check out all our other episodes on Meded Media.

Patrick realized he wanted to be in Neonatology until after his entire residency class matched into Neonatology. He spent a year being a peds hospitalist as he experienced a ton of deliveries.

He thinks the fellowship match is helpful in terms of streamlining and getting everybody a chance to get their application out to several people. 

A big downside is if you decide you want to do something else when you're already two years in. 

For residents taking an extra year to figure things out to become a better applicant, Patrick thinks doing a chief or hospitalist year is great. Being to able to work with other people in an actual, real setting allows you to understand your work skills. In fact, Patrick considers having this kind of real-life experience as a gold mine. 

This shows programs that these people really love the field and they're going to have so many more skills than people who just went straight through.

Patrick started medical school when he was 29 years old. He was a Theater major. He just got married at that time and had to work. Desire is another thing he looks for in applicants.

The ability to solve problems is very important so you really have to love problem-solving. Especially in Neonatology, there is a variety of illnesses so you always have to be solving problems. 

Other essential traits include exceptional communication skills and empathy. Moreover, you'd be working with a lot of other specialties. You should know how to negotiate and pull divergent views together and still come up with a really good plan.

Except for rheumatology, all of medicine is in neonatology. In NICU, the kids are sick and a lot of them are ventilated and unstable. 

What differentiates it from PICU or Neuro ICU or medical or surgical ICU is that a lot of their really sick kids stay for a long time. It's not unusual for kids to stay at their unit for 100-200 days. Some of their kids have even stayed with them since birth to a year.

The hardest thing to manage is children with underdeveloped lungs so there's that balancing act. Either help the lungs and keep the kid alive, but mechanical ventilation for 10 to 100 days is actually bad for you. 

To figure out whether an applicant for residency is a good communicator, Patrick explains they try to 2-3 very open-ended questions to let people be comfortable and talk. He personally evaluates how people treat his support staff. These are his section administrators, the people touring you, the fellows.

Patrick also highly values letters of recommendation from fellowship directors you have a personal relationship. He further shares this tip to ask a director if they could write you a really good or superior letter of recommendation. If you get any hint of body language that it isn't an equivocal, enthusiastic yes, then do not take that letter.

There's medical literature on interviews that talk about a lot of the code phrases in letters of recommendation. It tells you of phrases that program directors look for.

Already two years as a program director, Patrick admits it took him a while to write good letters. Because you want these people to go out, be successful, and get a really good fellowship. 

But sometimes when you're selling somebody the way you want them to, you actually aren't. You could say one thing but others may read it in a different way. So it takes a bit of skill to get this down.

Nevertheless, the letter of recommendation is just a tiny piece of the application so you can make it up in so many different ways.

There are about a hundred NICU fellowships and what he does is different than other directors do. But first things first, know your audience. You don't want to apply to a hundred programs. Around 10-15 that fit you would already be good. It has to fit you and your goal.

Patrick comes from an academic program and his goal is to generate leaders in the field of neonatology over the next 5, 10, or 20 years. So he's looking for that capability to be a very good clinician. This is hard to prove but essentially, just do well on all your rotations in residency. Patrick actually looks all the way back to your medical school rotations.

He also looks for that potential in research. Although not mandatory, you should at least be able to spark their interest. He's looking for someone who is able to demonstrate interest, curiosity, and the desire to solve problems.

Some people could come in with really good publications and that's an easy one to show them you're interested. But that's rare. So you have to be able to show them at least some interest. 

The personal statement is also very crucial. Patrick says that out of the 100+ applications and personal statements they've read, 95 said they love neonatology because they love babies and this baby and this family changed their life. But he admits his brain just hurts reading them because everybody says the same thing.

Tell them a unique story and what fires you up. Tell a story of something you've done and done well. 

For instance, you love dancing and been doing it since you were three. Then you've got great grades despite dancing 15 hours a week. You kept doing it in college and you're still going to do it now. But you've discovered your passion is being a doctor in neonatology. This shows the admissions committee your commitment, work ethic, and balanced life.

The hardest applications for them to read are those that are trying to build their application. They've done a hundred things for one week each. There's so much stuff on the paper that they can actually tell what's meaningful and what's not. They simply want to know about you. But instead of them knowing you, they might just think you have a very busy CV.

Instead of saying so much stuff, tell a story that demonstrates your longevity. Being a subspecialist, you're going to be doing this even when you're 65. Investment is what Patrick is looking for.

The application comes in different chunks. The personal statement is a letter that's 500-1000 words long. You can put anything you want in there. Patrick recommends you do research if you're interested in an academic place. Otherwise, if you apply and not say anything about research, people could get confused.

You have to give 3-4 letters of reference. You can also get more than that. The important thing here is to get good people that are known in the community. More importantly, these are people who can enthusiastically talk about you.

In one of those references, there's a summary letter of your pediatric program director with a very specific language that they will use.

They will also look at all your medical school transcripts. Most medical schools make a summary statement about who you are. They will probably have a paragraph that would say what you did and what's unique about you during medical school.

All in all, it ends up being around 40 pieces of paper on an average person. This would also include your hobbies, posters, presentations, papers you wrote, visa status, permanent address, languages spoken, etc.

If you're looking for programs, look at their websites and reach out. Work those connections you have with the nurses. They should know stuff about the program directors and the programs. Patrick personally wants applicants to know his worst before they get to the program. Talk to the junior people.

Patrick is 100% convinced that they can teach students every skill they need to have. You need to have some manual dexterity but you don't need to be able to play the classical piano for two hours. The level is relative.

Moreover, the biggest thing in neonatology is intubations. In neonates, the airway is very different than even kids or adults. Some of their kids are very tiny, the smallest kid they've intubated is 275 grams. The airway changes all the time.

That's one of the hallmarks of neonatology is you're constantly developing underneath. All that being said, you've got to have the skill level to intubate along that spectrum.

They also put in test tubes. They catheterize the umbilical, arterial, and venous lines. This takes a little bit of time. Nevertheless, Patrick is never worried about people's ability to do procedures.

Patrick explains there's a variety of ways for people to be successful. And the people who are successful as a fellow are sometimes different who become ultimately successful down the road. 

The ability to be curious is another great trait. What's unique about Neonatology is you're going to be working relatively hard and putting in a fair amount of time, like a ton of weekends. The people who are successful are those that are willing to do the work, communicate well, and are good problem-solvers.

Patrick explains you've got to get the program letter of agreement with regard to insurance, among other things. It's doable though. And it's useful. But this is not something Patrick would personally look for because especially for those coming from a small place, it's hard for them. Hence, an audition rotation doesn't help them too much.

Patrick's doctor is always an osteopathic doctor. He applied 50-50 when he applied to medical school. What he really likes to see is the research aspect.

However, he feels that a lot of the osteopathic residents that apply to him don't have the research chops or don't demonstrate their interest in research. This is unique to the top 15-20 programs in neonatology. They're all big centers and people are doing a fair amount of research.

Hence, if you're an osteopath and interested in neonatology, you've got to be able to show to them that you're interested or have that experience. This can be a summer lab or finding somebody wherein you can do some type of research.

Some interest or experience in bench research is also something that's desirable as this is rare in pediatrics. This is so hard to pull off, but if you do, this makes you incredibly desirable especially to the big programs.

At the end of the day, Patrick really just looks at your ability to be a leader in the long run and curiosity.

An easy no-go for applicants would be felony conviction. This would be logistically challenging for him in terms of the level of additional work he would have to do in order to get the person approved.

Some programs have a hard cut-off for board scores. They don't have it though at Patrick's program. Instead, he looks for long-term potential.

Moreover, when you fail your boards, this can be problematic. This is hard for any program director to swallow. It's not just about being mean. 

If you fail peds boards, they would then have to set a chunk of time out of your second and third year of fellowship so that you can pass your peds board. And if you fail peds board enough, then you're not boards-eligible for neonatology. 

And if you fail neo boards, even though you're working somewhere else, they're still your responsibility so they have to find ways to remediate you with the American Board of Pediatrics or the ACGME.

Whatever you do, figure out what you need to do to pass those exams or it will just hurt. And it will keep hurting forever. Or this will have negative consequences on the people hiring you.

Patrick adds that if enough people fail your peds board, the ACGME becomes extremely interested in your program. They're interested in hard metrics. 

If enough people fail, they're going to lose their accreditation. They could either get on probation or they could get citations. Each of those things has adverse effects on the program. And they can't recruit as well obviously. It then potentially becomes a bigger problem.

Patrick recommends that if you're interviewing, really find out what the day-to-day life is. There is a fair amount of heterogeneity among the programs.

You have to do a minimum of 12 months of clinical service. You typically show up between 6 or 7. Do rounds and sign out and manage the unit and the myriad of problems that show up. You'd be teaching residents and then signing out again. There would be calls and weekend calls but these vary a lot.

You've got to have a research project in some way, shape, or form. And there are a couple of ways to meet that. You could get a master's degree. You can do a QI project or administrative stuff.

You also have to do a followup clinic. Every major center that does neonatology has a follow-up clinic. They measure the developmental outcomes of their kids that are really tiny and high-risk.

At the end of the day, what Patrick is worried about is the output. So he really doesn't care how you do it. That said, he makes sure you have the help you need and he can step in when necessary.

You will be taking care of babies a lot and you'd be in the hospital a lot. But the rest of your life will vary depending on the program and what your research interests are.

Know what you're getting into. What Patrick sees a lot is that people get attracted to the field by a dynamic mentor or a dynamic faculty member. And people don't think about the lifestyle very much.

Think about what you're going to be doing as a resident, as a fellow, or as an attending for the next thirty years.

What you could be doing as a resident is way different than what you're going to be doing as an attending. So try to cultivate those relationships with attendings in the middle of the night. Ask them what life is like raising kids or how it feels when you're taking calls at 65 years old.

If you don't like doing night calls and being in the hospital for a good chunk of your life, it probably isn't for you.

If this is something you’re interested in, Patrick drops some resources you could look into. Check out ONTPD and TECAN for more NICU-related resources.

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ONTPD

TECAN