Specialty Stories

Dr. Philip Chan is an academic Infectious Diseases physician at Brown University in Rhode Island. He has been out of training now for about 8 years. He talks about his typical day, why he chose this specialty, the training path, and an inside look into this field.

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Philip recalls being interested in Infectious Diseases (ID) back during undergrad. With a Major in Microbiology, he was basically interested in bacteria, viruses, infections, and how to solve such problems.

Although Philip's dad is a cardiologist, he was already interested in fixing things at an early age. So he went to college majoring in Engineering. Then he realized he wanted to go to medical school so he shifted to Biology. However, he thought it was too generic so he then changed to Microbiology, specifically focusing on genetic engineering.

Philip says you've got to have the ability to think through a problem from top to bottom. You also have to have a particular attention to details. He advises medical students, especially early in their career, is to think about a problem in a timeline. You have to be able to put things together in a timely fashion and think through the different problems and problem-solving critically.

He initially got into the field of HIV early on in his career mainly due to the research aspect of it. But as he progressed, he had gotten so much interested in the intersection of HIV, social justice, and health disparities. A lot of his work is presently focused on public health at the community level and engaging populations across their state.

During medical school, Philip found everything to be interesting. He loved his surgical rotations as well as OB-GYN, Medicine, Pediatrics, and Oncology. But when he got to residency, he felt he was fully committed to Infectious Diseases. He did consider Oncology due to the genetic research he did at that time. But he eventually landed on his current specialty and he's happy he did.

What he likes about ID is that it touches every part of the body. There's a broad overlap of lots of other fields and disciplines. You can actually cure a lot of infection. A lot of medicine now is managing chronic diseases. That's fine. But one thing that appealed to him about infections is that you can cure a majority of them. You can make people 100% back to normal.

"A lot of medicine now is managing chronic diseases... but one thing that appealed to me about infections is that you can cure a majority of them."

Philip categorizes patient care in two types. He does consult in the hospital where he'd be dealing with "bread and butter infectious diseases" These include endocarditis, osteomyelitis, diabetic skin, and tissue infections. They also treat a spectrum of all other infections from malaria to TB and to many other sorts.

Moreover, the outpatient side has become more of his "bread and butter." This includes HIV care. He started the prep/prophylaxis clinic at their site. He also runs their STD clinic. He didn't receive enough training in these through fellowship and residency. But the outpatient ID care has taken a lot of his time now.

About a third of the time, there are clear culture data to help guide the decisions. Then a third of the time, they don't have culture data. Cultures may not be accurate, negative, or they're not drawn correctly. Then there are also lots of bugs that don't grow. Philip believes that about a quarter of the time, they're shooting dark and making their best guess. Then they're just guided by other aspects of the clinical patients. The other third of their time, they deal with random things that they get called for. Majority of the cases would be fever. For instance, there's a rising blood count. Others would be taking random questions that may be unclear to the primary care team. 10% of the time would be people getting diseases from other countries like malaria, TB, etc. And a small percent of that time, they're able to nail the diagnosis of some really random diseases. They give them the appropriate antibiotics and cure them.

"You've given the appropriate antibiotics and you cure them. That's one of the greatest feelings in ID."

Funny how Philip thinks that none of it does look anything like his job. 1 out of every 10 patients, he sees the complete mystery and you try to piece things together. One thing they really love to do as ID doctors is to dive into the social history. This includes the person's demographics and how you frame them epidemiologic-wise. And just to be clear, there is no housebreaking involved.

"For many parts of medicine, the social history doesn't necessarily matter quite as much. But in ID, the social history can really be everything."

Philip believes there are pros and cons to each. Basically, it's about what you like to do. In private practice, there's incredible flexibility especially if you work for yourself. You can make much more in the private world depending on what you do.

He describes his career as being very academic and research-oriented. He's also the PI of several NIH grants and other grants, which you can't do in the private world. For academic ID careers, you can get involved in research and public health. You have the chance to get involved in lots of other different committees and leadership roles and stewardship. You can work for the Department of Health.

"There's a lot of other opportunities in the career of ID to really spread out."

Philip is doing a ton of research at a major Ivy League institution, yet he doesn't have a PhD. This is concrete proof that it is possible to do research without that PhD. After his undergrad, he got a masters in Genetics. So he has some research experience that he has built on.

What he recommends to students is that if you're really interested in research, really collaborate. One of the keys to successfully writing NIH grant is he always leads the grant with a PhD person. The NIH loves this as there are two different complementary skill set – one a clinically oriented researcher and the other a PhD-driven researcher.

Philip holds clinics on Thursday and Friday afternoons. For about 4-8 weeks of the year, he does inpatient service time where he sees most of the bread and butter disease cases. Then the rest of this time is spread out running various research and the programmatic aspects of what they do. He's spread across various institutions, pushing different agendas related to HIV and other STDs.

Compared to other fields, ID is a less procedure-driven field. But there are a lot of things you can do, which are quite parallel to what an internist does. For instance, they do lumbar punctures, thoracentesis, and other procedures. There are other physicians who feel comfortable doing biopsies.  Nevertheless, they routinely take cultures.

"Compared to other fields, ID is a less procedure-driven field."

According to Philip, the beauty of this field is that there's not many emergencies where you have to go into the hospital ever. Hence, this gives them a very good quality of life in terms of taking calls. He personally takes calls a couple of months where he has to answer phones through the night. However, for academic institutions, there's a fellow who takes all the calls. And if there's something they can't answer, they then refer it to the attending. And this happens to him only about 1-2x  a year. For a lot of the calls, they'd usually give the patient antibiotics and see them in the morning for evaluation.

Philip says he has a good work-life balance. His wife works full-time so he actually does a lot of the childcare in their household especially in the evenings. Although you have flexible time, you have to put in the time to be successful. But you can be flexible in terms of how time is managed. He makes sure he exercises everyday.

"As an academic ID physician, you have the flexibility of your time."

Infectious Diseases is a fellowship after internal medicine residency. You go through the traditional 3-year internal medicine residency. In general, you go through a two-year clinical fellowship after that. There are numerous variations such as research-oriented fellowships combined clinical research fellowships for 3+ years. Given that ID is an especially research-driven field, there are lots of places that combine clinical and research together. The typical pathway is two years of ID fellowship. A number of his colleagues come from Med-Peds residencies to do Adult ID and Pediatric ID fellowship over 3-4 years as well. Pediatric ID is a specialty so you can go from a pediatric residency into a pediatric ID fellowship.

The top programs in ID tend to be competitive but there is not as competitive per se as Cardiology or GI. To be competitive, you should do well in residency as a rule of thumb. Be involved in something that really demonstrates your interest. ID is very diverse as there are a lot of people from various backgrounds and experiences that are interested in the field. For instance, there are people interested in infection control, antibiotic management, international health, HIV/STD pathway, etc. So try to explore these through residency. Do research or other projects with a mentor to really show and demonstrate your interest. Or to find out if this is really something you're interested in and that you want to continue this pathway. Just do something outside of your normal residency duties. If you're interested in academic medicine, you can get involved in some grants or publications.

There are various routes to become certified in HIV care. One is to do a fellowship in Infectious Diseases. As an internal medicine doctor, there are certification programs where you can become a certified medicine physician in HIV care. This is generally a one-year fellowship. Once you've become specialized, there isn't any "next step" in terms of specialty. Those that really take the next level are research experts. These are people who have developed research expertise in drug resistance, for instance or a neurological complication-related to HIV/AIDS. Usually, these are people who have done research on a specific topic of HIV. These are world-renowned experts in a specific aspect of HIV.

Within your typical ID fellowship program, there are usually no specific tracks where you can get certified in. Usually, it's based on where you spend your time on. There are elective months as well as clinical care. A lot of these are self-directed and self-driven. There are programs, workshops, and courses being offered at academic institutions where you can start to develop specific interest and focus within aspects of infectious diseases.

"Most of what happens in how one develops one's interest and expertise, within infectious diseases, is based on where you spend your time."

Alternatively, the people that develop expertise in meningitis or fungal inspection or STDs are people who have developed programs and research portfolios around those different topics.

One of Philip's mentors is a DO who runs infectious control at Rhode Island Hospital. He routinely calls him for pieces of advice. He knows other fantastic mentors who are DOs.

"It's less about the degree after your name and more about what you make of yourself and how your career transpires."

Philip also provides primary care himself to his HIV positive patients. The way medicine has gone, as he puts it, is that everything is subspecialized that it's so impossible to be good at everything. You can't just keep up with every single aspect of literature or every single disease. He found that through the years, he has become less comfortable managing aspects of diabetes and primary prevention related to cardiovascular disease.

Moreover, there are some diseases like HIV that if you engage all primary care physicians, we would all have the potential to make huge strides in addressing the HIV epidemic. So they're trying to engage the primary care community in assisting patients with HIV testing and STD testing.

Other specialties ID physicians work the closest with include internists/primary care and hospitalist internists.

There are tons of opportunities for ID physicians to get involved. He has colleagues across the world who work internationally. There are people who provide care at international sites and those who consult with NGOs and the WHO. Nationally and locally, there are many health departments across the country that have consulting physicians. Some even have full-time physicians for infectious diseases within public health. Personally, Philip consults part-time for the Department of Health aspects related to HIV and STD. There are also opportunities at other outpatient health centers. Some of his colleagues provide consulting services related to Hepatitis C treatment, HIV care, and other aspects of ID care to community health centers, NGOs, etc. A lot of community-based organizations have medical director roles related to substances treatment, AIDS service organizations, STD clinics, etc.

For Philip, leadership was something he had to learn on the fly. He currently manages a team of over a dozen people. The business aspect is something they don't teach you in medical school, as well as how to manage people and how to be a leader.

They train you very well throughout medical school and residency to be a clinician. But for basic business/leadership/managing skill was something he had to learn on the fly. This was something he had to do everyday. That being said, it was something he wished he had formal training with given his current positions.

What he has done though was to find key mentors or people who have been through this time and time again. He'd lean on them heavily and ask them questions about how to navigate different situations.

"Seek out a couple of key trusted people that you can ask confidentially some tricky situations if you ever find yourself in them."

Philip has gravitated more into the preventative side of infection, which was something he didn't anticipate through his training. He started their HIV preexposure prophylaxis program. He sees a lot of people that are at risk of HIV and one of his jobs is to keep them negative. He enjoys interacting with young HIV positive people. Preventative care wasn't something he saw doing 10-15 years ago. But he has now found this to be the most enjoyable aspect.

"I feel like I do a lot of education, counseling, teaching, and mentorship to my patients – guide them through difficult situations, mostly, but not all related to their health."

On the flip side, what he likes the least about his practice is the administrative aspect that can become sometimes overwhelming. At some point, the administrative side of medicine may start to weigh heavily on your career. So just set some clear boundaries and structures to help manage that time. In fact, Philip just sat on a panel for physician burnout and found that the EMR is one of the number of causes for physician burnout.

Philip says that for those considering careers in HIV specifically, is to consider places where HIV is affecting people most, including the deep south. A lot of money and resources are now being redirected to such places where HIV is hit the hardest.

In terms of HIV cure, Philip sees an optimistic future in the fact that it can be done. a couple of patients now have received bone marrow transplants with HIV mutations to make them resistant to HIV infections. And when implanted with a bone marrow transplant, these people can now be cleared of HIV. There could still be remnants of HIV but people in the field are considering this as functional care. However, this is not something really applicable to the general HIV population. Reason being is that in order to get a bone marrow transplant, you have to destroy one's immune system. Bone marrow transplant is for those with leukemia and other blood-borne cancers. Also, there's a 25% mortality rate with bone marrow transplants. And you wouldn't want to risk that percentage for putting HIV medication that can keep you controlled for life. All this being said, it has the potential to cure HIV.

Ultimately, Philip would still have chosen to be an ID doctor if he had to do it all over again 110%. His advice to students is to do it early. It's a fantastic career and he's 100% glad he did it. There are tons of opportunities with some overlaps with international careers, public health, and public policies.

"Try to explore a career in ID especially if you're interested in public health, social determinants of health, addressing health disparities."

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Dr. Erica Sneider is a community Colon and Rectal Surgeon who joins me today to discuss why she loves her specialty and traits that make a great surgeon!

Dr. Gilbert is a Nephrology Program Director at Tufts Medical Center. Today, we discuss traits that make a good Nephrologist and how to be competitive.

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Gilbert initially thought he was going to be a primary care doctor. It wasn't until his Junior year of residency when he got interested in Nephrology. He saw how it bridged his interests in primary care as well as the intellectual stimulation of the intensive care unit, transplant, and more.

Nephrology patients typically have multi-system organ disease. For instance, patients with kidney disease oftentimes have endocrinology diseases like diabetes. They can also have rheumatology diseases like lupus or vasculitis. Many times, they have co-morbid cardiovascular disease or pulmonary disease. Gilbert wasn't looking to be a specialist that focused on one small area. Instead, he wanted to care for the totality of the patient. And being a kidney disease doctor allowed him to do that.

"They really touched on the breadth of what is medicine and that I find very attractive."

There are many bits and pieces to becoming a good nephrologist. There are different elements of medicine involved such as critical care and procedures. A lot of times, you have to deal with an individual's goals. You must be interested in the holistic care of dialysis and transplant. You must have a solid grounding in the general aspects of medicine. You have to be organized, compassionate, and empathetic. You have to provide patient care on all levels.

If your focus is in research, you have to have a track record where you know how to post questions and frame answers. You have to be able to recognize the core issues that need to be explored.

"There's a whole host of different things that people can get out of a career in nephrology."

If you're interested in critical care, you want to organize and prioritize complicated care that ensures the needs of your patients are met. They look for people with particular skills that align with what it is you want to do.

You are usually evaluated based on your track record. They particularly look at past activities, performance in various roles during residency training, and organization affiliations. They look at your letters of recommendation, and a little bit goes to your board scores and academic performance. They look at everything to figure out whether they're a good fit for a particular interest they have in nephrology.

Gilberts points out how applicants often focus on presenting what the programs are looking for. But they're looking for niche training when you go into a residency program or a specific specialty. You no longer have to impress anybody. Rather, you need to find the training to provide you with the skills needed to succeed in the career you want. So be honest enough to come out and tell them what you want. If they welcome you, great. If they don't you're a good fit for them, then don't train in a place that's not aligned with your career goals.

At this point, applicants need to be self-aware of what they're looking for out of their career. They have to accept that some programs are going to be able to provide that kind of training while others may not. That's okay. The training is there to help you launch the career you want.

If you had red flags in your application but still want to take this journey, you need to be accountable. Acknowledge that you didn't do well on an exam. Give them some background about what happened and it may be something they could look past. Be upfront about it. You can communicate this in the essay. Ideally, you can do this during the interview. But many times, the board scores might hold up your selection for an interview. So it has to be acknowledged before that. Some programs screen the applicants based on their board scores so those with poor board scores may not get the benefit of an application read. Gilbert believes this is unfortunate because the board scores don't really reflect somebody's potential to be an outstanding physician.

"I don't think that the board scores reflect somebody's potential to be an outstanding physician."

Moreover, Gilbert sees some benefits to a pass/fail system compared with a grading system. You usually use the former when the objective is to identify competency. At Tufts Medical School where he teaches, the first two years use the pass/fail system. You need to demonstrate a level of competency in your understanding of biochemistry and genetics. They're looking for foundational material that will prepare students later to perform clinical duties at a high level. Once you get into the clinical setting, then they give grades because they could now see people who can excel in different areas.

Gilbert thinks there are challenges to making the boards pass/fail, which identifies a level of competency. There is data that people who do well on the boards are far more likely to pass their specialty boards. And those who have struggled on the boards have oftentimes struggled to pass their certifying examinations. So program directors are cautious about people who present risks of failing the certification boards.

Nephrology is a mixture of both outpatient and inpatient medicine. There is a lot of outpatient ambulatory clinic where they take care of patients with chronic kidney disease, chronic electrolyte disorders, hypotensive disorders, transplant patients, dialysis patients. Alternatively, nephrologists have a significant role in the inpatient hospital life setting. They take care of patients with kidney disease, kidney injury, and chronic kidney diseases who have been hospitalized. They also deal with electrolyte abnormalities, calcium and magnesium-related disorders, and acid-base disorders. There also get involved in the transplant setting where they adjust immuno-suppression. They manage infectious complications that occur in unique populations.

When they design their fellowship training program, they prepare individuals for the breadth of nephrology in terms of clinical practice. They have about 50% of their responsibilities aligned with inpatient medicine. This could be in the form of consult services, ICUs, and transplant services. While the other 50% of the effort is in the outpatient setting.

When patients come critically ill into the emergency department and require dialysis, fellows may need to come in and evaluate the patients. They assess their candidacy for dialysis and sometimes this can happen in the middle of the night. They may have to do procedures such as placing dialysis catheters occasionally in the middle of the night.

"There are times that fellows are performing home calls where they need to come to the hospital to evaluate very sick patients. But it doesn't happen very often."

In terms of performing procedures, nephrologists usually replace non-tunneled catheters used for dialysis. They also attach dual lumen catheters that can take blood out and return into the circulation at the same time. Standard triple lumen catheters

are very large catheters so they require experience in the placement of these. Nephrologists and renal fellows develop the skills to place very large catheters into the body. They also learn to perform kidney biopsies in both the native kidneys and transplant kidneys to understand the underlying pathology of kidney disease. Nephrologists also perform invasive procedures.

There is a burgeoning field within Nephrology called interventional nephrology. Many people who enjoy doing surgeries may pursue a career in this area. Small surgeries can be performed as well as grafts, PD catheters, and vascular procedures such as angioplasty, stents, and fistulas.

"There are more and more procedures that are finding their way into nephrology."

For Gilbert, nephrology means a lot of different things to different people. As mentioned, he was initially interested in general medicine and family medicine. He wanted to be a physician in the community setting. He thought he'd do general medicine and then internal medicine at the end of his medical school training. He basically wanted to be the primary care doctor for a specialized group of patients. Then as he went on with his training, he was in a primary care track within an internal medicine residency. And as he explored a little bit more, he found it so interesting to do all the things a nephrologist does.

Gilbert advises students to learn your interests and learn yourself then you will quickly recognize the field that's right for you. He knew what he wanted to do and when he finally heard what a nephrologist does, he knew it was the specialty for him. He knew nephrology would allow him to unite all of his different interests into a very satisfying and rewarding career.

"When you know yourself really well and then you recognize the field that can bring that all together, you're almost assured of finding a profession that you're never going to get bored of."

Nephrology is a two-year accredited fellowship training program by the ACGME. Medical students need to do three years of internal medicine. Once completed, they can do a two-year nephrology fellowship. This is typically spent with one predominantly clinical year and a separate second year of individual exploration. This could cover areas like research, quality improvement, etc. Many programs offer a three-year training program. For instance, individuals want research training so they go through one predominantly clinical year and two years of research. After the two-year fellowship, they can do an additional year of subspecialty training in transplantation (1 year), glomerular fellowships (1 year), ESRD (end-stage renal disease)/dialysis care, procedural interventional nephrology (1 year). In total, fellowship training in nephrology is at least two years and this could go up to four or five years.

Gilbert explains that the training for DOs and MDs is very similar. There may be a difference in the structure of the curriculum of the two programs. But they have both DOs and MDs in their program. They feel very comfortable in either one of them.

Moreover, there are a lot of misconceptions around nephrology and they're demystifying those in the residency program. These misconceptions basically push people away from the specialty that they work really hard to correct on the residency level.

Misconception #1: Nephrology is very, very hard, with very, very sick patients.

Talk about the differences between salt and water balance, hyponatremia vs. hypernatremia, and sodium overload vs sodium depletion, etc. The patients who develop acute kidney injury are oftentimes sick with multiorgan failure. But a lot of this is algorithmic. If you can keep the patients organized, there are ways these issues can be addressed.

"There's this conception that nephrology is just really hard and with really sick patients. But a lot of this is algorithmic."

Misconception #2: Nephrologists work really hard.

They come in early and stay a bit later. But they're there for the patients. Their hours aren't any longer than any other specialist. They don't get called in any more than any other specialists. They're just taking care of their patients.

Misconception #3. Nephrology is poorly reimbursed and nephrologists don't get paid that much.

Nephrologists have dialysis, which is a money-maker. The reimbursement for dialysis is generous.

Gilbert thinks that nephrology training is changing. The standard curriculum is evolving. In the future, nephrologists are going to really explore the wealth of where resources can be used. It could involve one year of core fundamental training.

There could also be more opportunities for the future nephrologist to subspecialize in areas they find particularly interesting. For instance, onconephrology addresses all the forms of kidney diseases associated with cancer care.

There are interventional suites where a nephrologist can perform angioplasties and minor surgeries in an outpatient surgical center. Transplantation has already been identified as a subspecialty. This way, trainees can really focus on immunosuppression and its complications. There are ballooning areas where nephrologists can offer their services. For example, they can be very commonly involved in critical care. For the subspecialization, trainees should really explore their interests and whether it's the heart of what they want to do.

Gilbert encourages students who might be interested in the field to immerse themselves in nephrology even over a short period of time. Gilbert describes this field as very intellectually stimulating. There's always something new. Dialysis patients are all different as well as transplant patients. That being said, this requires a lot of careful thought and commitment to these individuals. And that is so rewarding. In fact, he claims to have never been bored for a day in his career as a nephrologist. There are so much going on that it's just a lot of fun!

"The field of nephrology is intellectually stimulating in so many different ways. Everyday is absolutely different."

Lastly, nephrologists are very upbeat, positive, excited, and enthusiastic individuals who love what they're doing. They're happy to share their understanding of these disorders. He encourages students and trainees to find a way of finding a mentor, specifically someone within nephrology who can share this kind of excitement for them.

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Dr. Jairo Barrantes joins Ryan to talk about Academic Sleep Medicine including what he loves about it, what call looks like, and why he chose academia.

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Jairo's interest in sleep medicine sparked during his pulmonary critical care fellowship, where their director was the head of the American Academy of Sleep Medicine. That being said, a pulmonary physician has too little exposure to what sleep medicine really is including the different diseases you come across. Sleep medicine involves 80%-90% of sleep apnea. While the training you get as a pulmonologist is the sleep apnea part and not so much exposure to all other diseases that sleep medicine entails. This opened up different doors such as narcolepsy, parasomnia, and insomnia, which may up the main problems of sleep medicine today– but there are more others apparently, especially in children. Jairo describes sleep medicine as a very fine specialty where you get the opportunity to see all patients.

Jairo says that most people choose this specialty for being gentle in terms of not having any calls and you only get to work from Monday to Friday. You infrequently get phone calls from the sleep lab at night time. So many people choose this because of the lifestyle. However, what makes you a good physician is to have a good understanding of the pulmonary and brain physiology. We sleep 33% of our life so we sleep for many years. And that's part of the time that no one really cares about. That period of time, a lot of changes happen during our sleep. Metabolism slows down as well as your brain function and this has that recovery and immunology component.

Jairo explains that the reason many people die during their sleep is due to surges of stress once your metabolism goes down and when your body is already deconditioned, this can cause a heart attack.

You may choose to do only adults or only pediatrics, or both as what Jairo does. For the children, the most common concern would be sleeping difficulties. Childhood insomnia composes 80% of his consults. The rest would be children with sleep apnea. Interestingly, sleep apnea in children is often misdiagnosed as ADHD by primary care physicians and pediatricians and they prescribe the medication like stimulants to keep them awake and focused during the day. But the reality is that these kids are sleep-deprived and have got poor quality of sleep. That could be sleep apnea that hasn't been treated for years and have been in medication to keep them awake. Suddenly, you go ahead to treat the sleep apnea and the kid's behavior improves. In fact, about 40% of children that have been diagnosed with ADHD were actually suffering sleep apnea. The rest of the patients would then be dealing with parasomnias, which are irregular behaviors during sleep time such as banging of the head or entire body during sleep.

Obesity and narrow airways may cause sleep apnea and this is easier to notice among adults. However, there are other multiple solutions for this such as medication to help them sleep. Jairo also likes to use common devices like fitness trackers to help patients with insomnia so they can develop better sleep patterns. The key is to sleep right at the wrong time. For instance, teens go to sleep at around 1-2 am and wake up at 11 am. People think they're lazy, but they just have a different sleep pattern. Unfortunately, this is causing disrupting in schools. In fact, in Minnesota, people are having their children start school later at 9am-10am and they scored better in their standardized test because they perform better when not sleep-deprived.

Some people with parasomnia may act their dreams and they think they're playing karate in the middle of the night. That can be dangerous for the bed partner, or they can injure themselves since they're pretty much asleep when they're acting their dreams. And they could hurt themselves with sharp objects in the house, or fall off the mattress. Hence, these disorders should be treated.

Jairo admits to never having been back to the lab. The only time he needed was during their pulmonary fellowship. Most of the centers are outpatient sleep facilities. This makes it very convenient for people. In pediatric medicine, most of the fellowship are three years. So it's very attractive for them to have a one-year fellowship. Moreover, Jairo describes the salary is not bad at all for the amount of extra training you do after your internal medicine, pediatrics, or psychiatry, so it's very similar to primary specialties.

Depending on where you work, they bill time for sleep interpretation and you have your schedule close for a couple of hours so you can do the sleep studies for the night. Jairo also points out that many people stay away from sleep medicines due to economical reimbursement. It was better during its golden years some 20 years ago but Medicare adjusted the prices and now, you get a glorified internist salary without calls. Not bad at all, however, it wasn't as good as it used to be back then. That being said, still, it's a very mellow specialty to go through and the number of diseases is limited with about 20-25 conditions with different subdivisions compared to doing general internal medicine where you have to treat thousands of conditions.

Jairo would usually go to the office and most of the patients prefer to schedule their sleep studies early in the morning. So you do a sleep study interpretation from 8-11am. Then after the clinic from 11-12 for lunch, you go back to the clinic and finish at about 4 pm. You wrap up and then go home. This happens Monday to Friday. He still has enough time for his family as he still gets to take his daughter to ballet classes and other activities.

As to why he chose the academic setting, there are opportunities for research available. This is one area in the specialty where you can develop your career. And there are also plenty of areas to do research. Alternatively, you don't get the opportunity to do research in the private sector and you focus more on sleep apnea as that's where money is generated. So you need to be linked to an academy to be able to develop sleep research.

There is plenty of themes or areas that you can do it, but in order to develop that, you need a little bit of protected time, access to key people doing statistics and interpretation. You also need people to help coach you how to write articles properly. While the academic centers get more complicated cases. Hence, case reports are easier for them to make when from the academic side.

Additionally, Jairo loves to teach. He finds being attached to a center that has Sleep Fellowship as very gratifying.

There are different ways down the Sleep Medicine path. Initially, you have to have a base specialty and then you can apply for sleep medicine from there. You can become a sleep physician from being a general internalist or from general pediatrics. You can also come from pulmonary critical care, psychiatry, psychology, and neurology. So finish your basic specialty then do sleep medicine fellowship thereafter. You take the board for sleep medicine and become a Diplomate.

Jairo says that it's easy to find a job in sleep medicine because, in the last ten years, the doctors who were practicing sleep medicine weren't board-certified. Hence, they didn't have any formal training. And when the boards came, it was very difficult for those physicians practicing without formal training to pass the board. Those people shied away and they haven't studied again to be able to take the boards. Nevertheless, people don't realize it's a good specialty since it's easy to work with the schedule because it gives you a lot of flexibility. Plus, he gets to have weekends off.  Also, the amount of RVU they can generate from the sleep is significantly higher than what you can generate from being a primary pulmonologist. This means they give you more forgiveness in time and still receive the same expectations from the hospital without working extended hours. Or if you're paid by incentive and reach a certain amount of RVUs a year, you're able to reach those RVUs with the sleep part which you will never reach just with the pulmonary part alone or psychiatry work, whichever specialty you have.

Matching into sleep medicine is not competitive at all. People don't even know what sleep medicine is. But Jairo thinks it's going to surge once people getting paid with these RVUs. There are about 60 programs that are eligible and out of those, about 60% get filled.

There isn't much opportunity to subspecialize once you get into sleep medicine. You basically choose your niche of practice usually depending on your background. For instance, if your background is neurology, you usually focus on circadian rhythm disorders, seizures, and movement disorders during the sleep compared to doing sleep apnea. In Jairo's case, he does mostly sleep apnea and uses of non-invasive positive pressure ventilation at night. He also does what he calls as special populations like children who have facial malformations or other conditions that leave them with very narrow airways and have severe sleep apnea that requires tracheostomies, advanced ventilators, or non-invasive positive pressure ventilation at nighttime, especially patients with APS who become dependent on those during both nighttime and daytime.

Jairo wishes primary care physicians would realize that sleep medicine is more than a sleep apnea. But that's not what just the sleep medicine entails. It's more than just prescribing the CPAP or the BIPAP. A lot of knowledge is involved and a lot of different opportunities to treat the patient better. Additionally, there are many diseases that are preventable or better treated when you have a better sleep pattern at night. For example, if you have diabetes and your sleep apnea is controlled thereby giving you good sleep, your insulin requirements go down by 30-40%. The same happens to people with hypertension where they notice some drop in the amount of medication required for hypertension when they're treated for sleep apnea or insomnia. If they're able to understand this, primary care physicians would be more enticed to know more about sleep medicine so they can do basic practice in their practice, says Jairo. As a general internist, you can prescribe the CPAP and sleep study. But if you have the basic knowledge and interest in that, then you won't have to refer to a sleep specialist, which can be very difficult to find these days. In fact, it may take up to 6-8 months to get a sleep specialist available. This actually discourages patients to pursue any longer since they can't find anybody to see them.

Other specialties they work the closest with are mostly pulmonologist, bariatric surgeons, psychiatrists, and child psychiatrists. They also work with neurologists for patients with ALS or spinal trauma. They do work with cardiologists as well as endocrinology. They're trying to get better control of irregular heartbeat at nighttime or daytime and this decreases the frequency of relapses of atrial fibrillation after ablation when sleep apnea is being treated.

One area would be commercial devices. They're looking for people developing new technologies. If you get to work with one of the companies that develop non-invasive positive pressure ventilation, there are opportunities to go into the commercial or research side. You would now be part of the protocol. But if your center is standardized and needs to forfeit all of the conditions of the American Academy of Sleep Medicine, you will be able to get research going on in your lab. There are private doctors who decide to devote all of their time or 80% of their practice to do the case being paid by the research study.

When he did his residency in internal medicine as an intern, one of the sleep doctors gave them a talk about sleep medicine and didn't mention about it and he was making good money at that time. Today, the population they work with include patients that are very gratifying as it enhanced their quality of life. Although there are some that complain, the majority are still grateful for what you do for them. Interestingly, you don't need to see your sleep patients very frequently. You may only seem them every year and they can do very well with that.

What he likes the most about his specialty is the schedule. Interestingly, Jairo doesn't find anything that he doesn't like about his specialty. He enjoys every single minute he's at work. Maybe, having patient with insomnia that is very difficult to treat can be upsetting for him so you can end up being a dispenser of control medications for them. But as far as you do your job right, most of your patients get well.

People are becoming more aware of the wellness and lifestyle so sleep medicine is going to start growing more and more. And perhaps in the next 10-20 years, physicians are going to be very aware of the benefits of having a good quality of sleep. Hopefully, there will be more physicians coming to learn what sleep medicine is and practice it. This will lead to better reimbursement and more opportunity to treat other people.

If he had to do it all over again, he'd still do it. In fact, he would even do it first over the pulmonary part if he'd just have to take sleep medicine. Although he loves pulmonary, he finds sleep medicine as more gratifying.

Jairo says that sleep medicine is a wonderful field where you can achieve many personal goals in relation to your career. Career is significantly easier when you do it from the sleep part because there is a blank canvas to be painted compared to other specialties. So this is a fine specialty to pursue.

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Dr. Joseph DeRose is an academic Cardiothoracic Surgeon. Today, he discusses the length of his training, the competitiveness of his field, and why he loves it!

Meanwhile, please don’t miss all our other podcasts on the MedEd Media Network so you can get all the resources you need in every step of the way towards finally becoming a physician!

As a third-year medical student, Joseph liked almost everything. He even thought he was going into interventional cardiology. But he realized it's a medical specialty which means doing three years of medicine and three years of cardiology and then interventional cardiology. But he realized he liked surgery more than medicine.

At that time there was no direct pathway to cardiac surgery. He went to general surgery training and found there were a lot of areas in surgery that he liked, but still much very interested in the heart. After doing multiple rotations, he decided to do cardiothoracic surgery based upon the thought process built around whether you can't be happy doing anything else.

First, you have to be interested in acute care. Most of the cardiac surgery is care that's high intensity but very focused on temporal relation. You're taking care of severe and critical issues but you're taking care of them in small periods of time. So you have to like being in a hospital and critically ill patients. You have to also like other things because cardiac surgery is not just a mechanical field. You really have to enjoy pathophysiology and a bit of cardiology since a lot of patient care goes on.

Because cardiac surgery is a hospital-based practice, there are other things that go into being a cardiac surgeon regardless of whether you work for an academic institution or private practice. This includes enjoying teaching. There's constant education going on even if you don't have a fellowship. You're educating PAs, nurses, perfusionists, and junior faculty.

Apparently, research is an intimate part of the field. This occurs even if you're not in an academic program. Cardiac surgeons are frequently involved in clinical trials and clinical research even if they're not academic, per se.

If you like those three, this can be a great field for you. In terms of traits, you have to have a lot of mental and physical stamina to be a cardiac surgeon. You have to be even-keeled as things can get very up and down. So you have to be able to take different things as they come.

Going into this, Joseph initially considered vascular surgery for some time and to the last minute, he decided it wasn't for him.

Coronary artery disease is the most common he sees but there are many ways to take care of that now – regular, conventional bypass surgery, stents, robotic surgery, minimally invasive surgery.

Another common disease would be valve problems – aortic valve, mitral valve, leaky valves, stenotic valves, etc. There are situations where patients can be offered various options such as open surgery, minimally invasive surgery, transcatheter, structural heart interventions.

Other areas of specialty include aortic diseases involving aortic dissections which are a high-intensity part of the pathology. Heart failure is another common disease among patients which includes things like heart transplantation and artificial hearts.

Cardia surgeons are sort of tertiary or quarternary referrals. So patients have typically seen the medical doctor or cardiologist before they're being called. However, even if you're called with a specific diagnosis, that doesn't always mean the diagnosis is completely worked up or correct. It doesn't mean that the person has been completely evaluated as to whether they're a potential candidate for different interventions.

The evaluation of cardiac surgical patients for the cardiac surgeon is much different than any other surgical specialty because we're expected to evaluate every part of the patient's body. That said, appreciating the subtleties of every patient is what makes you successful or not. And that's what makes it so fun as well.

As an academic heart surgeon, Joseph does research and runs the residency program. He also has a very busy clinical practice and does about 300 cases a year. A typical day would be getting in at 7 am working on academic things before going to the OR. He also makes rounds with the whole team and sees all the patients in the ICU and the floor before going to the operating room, which starts at about 7:30 am. They can have 1-3 operations going simultaneously, being involved in the OR most of the day and being available to respond to other issues and concerns in between operations.

Once out of the operating room, Joseph gets on his computer. At the end of the day, they round up with fellows and PA's and see patients they've just operated on or patients that are having issues throughout the day. They also see patients that they've gotten called about for consultation and assess them to see them if workup is needed or surgery. Then he could also be on conference calls for clinical research trials he's involved in a couple of times a week. He may also go to administrative type dinner whether it's for planning or recruitment, etc. A full day for him, yet enjoyable.

Joseph points out that call is something that every surgeon needs to take probably for the rest of his life. Taking calls for them is a bit unusual because they cover things like regular bread and butter heart surgery as well as heart transplantation, lung transplantation, aortic dissection, ECMO (extracorporeal membrane oxygenation). Generally, they take about 6-8 calls a month including one weekend.

In heart surgery, it involves making rounds on the patients in the ICU and the floor every day of the weekend. They also cover emergencies that occur at night and when they do, the operations can take long for about 6 hours.

Having been in practice now for 17 years, Joseph is married to an internist and now have two children, 21 and 18. He coached his son's soccer team and baseball team since he was in 3rd grade until 8th grade. Then when he got to high school, he played varsity lacrosse and went to every game whether home or away. He did all this with planning. And it can always be done. He also coached his daughter's soccer team. Moreover, Joseph is lucky to be working in a big group of people he's known for a long time and they're all very supportive of each other's family life.

The traditional path requires four years of medical school and then you apply to general surgery residency, typically taking 5 years. With most cardiac surgeons of today, they'd all spend an additional year of research in cardiac surgery because the application process is incredibly competitive.

A lot of applicants that are now going through the traditional path mostly don't do extra research. But by the time you get to your fourth year, you have to apply to either a 2- or 3-year fellowship. That's in cardiothoracic surgery. So that's 4 years of medical school, 5 years of residency, and 2-3 years fellowship.

Joseph recommends that even though you've done the traditional path, spend an additional year thereafter focusing on a super fellowship in a higher intensity-focused area. For example, do an extra year in heart transplantation or if you want to do thoracic surgery, do an extra year of minimally invasive thoracic surgery for instance.

In cardiac surgical fellowship, you have to train for 2-3 years in three areas: adult cardiac surgery, general thoracic surgery (including lung-esophageal surgery), and pediatric heart surgery. This is a lot to learn in a short period of time, hence, Joseph recommends an additional year. That's a total of 8 years in training on the traditional pathway.

In 2012, there were less and less applicants for cardiac surgery and one of the reasons is the sacrifice it takes to be a heart surgeon. And a lot of people were less inclined to make those sacrifices. The second reason is the reimbursement concern where people didn't feel they were well-compensated. This prompted the association to develop an I-6 program where you apply directly out of medical school and you're being matched into cardiac surgery. You still do about 3 years of the traditional general surgery training and within the final three years in cardiac surgery includes weeks and months of specialties important for cardiac surgery such as interventional cardiology, echocardiography, perfusion. This cuts off two years the training length although many of the programs also do an additional year of research. Those that finish the I-6 program will also take an additional year of super fellowship training.

The I-6 application process is more competitive because of a much larger group of people looking at it with a smaller number of spots. There are about two applicants for every spot. To be competitive, you have to have great grades, with at least one or two publications already and have done some research in medical school.

You don't need as high a qualification coming from a general surgery program. That being said, there are still some excellent traditional training fellowship programs as well as I-6 programs that aren't so good. This is something students should consider as well. Interestingly, of the people that don't match in the I-6 program and go to general surgery, only about 5% of them that while they're in general surgery, decide they're going into cardiac surgery.

For instance, you've done three months of congenital heart surgery and like it, you can't be a pediatric heart surgeon. You've got to spend an extra year doing congenital heart surgery. If you're a thoracic surgeon and non cardiac thoracic surgeon, there are super fellowships in any number of specialty areas for that. It could be an extra year in surgical oncology or in minimally invasive esophagectomy, or an extra year in lung failure or lung transplantation. So there are a number of areas where you can get additional training. In adult cardiac surgery, the major ones would be another year in adult heart surgery. But the three most common ones are heart transplants, minimally invasive heart surgery and mitral valve repair surgery.

An osteopathic medical student has to go into a general surgery residency training program. It can be an osteopathic training program but must be approved by the ACGME. However, if you do that going through the traditional pathway, there are no obstacles. If you're a good candidate, you can absolutely become a cardiac surgeon. In fact, in their training program, they have several DOs over the years and many of them have been outstanding. However, this is not offered in the I-6 pathway.

Primary care has changed a lot over the years. Internal medicine has been very stratified with inpatient and outpatients where they no longer have their own individual patients. Because heart surgery is so much of an evaluation process that includes the entire patient, cardiac surgeons need help in evaluating their patients for their end-organ dysfunction. But a lot has been fractionated where they'd call the specific specialties. But Joseph points out that this is not so helpful since each specialty will focus on their specialty area. What you need is someone like the heart surgeon like an internist who's evaluating the whole patient and all of their medical problems to assess whether an intervention is going to make them either live longer or feel better. And this can still be improved upon, Joseph believes so.

Other specialties they work closely with include cardiology, GI, pulmonary, and renal to help manage patient's post-op. There are people in his team where each one may direct a program upon which, you're almost always directing that program with a medical cardiology person specialized on the medical side.

Cardiothoracic surgeons are a totally different breed. From the beginning of your training, you're taught that it's not just about doing surgery but it's also about being a leader and learning how to talk publicly and learning how to expand your horizons. Most cardiac surgeons aspire to do other things such as politics, media, administration or lead a department. So there are immense opportunities out there but a lot of it has to do with the training.

Moreover, Joseph points out that training is really hard. Things have changed with hour restrictions but it's part and parcel of all of it in making you think about not just about being a technician.

As to gender demographics, Joseph seems not to notice any division as people are going into fellowship. He recently looked at the applications and there were 40% women and 60% men.

Joseph says that when you go through medical school and in training, we're not really taught how we exist in relation to the real world. We only know how we exist within the confines of our training programs. There are a lot of things that you need to learn by mistake to figure out how to function better the next time. This is common in areas like the medical-legal area. It has nothing to do with mortality/morbidity or with right or wrong. So you have to learn how to appropriately document what you do in the chart to protect yourself. The other area is on the business end.

Not having an idea about how the business of medicine works puts you at a disadvantage when you're trying to negotiate your first contract, or realize what's important to the hospital versus what's important to you from a financial standpoint.

In cardiac surgery, though they get exposure to outpatient medicine, it's only by experience that you start figuring out all the interpersonal dynamics that occur when you see a patient in the office or on the floor for heart surgery. You need to understand what the interplay is between a patient's family members and what you're going to talk to them about. You have to understand the reactions of patients when you talk about life and death.

Joseph loves that it's something new and different everyday and how it's all a dynamic process. There are so many things that go on beyond just the operation and you have to be very intuitive and be very careful about when it comes to managing patients after surgery. He also loves the educational and research parts of it. Many students do cardiac surgery for the excitement, but after a while, surgery becomes the easy part as it can get to be a routine. But it's the different interplays in patients and each pathology are just amazing. Ultimately, he loves being there for the patient in their most trying times, whether that's saving their life or sometimes helping them die.

What he likes the least is the litigation portion of it. There are lots of lawsuits in cardiac surgery and there's nothing more painful than to have to go through that, says Joseph. Though 95% of all lawsuits get dropped and 5% just go through the trial and ever settled, it's a part of life and it's something any doctor wouldn't want.

Joseph believes you have to take a broader perspective on it. He has been seeing and hearing how stents are going to take away coronary bypass grafting. But cardiac surgeons are always intimately involved with new technology whether on the research end or on the clinical end. New developments are in terms of the structural end and cardiac surgeons will continue to be involved in, as well as heart failure area with all the devices coming out. They're becoming less and less invasive, helping more and more patients.

That being said, Joseph definitely sees a brighter future for cardiac surgery. In terms of job perspective, there's a lack of cardiac surgeons going into the field about 5-10 years ago. A lot of the surgeons retiring in the last 5-10 years has left a huge opening for cardiac surgical positions. So getting a job in cardiac surgery is much easier now.

Finally, if he had to do it all over again, Joseph would still do the same. He loved what he does and still loves coming to work everyday. He thinks there is no other job that's as exciting as they do but you have to have the right personality to take on the challenges that it brings. Yes, you get to save lives but people die as well so you have to be able to deal with that.

Ultimately, he wishes to impart to students that medicine is the noblest of all professions. It's something you have for yourself forever. It is not a job. In cardiac surgery, Joseph explains it's the same kind of discussion, except that it's on steroids. People may ask you why you want to sacrifice your life to do those kinds of things as you're not going to make as much money or things are going to be hard and there are lawsuits. But you're doing it for something else. You're going into it because you love it and if you do it this way, there's nothing more gratifying than this.

MedEd Media Network

Dr. Dave Winchester, a fellow Gator, joins me today to talk about why he chose academic Cardiology, how Cardiology is changing, and why he enjoys what he does! David has been out of training now for 8 years. He graduated from the University of Florida where he now works as an academic.

Meanwhile, please do check out all of our other podcasts on MedEd Media Network so you get to have as many resources you need, as you journey along this path to one day becoming a physician!

Dave's interest in cardiology started with medical school onwards. He enjoyed doing it more than other things. But he didn't really commit to it until halfway through his first year of internal medicine residency. He also loved the first rotation he did in Cardiology. And since then he knew it was something he wanted to do.

Halfway through his first year of internal medicine residency, he loved his first cardiology clinical rotation. Compared to other similar specialties, they've all got acute inpatient conditions that can be exciting and have got chronic outpatient management. But it was something about acute MI management and reading. Although he had little interest in pulmonary critical care as he found it to be challenging, fulfilling, exciting, he saw the same in cardiology as well.

Dave chose the academic route over the community setting as he enjoys the opportunity to stay highly engaged with teaching. He also wanted to do his own teaching and he thinks the only way to do this substantially is within an academic setting.

David does both clinic and ICU, as well as imaging and in-patient hospital care. He sees cases like MIs, heart failures, atrial fibrillation, and dysrhythmias. He does preventative care – pretty much everything within cardiology.

At their institutions, services are being broken up a week at a time. He'll have one week as the ICU attending and one week as the clinic attending. As an academic, he has some grant support so some weeks, he doesn't have a clinical responsibility and his job is to teach write papers and grants.

When in the clinic, he's doing full time at their VA hospital and they have a team approach where he sees patients in clinic but he sees almost every patient with either a resident, fellow, nurse practitioner, or a physician assistant. A full day of clinic for him would be 8-10 new patients in a half day where the patient has initially been seen by someone else. Then he comes in and helps with the assessment and plan.

When he's at the ICU, Dave takes care of all the in-patient consults for the day as well as rounds composed of which the unit has 16 beds with 4 of them, typically cardiac patients.

In academics, Dave says there is not so much opportunity for the general cardiology to work with their hands. There are subspecialty cardiologists that do most of the procedural stuff. There are still some though that do invasive procedures in the community.

As an academic cardiologist, Dave illustrates a layered call structure. He might be responsible for any number of facilities, with at least a cardiology fellow on call with him, who's going to take the majority of calls up front. When he's in clinic, they'll be responsible for the primary assessment of that patient then they call him to go over what's going on with the patient. He may take the call from home or come in and see the patient himself. He may also see the patient first thing in the moment when he comes in. When on the ICU, he'd be on call 24/7 but he'd only have to come in rarely or occasionally.

With 11 cardiologists at the VA that share duty, each of them gets to take about 1 week of call every 11 weeks.

As an academic and having some grant fundings supporting his effort, his clinical responsibilities are reduced to match what's not offset by his research grants. His research productivity is up to him. As long as he's generating research findings and getting them published and pursuing additional funding, his clinical demands are relatively easy to meet. That being said, he considers himself to have a good work-life balance.

The opportunity is always there. Not everybody avails himself of the opportunity and academic medicine has changed a lot over the last couple of decades. There are a lot of people now that are in the academics or academically affiliated but may be doing 100% clinical work.

It doesn't matter whether you have a PhD or not. Dave doesn't have one and he says it hasn't affected anything for him. But he's a relatively nontraditional researcher. He doesn't have a lab, he doesn't have mice, or any testing near him. He describes all of his research as being built around health services research or health systems science.

He's looking more at the bigger picture of things – outcomes, quality of care, reducing low-value care, and things that don't require a traditional lab. While you can get advanced degrees in those fields, there are very few researchers that he networks with who are MDs that also have PhDs. That said, there are PhDs in those fields, but very few that are both.

First, you go through three years of internal medicine residency and three years of general cardiology training as the basic. There are a couple of variations with some programs where you might do a year or two of research. If you want to work in a genetics lab or a pharmacology lab or something else, there are opportunities to do that. You might spend a year doing that and it could give you a leg up on some of the grants.

In terms of competitiveness, Cardiology is pretty more competitive than it is with Internal Medicine. This is based on some medicine residents that he gets to work with and mentor every year. Some of them don't get in so it can be pretty challenging.

To be a competitive candidate, sometimes it starts with what program you're coming out of. Are you coming out of a highly respected academic internal medicine program, or are you coming out of one that doesn't have a track record of producing people with an interest in academics? This is actually one of the things that some programs look at in their decision process. Some programs still look pretty highly on USMLE scores, and so that can continue to be an important factor along down the road.

Moreover, there are opportunities for medicine residents to do research and to do other sorts of extracurricular things. That said, being involved in that as early on as you can I think is certainly not going to hurt and it can be quite helpful.

Within the field of cardiology, there are three ACGME recognized fellowships that are officially sanctioned by the governing body for residencies and fellowships, namely: Invasive Cardiology (1 year), Electrophysiology (two years), and Heart Failure Transplant (1 year).

There are non-ACGME approved fellowships in things like structural heart disease. So if you wanted to be an invasive cardiologist and then also do percutaneous valve procedures, that's a fellowship that you could consider doing, and imaging is another one. Dave is the program director for an imaging fellowship at UF, and those are variable depending on what the needs of the program are. Some of them are based on cardiac MR, or cardiac CT, cardiac echo, etc.

One of his classmates in his fellowship class was a DO and he is an incredible guy. He had no concerns or reservations, and there was no distinction made between MD and DO. So there's not a whole lot of difference, but there are some institutions in some regions of the country that don't have similar views.

Dave wishes that referring providers felt a little bit more comfortable with symptoms that occur in the chest. There are a lot of people out there who, when a patient describes any kind of chest pain, will immediately and reflexively send them straight to the emergency department. They’d call up frantic for a stat consult.

Sometimes that's necessary, but frequently, it's not. It not only puts strain on the systems of care, but it can harm the patient too if somebody tells them, "Go to the ER or you might die," when in reality they've got either non-cardiac symptoms or it's a patient with known coronary disease and they have stable angina that's completely manageable with medical therapy.

Moreover, Dave has also noticed, in general, a lot of use of the pronoun 'they' on rounds and in clinical care. 'Cardiology wants this or they ordered such-and-such test.' People have names and so they have to be specifically mentioned – people that are speaking to specialists, and specialists, when they're getting back to referring teams, could do a better job of.

Additionally, there are primary care docs who simply don’t want to get their hands on “heart stuff” and Dave appreciates their honesty. But he has also encountered other people who are terrified that something bad is going to happen to the patient. Dave totally understands this but if the patient had a stress test three months ago and they're on all the appropriate therapies that they need to be on, then they don't need to go down that road again. They don't need to send them straight to the cath lab or repeat a nuclear stress test.

Other specialties they work the closest with include cardiothoracic surgery, anesthesiology, hospital medicine, and the emergency department. The emergency room is where a lot of chest pain shows up and begins their evaluation. And there are better and not so great ways of conducting those initial evaluations. Dave works with their emergency medicine specialists to try and develop some streamlined models of care for chest pain

Dave has done routinely done lectures for their fellows, as well as for our internal medicine residents. In the past, he has done career development curricula for medicine residents and helped them trying to figure out which specialties they want to go into.

You could also do some teaching. Dave is currently teaching medical students on the first, second, and third year at a different number of settings. He also did some undergraduate teaching.

One of the things that drew Dave to Cardiology early on was that there was the opportunity to continue to decide further if he wanted to pursue a subspecialty or not.

Dave got some advice during medical school that he thinks is a useful thought exercise. He actually was on his OB/GYN rotation, and one of the faculty asked him, "What do you want to be doing at 3:00 AM?" And the concept was that as a doctor, you're going to be on call, there's at some point in the middle of the night when somebody is going to call your phone. It's going to be 3:00 AM, and what do you want them to be calling you about? What are you motivated or excited to go and do at that time?

And Dave has reflected back on that at a number of different stages in his career, and that was one of the things that he thought about when trying to decide whether he wanted to do a subspecialty fellowship or not.

In particular, the one sub-specialty he was the most interested in was invasive cardiology. He enjoyed being in the cath lab, but not the difficult cases. And that was his thought process for not pursuing it as a career.

He admits not having the temperament for that, and so he was best served and the patients were best served by doing something he was more passionate about, which was imaging and general cardiology.

What he likes most about cardiology is something about the disease processes. He enjoys providing explanations to patients about what's going on with them. And what he finds to be one of the most rewarding experiences in cardiology is taking that time with patients and really helping them to understand their disease process.

On the flip side, what he likes the least is how some doctors can be uncomfortable with taking some cases. However, he’s willing to help since it’s for the best interest of the patient anyway. That’s his job as a specialist and so he needs to make the best of it.

Some exciting changes in the future include structural procedures where they’re now alter structural elements in the heart, which is just amazing. So that's continuing to be advanced and refined.

In imaging, there's three-dimensional imaging coming online, particularly with echocardiography, as well as new advances in CT technology that may be able to let us make functional assessments of stenoses, whereas CT normally just gives us pictures.

There's PET imaging and neurotracers coming online for positron emission tomography that has the potential to further improve diagnostic accuracy prognosis for patients. Moreover, Dave believes that prevention is something he sees more and more interest in within the cardiology community.

If he had to do it all over again, Dave certainly would. He’s happy coming to work every day, and he points out that this is really what you want in any kind of a career.

Finally, he advises premeds and medical students to go out there and experience as many things as you can. Get a broad exposure to a variety of different specialties.

For some people, they just know it’s the path they want to take. But for other people, they just don’t. And they get to the end of their medical training, and they're just not quite sure what to do, and even if that's the case, there are plenty of good jobs to go out there and get started doing. All this being said, continue looking for that thing that's really going to be fulfilling for a long and fruitful career.

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Dr. Edward Schloss joined me to talk about his journey to Cardiac Electrophysiology, what 17 years in the field looks like, and his likes and dislikes of his specialty.

If you're a premed student, go check out all our other resources on MedEd Media Network. If you're a medical student, go check out our newest Board Rounds Podcast.

Coming out of undergrad as an engineer, Edward wasn't sure he wanted to be a doctor and only found out as he got further along. It was during second year of med school that he had an ECG class and they were already problem-solving instead of just plain memorization. He also got through different phases such as rheumatology, nephrology, and primary care. In fact, he recalls telling himself one evening that he wasn't going to be a cardiologist.

He actually got interested in serial drug testing back in the old days, where they would take people who had cardiac arrest into a lab and they would pace their hearts in order to induce the arrhythmia. They would start the medication and bring them back and do it again. Until he got to the people that did electrophysiology and got mentorship.

Edward says you have to be analytic. You have to be able to look at data objectively and there are going to be mountains of data and you have to sort through the good and the bad. In the lab, you have to be highly meticulous. You have to be focused and meticulous for hours on your feet to be able to get through that.

Moreover, establishing relationships with patients is also super important. They don't meet patients on the table, but they meet them ahead of time. They deal with people that are very vulnerable and intimidated. Many of them have been through something life-changing. They're facing the risk of cardiac arrest or they've been through it. Or they're scared to death about their arrhythmias. So you need to humanize it and gather their trust before they hit the lab. And for many of these patients, you follow them for many years. Having a lot of device patients, they have metal in their body that he's responsible for, for the rest of their life.

"These people have a hunk of metal in their body that I'm responsible for for the rest of their life so they're kind of married to me professionally."

Edward illustrates a mix of patients coming in. There are young people with palpitations, fainting episodes, which are common. As they get older, you start to see patients who may be healthy but have developed atrial fibrillation from a variety of causes. As you go further to the older population, you'd see patients with myocardial infarction and then you get to the heart failure population as they get older. Edwards favorite is the 90-year-olds who may have a heart block and fainting episode and you put a pacer in them and they're good to go.

Edward has a good number of referring physicians, mostly his own partners. When patients hit the door, it's not unusual for them to be ready to go. So they've probably had their echo or their medications, etc. A lot of times, they don't know what they need which is pretty common. So it's common for Edward that he'd have to craft the patients' expectations a little differently.

"If they think they know what they need, much of the time they're wrong. That's not because they're not good doctors. It's just our field is so highly specialized."

Edward arrives before 7 am, depending on how much is going on in the hospital. He runs around and sees his post ops. It's very important to see people the day after their procedure personally to cement the relationship. Then he makes it to the lab or the office by 8 am. His days are generally either all day lab or all day office. On an office day, he'll see patients from 8-8:30 and from 8:39 to 5 or so, he sees his patients. Some days can be light, others can be busy.

On a lab day, they do procedures that can sometimes take a short amount of time. Sometimes, it takes several hours. It's hard to predict which number of hours. Typically, his day is done by around 6 pm.

Edward chose the community setting over academic. He was one of the aggressive fellows who felt ownership over his patients. He jokes around that by the time he got done he was a "PGY-8" which just means that it takes a long time to become an electrophysiologist. So feel kind of ready for it and want to do things yourself. So he hated it when his attendings would lean over his shoulder and take control of the catheters or do access. He realized once he got out of practice that he wasn't going to change. So if he had to do an academic practice and had to teach fellows and give them control, then he would have a tough time with that. Then he found research later in his career but he tried to skirt away from it as much as he could. He did enjoy teaching but he wasn't sure if he was going to be patient about it.

If somebody hits his door as new patient evaluation, he does a procedure on them of about 75%. For the 25%, he sees a lot of people come to him for benign palpitations and sometimes all they need to do is put on a monitor and determine they're benign and reassure. This doesn't lead to a procedure.

Basically, taking calls has evolved over the course of his career. Most electrophysiologists he's talked with would like to be purely electrophysiology on call. But it took a long time to get to that point. He'd take calls every fifth night and every fifth weekend. He used to do general cardiology call. Then as they got bigger and built an electrophysiology-specific call, the calls got less frequent. But as it got less intense, it became high acuity calls and in many cases, they're very knowledge-based, difficult, complex calls.

Edwards admits going through periodic retirement fantasies, not because he doesn't love his job, but because he just loves his home life. He's got a phenomenal family and a great place to live. So he enjoys being away from the hospital. Weekends he just shuts everything down so he can stay at home and have a nice time.

"When you're here, you've got to be here. So you've got to actually devote yourself to that."

You start out as an internal medicine resident after medical school which is three years. And then you decide whether you go to cardiology and get a cardiology fellowship which is another three years of general cardiology. Then you subspecialize and choose electrophysiology. Depending on what program you're in, that might be combined into the general cardiology program, or it might be a separate fellowship. For him, it was a separate fellowship that added two additional years. In total, it's eight years of postgraduate training before you finally get a real job.

In terms of competitiveness, Edward thinks it's still the interventional folks are the most popular. But there are also attending EP (electrophysiology) spots. He thinks it depends on when you get out and what the path is. But just the cardiology itself is tough to get into.

"EP is a very narrow field but within that narrow field, there's a fairly significant breadth of knowledge."

Edwards describes the specialty as cutting down in the middle between two basic worlds at least within procedural, namely: device implantation and ablations. The amount of research, attempts, and trials before ablation became actually refined to what it is right now, Edward would describe as the longest procedural research type of learning curve he has seen within his field.

The DOs Edward has met he'd consider as some of the best docs he had in practice during his fellowship. He personally didn't feel any bias at all. He hopes it's still as open as it was when he was there. They were just rocking and rolling it just like everybody else.

Edward feels blessed to have a healthy referral environment. But what he could tell primary care physicians to help cardio electrophysiologists with patient care is first knowing when to refer. And this is true to a lot of other specialties. There are people who are out there but they haven't been referred. And some of their patients have been held onto too long before they could have done something food for them. So if you've got somebody who had heart failure and they haven't seen an electrophysiologist, please refer those folks out. Atrial fibrillation is a classic example where the evolution of how it's being treated has changed quite a bit and not every primary care physician may be aware that they've got great treatments for atrial fibrillation now but they need to get the people earlier rather than later.

Additionally, basic testing is important and this applies more to his general cardiology colleagues rather than the primary care physicians. But simple things like just getting EKGs and people that are symptomatic. It's not unusual for him to see somebody who has had an echo, MRI, or cardiac cath, but has been six months since their last EKG and then they will find something that changes the whole game just because the EKG wasn't checked.

"We've got great treatments for atrial fibrillation now but we need to get the people earlier rather than later."

Edward says EPs are rarely referring out. But they have healthy working relationships with their general cardiologists and heart failure specialists. So it's 90% other cardiologists, although he does work with primary care physicians. But the pathway to a referral from primary care is to put them first into the cardiology system and then from within the cardiology system, they can then be referred to an EP.

They work with very complex and technical equipment, very technically complicated. It may not be unusual in medicine but once patients leave the hospital, they still have that equipment inside their body. And that has to be maintained, serviced, and troubleshot. So pacers, defibrillators, biventricular heart devices are super complex. There are lots of things that could go wrong and lots of nuances to how they program the devices. So the industry is critical for them to be able to manage those appropriately. You will have an opportunity to work in the industry. At the MD level, you can consult. Some people work full-time with industry.

"Done right, industry-MD partnerships are very healthy. Done wrong, obviously, it is the dark side."

What dawned on him as he went out to practice was that the overwhelming amount of information they had to deal with can become absolutely critical that you need to build a team around you and you need to reward and support that team. And they will return to you what you need to be able to take care of your patients. So you'd have to train these people and keep them otherwise you're going to be up the creek if the right people leave you. So take care of your people.

"It's literally impossible to do this without this healthy group of supportive people."

What he likes the most as a cardiac EP over his years of practice is appreciating the nuance of patient care. Coming out of college as an engineer, he didn't realize how much he liked patient relationships. Another thing he likes is the troubleshooting and complex management of devices. It's a big world that is somewhat impenetrable early on. But once you get in a little bit deeper, these things just open up into so many interesting things.

"Barely a day doesn't go by that I don't see something I've never seen before and it just blows me away just how much nuance and difference there is in what we do."

Electrophysiologists are very passionate, as Edward describes it. They love what they do and almost nobody knows what the hell it is that they do. And this keeps getting bigger and bigger as they people try to understand this and the world just opens up to you.

On the flip side, what he likes the least is pleasing masters that don't have their best interest in mind. He doesn't like checking boxes or doing unnecessary documentation. He doesn't like following the rules of someone who doesn't literally understand why they wrote those rules – the faceless beaureaucrats – for lack of a better term.  Regulatory requirements and fighting for thingsfor your patients from people that are not invested or informed or experts are very challenging.

"It's very challenging to do the things that are necessary to do the job that have absolutely nothing to do with the delivery of health care."

Edward says that if you're a medical student coming in, dive in! This is not going anywhere, and it's just going to get more and more interesting and more exciting. Their patient population is not going anywhere.

In the field of devices, we're getting away from the traditional way of delivering energy to the heart which is through leads that pass through the vasculature and down into the heart.

We now have very early stages of fully, self-contained pacemakers that go inside the heart entirely, the size of a big pill. This is still in its infancy but the leadless technology of where we're going with devices is getting bigger. It won't completely replace the traditional leads, but that's where we're heading and it's very cool. Plus, Edwards says they're fun to put in!

On the ablation side, you'd have to figure out where the arrhythmias are arising in the heart and then how to isolate or eliminate the tissue causing that to arise. Most of those techniques are catheter-based and either freeze or burn. You do a lot of sophisticated mapping to try to figure out where to go. Another amazing thing now is a group partnerring with radiation oncology to external beam-radiate the heart and eliminate arrhythmias that way. Still under thorough investigation, but most of them are excited about how this is going to happen. It could revolutionize how abalation is done.

Edward is pro and informing patients and giving them access to data. But it is a challenge to do that correctly. The problem you can run into with Apple Watch is that you're casting an enormously wide net on a very low risk population. No matter how good the technology is going to be, you're going to see a lot of false positives, which are going to lead down rabbit holes and additional testing – not to mention the fear on the part of the patients and their families and the resources that are going to get used up in the process.

Even in the true positives, you're going to see a lot of detected asymptomatic atrial fibrillation. Frankly, we have very limited information about what to do about that. We know a little something about asymptomatic atrial fibrillation because we see it in devices. There are people walking around with pacers in their heart who may not have a diagnosis of atrial fibrillation. But the device will pick it up. And there's still enormous controversy about what to do with that population.

"We've got to justle as a discipline to figure out how to manage these folks."

If he had to do it again, Edward would still choose the same. There's nothing in medicine that he could imagine he would do more than electrophysiology. It's got all the techy stuff, troubleshooting, engineering, relationships, surgeries -  all these that fascinate him along with the crazy good outcomes, seeing people rise up. It's gratifying how you can turn people around

Ultimately, Edwards advice to those considering this field is that if you've got the bug like somebody shows you a crazy EKG or someone comes out with a dev.ice and looks cool,t hen don't be intimdiated. Seek out the right people. You're not going to figure this out on your own. He suspects it's going to be tough to get into fellowship unless you have some contacts. So find somebody like him who would be thrilled that you found this interesting as most people are scared away or just not interested. The stuff is going to look complicated and boring. But just hang in there. After a while and with the proper teaching, it's all going to open up and it's going to be just incredibly fascinating! And then you'll be part of the club.

"If you get the proper teaching, it's all going to open up and it's going to just become incredibly fascinating! And then you'll be part of the club."

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Board Rounds Podcast

Dr. Renee Rodriguez is a community-based Pediatric Cardiologist. She shares why she loves children’s hearts, a typical day, and whether she has balance in her life. Meanwhile, be sure to check out MedEd Media Network for more helpful resources.

The first time she realized she wanted to do pediatric cardiology was the second she started residency being her first rotation as a pediatric resident. For her, residency was the best thing that ever happened since she wasn't in school anymore. She did another rotation but it wasn't as fun as cardiology.

From a physiology standpoint, Renee finds congenital heart disease super interesting. It's like a puzzle where you have to figure out where the blood flows based off of what the anatomy is. So she fell in love with congenital heart disease, to begin with. She also fell in love with the patients. For most kids with heart disease, they're neurologically intact. So Renee got to bond with each of the patients

Renee would describe pediatric cardiologists as having a unique personality of being able to not only communicate with kids, but also surgical in nature, are cut to the chase, and have high expectations. And she felt she resonated with it as she wants things to be more hardcore.

Renee describes a good pediatric cardiologist as being constantly questioning what is happening and trying to evaluate things in multiple different ways. Try to understand how to use those different modalities to answer a good question. You could order all of those tests on every patient but that would not be good care. So you have to be thinking about what you're trying to answer and how you can best answer it in a non-invasive way to get the results you need. And if you need to have invasive testing, what is it going to gain, the timing of it. So you need to be able to decipher how you're going to work a problem up. You have to be able to be collaborative.

In pediatric cardiology, you're working with surgeons, EP doctors, transplant, heart failure, pulmonary hypertension -- there's a lot of little subspecs when your patient is getting a little bit more complicated. As a pediatric cardiologist, you're needing to be the conductor in all of this between all of the different specialties when it gets pretty complicated. So be collaborative and be able to deduce how you need to work a patient up and what each test is going to give you.

"Be a calming collective presence for families. Patients who come to see a pediatric cardiologist are petrified, even if it's just an innocent murmur or the kid has chest pain."

Moreover, you have to be calm to the patients and their families as parents are walking in the door, worried and freaked out that their kids are going to die. Most of the time, the kids are totally fine. It's not going to be anything major. But if it is, it's going to be something they're going to live with. You're going to have to be able to dance that wine and speak with parents as you're trying to give them that information and guide them through it while not totally having them walk out of your office in shambles.

As an outpatient community pediatric cardiologist, she sees a lot of murmurs that are typically benign, like a small hole or small valve defects, nothing major, that typically doesn't require any procedures or intervention. One of the common ones that present later in life is a large atrial septal defect.

You don't necessarily pick up murmurs unless there's a significant blood flow across the hole on top of the heart that it causes some rumbling across the pulmonary valve. A lot of those kids present a little later when you hear that murmur and it can be mistaken a lot for a typical murmur so physicians don't necessarily send them until later. This would be one of the things that would require some intervention like surgery or cath procedure based off of the defect size.

She also sees chest pain which is rarely ever cardiac. In kids, it's typically musculoskeletal or lung-related. If it has something to do with exercise, Renee gets those referrals. She also does preventative cardiology, a large portion of her practice is cases with high cholesterol, obesity, pre-diabetes, family history of early coronary artery disease or hypercholesterolemia. She also does a fetal echo. That's a whole different realm of primary indications that a pregnant woman would need.

The large majority of her patients come to her undiagnosed and then she sees them. She built up the fetal echo practice because of the way pediatric cardiology is today where we rarely pick things up post-natally.

"Because of our imaging abilities now and good prenatal care, we tend to pick up most significant congenital heart defects in utero."

If you're a pediatric cardiologist scanning a patient, they're doing a fetal echo and identify a defect or a patient needs to deliver, you become that patient's pediatric cardiologist once they're born.

Meanwhile, general pediatricians will pick up as an outpatient such as murmur, chest pain, family history, etc. They may do an EKG before they see you but usually, it's the pediatric cardiologist that does the diagnosing, if anything needs to be diagnosed.

Renee comes in two and a half days a week. She comes in the morning. She basically categorizes her patients. Her heart-healthy lifestyle patients are her more preventative cardiology patients like high cholesterol or obesity patients. It's more about lifestyle counseling, nutritional, exercise, etc.

For cardiology patients, she will have them get an EKG before they come in. She will review it and walk in the door and decide if they need any further testing. She starts at about 8 am with an hour-long patient slot for new patients. Return patients will have half an hour usually. She sees patients from 8 to 5 on Thursdays and Fridays, doing echoes, and doing EKGs in the clinic room, answering in-basket messages from patients or answering phone calls. Then she's done by about 5:30 pm after she has closed her charts.

"I do a lot of pre-charting. I pre-chart on all my patients beforehand so that by the time I get to see them, obviously I will have reviewed the chart in its entirety and then I can just add in what I need to add in quickly.

In terms of taking calls, she doesn't take any in-house calls. She's actually surrounded by two major universities with very robust surgical and inpatient hospitalization with certain pediatric cardiology patients. So if they need advanced care, they can go to the two children's hospital near her. She also has some privileges at a couple of local hospitals where she can just get called anytime. And she has the option to take it or not depending on her availability. For her group, she's on call probably once every 6-8 weeks.

She can just get called by any of the pediatricians in the urgent care or in their clinics, usually reading EKGs or answering questions for them. If there's anything very dramatic where a kid needs to be evaluated immediately, she can have them go to the hospital she's privileged at and she can evaluate them there. Or if she knows the children need some advanced care then she could just send them to the children's hospital.

In terms of work-life balance, Renee considers having great balance. She built her outpatient practice to make sure it's a 100% possibility, reason that she took the decision to be part-time. That being said, she's able to balance her outside creative interest, her family, and her own self-care very well.

Renee felt she received excellent training in evidence-based, high-quality, very well-thought out pediatric care. Sometimes, when you keep that only in an academic setting, you don't get to disseminate that kind of care outside. It's important to bring that kind of care to a community-based setting to be able to provide that same type of care people who wouldn't be able to travel always to Stanford or UCSF, where they're located. She thinks this kind of care should be disseminated everywhere. These are the things that led her to be in the community.

"Sometimes, when you keep that only in an academic setting, you don't get to disseminate that kind of care outside."

After undergrad and four years of medical school, you do a pediatric cardiology residency followed by a pediatric cardiology fellowship. There are selective programs now where you can match in a path from medical school, you become a resident for 2-3 years and then automatically go to your cardiology fellowship, you're guaranteed a spot. But typically, it's a three-year residency in peds and 3-year fellowship in cardiology, and then a couple of years after that if you want to subspecialize.

There is a hugely growing field in pediatric cardiology called adult congenital heart disease. There are people who do adult medicine first and then spend time rotating through pediatric cardiology to get a better sense of congenital heart disease. They clearly understand the adult onset issues, but they need to understand the pathophysiology and surgical management of the pediatric realm. This is what ends up happening from the adult side and then they treat adult patients more than peds patients. Renee thinks that people who do Med/Peds could do that.

As to competitiveness, Renee describes pediatric cardiology as one of the more competitive specialties of peds. That being said, most people she knew ended up matching into some programs.

To be competitive, a resident has to be hardworking in everything they do regardless of what kind of rotation you do. So work hard and make great connections. Be a good learner and be open to opportunities. People talk to each other so never burn bridges. So working hard is always the right answer.

"Go the extra mile when you're on the pediatric cardiology rotation, but you really should do that across the board because you have no idea who knows who and who could say what about what."

After cardiology fellowship, other areas for you to subspecialize include electrophysiology or interventional cardiology, pulmonary hypertension. There's also CVICU, which you can do from PICU or you go and do additional training in cardiology. Or if you're a cardiology fellow, you can go from cardiology and do additional year in pediatric ICU. Or you can just do an ICU year.

There are also some preventative programs coming up where you can do an additional year of preventative cardiology. And adult congenital disease as mentioned above, which you can do from the peds side. There's also advanced imaging.

Renee never saw any DO students getting any different treatment or thought process. She believes that if you work really hard, there's no such thing as luck. Be there, be present. Work hard. Take opportunities where you can. Show off as your best self every time and you can get typically what an MD student would get.

"If you work really hard, opportunities present themselves from the hard work that you do."

"Pediatricians should feel comfortable developing a relationship with a pediatric cardiologist."

Congenital heart disease, for instance, is a hard thing to understand unless you do a deep fellowship in it. That being said, feel comfortable calling somebody, even just asking what the pediatric cardiologist thinks. At the end of the day, it's about having a team-based care.

A lot of what pediatricians see in the clinic would be really taking family history. So anytime you're seeing a kid complaining about chest pain, really take a detailed family history. And not just cardiac disease but general heart disease, like if anyone in the family has this certain disease or not. Renee advises primary care physicians that if at any time you worry about a heart problem, take a very detailed cardiac family history.

"Lots of things are genetic diseases that are passed down."

Other specialties they tend to work the closest with include those from the subspecialized cardiology field, interventionalists, EP doctors, sometimes surgeons, neurologists.

In terms of special opportunities outside of clinical medicine, you can get involved teams doing heart screening. There would be a lot more opportunities in the future as with technology and monitoring.

Renee really thinks pediatric cardiology is a very interesting field. What she thinks is cool is that you still get to see the people who you only read about on textbooks.

"It is a super interesting fast-paced, highly evolving field with a lot of really amazingly smart, fun people."

What she likes the most about this field is the way she's connecting with the patients and their parents. They are terrified the moment they walk into the clinic. But she's able to tell them that they're going to be totally fine. Of if there is something wrong, Renee is the person who can lead through this whole thing. Being able to take their hand through it all is something humbling. Conversely, what she likes the least is feeling like no matter how much you do, you can never tell with 100% certainty that everything is okay.

In terms of the major changes she sees coming into the future of this field, she mentions the power of the smartwatch where you can pick up certain things.

Ultimately, if she had to do it all over again, she would definitely do it. Her message for medical students and residents is that don't discount anything along your path. Really check all over again even if you think you've found what you really want. Don't get tunnel-visioned and think like you have to do well it a certain rotation only. Instead, work hard because everybody talks and pediatric cardiology is a super small field and everyone knows everyone. So you've got to put on your best face always. Always be showing up with your best self!

Follow Dr. Rodriguez on Instagram @reneeparo.

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Dr. Brittany Henderson is a former academic Endocrinologist, just switching to private practice and today she discusses her specialty, what she loves, and more.

Our goal for this podcast is to show you what is out there for you once you get through medical school. Too much focus is on the academic setting as you're going through medical school and the majority of medicine is practiced outside of an academic setting. However, medical students don't get that exposed that typically. Our goal here, therefore, is to compare and contrast different settings. If you’re still on your journey towards medical school, please also check out all our others podcast on the MedEd Media Network.

Back to our episode today, Brittany is an endocrinologist who has been out of training now for five and a half years. She has mostly been in an academic setting but is now moving to a community setting, opening up her own private practice.

Brittany started getting interested in the field during residency when she did an elective rotation with an endocrinologist, although she decided between this and geriatrics. She liked the patient population in geriatrics a lot but didn't like the subject material as much such as incontinence and the like. She likes endocrinology due to her chemistry background.

During her second year of residency, she worked with an endocrinologist who was in the community and was on staff at the hospital. She got more exposure to endocrine and general endocrine and tried to see what it looked like on a daily basis. She points out the power of mentorship.

"Really narrow it down to subspecialties and really look for those mentors around you to try to see firsthand what it looks like in the real world."

One must be able to look at the big picture but also be able to look at the little intricacies of how hormone systems work. As with her, Brittany's chemistry background really helped. You have to have an inquisitive mind and be able to think through things.

When decided she wanted to be an endocrinologist, she started working on some papers and presentations at some of the national meetings. She sees this as a very important aspect to be able to get into a fellowship.

Once you've identified your mentor, ask for cool cases that you're willing to write up. This would serve as your academic exercise. You're also going to be able to get publication case reports and poster presentations at some of these national meetings. Then you're able to put this on your application for a fellowship. Ultimately, this sparked her interest in doing an academic career.

Brittany has always loved the academics but she had an awakening that although she liked it a lot, she didn't want to be in the laboratory for the rest of her career. She didn't want to be struggling for grant money, which is a very hard thing to do in their field.

She then decided that as she joined the faculty, she wanted to focus more on clinical endocrinology. She was an academic endocrinologist for ten years and ran the Fellows Thyroid Clinic and the Thyroid Cancer Tumor Board, which are two institutions. She was the medical director for the Thyroid and Endocrine Patient Clinic. She loved it having had the time to do clinical work, write papers, and do research.

"But when you're split between doing a lot of clinic and wanting to do research, it's really really difficult to do everything well and have enough hours in the day."

All this being said, she pondered on what she wants better – clinic or research. She chose the clinic and decided to go to her own practice she wants to build a thyroid center. Most of her practice in the academic world focused on thyroid disease along with some general endocrinology. But she wasn't able to do some of the other components of thyroid medicine that she wanted to do like running specific programs, write a book about thyroid disease, and do integrated medicine approaches to conventional ones. Geographic location was another reason she had to consider. All this became the impetus for her transition to private practice.

"Be confident enough to change your mind and go in a different direction."

Coming from strong academics to a clinical career is like jumping off a cliff as she would describe it. She's just trusting that all is going to work out. Taking risk sometimes is a good thing.

Brittany deals with mostly autoimmune thyroid diseases as well as a lot of thyroid ultrasound and procedures in her clinic. She also sees a lot of thyroid cancer where she does lymph node mapping. They're also doing minimally invasive procedures such as sclerotherapy or alcohol ablation therapy for patients with thyroid cysts who don't want to undergo surgery. Alcohol is injected into the thyroid tumor within the lymph node or into the thyroid cyst. This kills the blood supply to the thyroid cyst wall or to the tumor. The patient can then avoid surgery. In fact, they see about 70-80% reduction in the volume of both cysts and cancer lymph nodes.

They also integrate radiofrequency ablation they use for cases that deal with the liver or the spine. The FDA just recently approved a probe for thyroid nodules so surgery can again be avoided in patients with benign thyroid nodules but with symptoms or are less attractive.

For thyroid disease, most of the patients that come to her already know they have an issue so they come to her for further evaluation. Other patients also come in who have thyroid symptoms and want to be assessed without previous diagnosis although this is relatively rare.

"For the more rare endocrine disorders, you're probably starting at square one. For thyroid and diabetes, they usually have a diagnosis by the time they get to you."

Back in academia, Brittany would be in the clinic for about four half days a week and she spends the rest of the time following up on labs and calling patients back. In the new EHR system, they're having an in-basket where they're getting patient emails and emails from nurses. This could take up a lot of time unless you have somebody dedicated to helping you with this. Wednesdays would be an academic day so she'd be teaching fellows and residents. And she'd write proposals and letters. You can also have options as to where your clinics are a lot of times. For instance, she'd have a clinic at the diabetes and endocrine center on Tuesday mornings and she'd see general endocrinology patients. And Thursdays, she be at the cancer center downtown where she'd be seeing all thyroid cancer and endocrine neoplasia patients. Then Fridays would be spent on a collaborative clinic with the ENT surgeon, seeing a lot of the parathyroid and thyroid patients and doing ultrasound and mapping surgeries.

What she likes being in an academic center is to be able to do a multidisciplinary clinic which she did in both places she was at. You're able to have clinic right alongside your surgeon or neurosurgeons and look at scans together.

For thyroid cases, she does ultrasound all day everyday. It's like her stethoscope where she's able to actually look at the thyroid gland to help her diagnose the disease. For biopsies and other minimally invasive procedures, she does it on a weekly basis for about 5-10 a week. And for general endocrinology, it's very procedure-based and technology-based. All of your monitors are talking to your iPhone while you're looking at trends and a bunch of data.

"Where diabetes management is going, it's very technology-driven. Eventually, we're going to have a close-looped system where you really don't need to make as many decisions because of computer technologies."

Ultimately, for diabetes care, it's more technology-based and for thyroid care, it's more of procedure-based. There are multiple subspecialties of endocrinology that can appeal to different personality types.

Brittany says one of the perks of being an endocrinologist is the minimal number of calls. There are very few endocrine emergencies and even if there are, usually the endocrinologist is just a consultant. So the primary team is able to stabilize the patient and you're able to go in the next day to see the patient.

In fellowship, Brittany recalls going once for a patient and had to make plasma freezes. A lot of diabetes ketoacidosis (DKA) treatment nowadays are now protocol-driven and the hospitalist or the admitting physician can start management for that patient. The endocrinologist comes in after their DKA and then gives recommendations on a home regimen the next day. All this being said, thinking through things and being inquisitive are great traits for an endocrinologist.

Brittany considers having a great work-life balance and there is enough time for rest and relaxation.

Endocrinology is typically a two-year fellowship. Brittany did a three-year fellowship since there are programs that do this. When she graduated and joined the faculty and was a fellow, she would ask some of other biopsies, offering if she could do extra biopsies and ultrasound. She also got an ACNU certification acknowledged by the AIUM (American Institute of Ultrasound Medicine) as endocrine training for neck ultrasound. As a fellow, you're supposed to have a certain amount of ultrasound and biopsies and be able to complete the entire panel of ultrasounds and biopsies in your first year as an attending. Then you have to submit a 350-page PowerPoint or documentation that you have done all of it before they approve you for a ten-year ACNu certification.

After getting certified, she was able to run thy hybrid clinic. She volunteered to run the Endocrine Tumor Board and the Thyroid Tumor Board to get more experience and to be able to lead a discussion on it.

Also during fellowship, she elected to go up and do a couple of weeks at a cancer center with a thyroid specialist for thyroid cancer so she could get more advanced training that wasn't available at her fellowship.

"That's possible to do some away rotations during your fellowship if your program director is amenable to that."

And when she moved over to her last academic position, she had enough experience to be the medical director for thyroid and endocrine neoplasia and she was able to run some of the multidisciplinary clinics. Hence, she actually made her own path. Additionally, there is a one-year fellowship in some programs but it's on endocrine neoplasia focused on chemotherapy, prescription, and administration.

As with the competitiveness in terms of matching, Brittany doesn't describe it as that competitive. They need more endocrinologists, some of the higher ranked endocrine programs are pretty competitive but there are slots of endocrinology and endocrine fellowships throughout the country. She describes it at 50% as far as the difficulty of getting in to match.

"If you're going into this, you're going to be going into this because you enjoy it, not because of the paycheck."

As far as reimbursement goes, sometimes even less than internal medicine and hospitalists. So you really have to love what you do.

You're able to basically carve out your niche such as diabetes, and obesity and weight loss medicine (a really big and hot topic). Brittany recommends that if you're going into any fellowship of any type, branch out to other departments and figure out your niche. heat sets you apart from some of these other fellows and other endocrinologists out there.

Brittany does all of her thyroid ultrasound and assessment. A lot of times, patients will have a scan done for another reason then they found a thyroid nodule. Then the family practice doctors would send them to radiology. or to ENT for assessment. Figure out if they actually need an intervention or if it's benign. Because 95% of the time, thyroid nodules are benign and they don't intervention and they don't need surgery.

Other specialties she works the closest with include general surgeons that do thyroidectomy, ENT, oncologists, nuclear medicine doctors, and pathologists, and nuclear medicine.

"It's good to know who you're going to be working with. It's also good to know who your patient population is going to be."

Most of Brittany's thyroid patients are women with an average age of about 41 years old. They are otherwise healthy and used to not being sick. For patients with diabetes, she would have a dichotomy of patients – young, type 1 and 2, overweight patients, etc.

You can go down the route of pharmaceutical development or molecular testing. These could be pretty rare positions though. And usually, you'd have to build up your reputation as an academic endocrinologist.

What she likes the most about being a thyroid specialist is her patient population, treating women and be able to put them into the right regimen. She finds it as very rewarding. On the flip side, what she likes the least is the number of labs, one on top of another. So you'd have to be looking at these labs frequently.

The major changes to be seen in the future for endocrinology is more minimally invasive techniques that are going to be widely used across the United States.

If she had to do it all over again, Brittany would still be doing it as she loves her specialty. That said, she believes that early exposure really helped solidify her interest in this career path that she had chosen.

Ultimately, if this is something you're interested in, she recommends finding an endocrinologist that specializes in thyroid disease, as not all of them do, and so work with them and try to get your feet wet early on to try and see if this is something that you really want.

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Fellows Thyroid Clinic

Thyroid Cancer Tumor Board

Dr. Nicholas Volpe is the Chairman of Ophthalmology at the Feinberg School of Medicine. He joins us today to discuss his journey and his 25 years in the field! Today, we talk about the things necessary to match into this specialty and how to become successful in it.

Be sure to check out all our other podcasts on MedEd Media Network.

During his second and third year rotations in medical school, Nicholas discovered his fascination with vision science. He liked procedures while recognizing that just being a surgeon that intervenes and disappears wasn't quite as satisfying as the kind of relationship that Ophthalmologists can have with their patients. So it was a unique blend of primary care of dealing with chronic patients with everyday needs and then superimposed on that is the chance to intervene surgically.

Nicholas describes this as a somewhat eccentric subspecialty within Ophthalmology as there are not that many Neuro-Ophthalmologists. It's one of the less popular subspecialties. In terms of choosing Ophthalmology, you have to have a certain interest, dexterity, and desire to do microsurgical procedures. In most Ophthalmology cases, it's 20% of their life. Unlike many other surgical specialties where you're operating three days a week and seeing patients one day a week, in Ophthalmology, there's still a fair amount of outpatient work in addition to the surgery.

Moreover, you have to have a true interest in vision and helping people see. It's a lot more fun to be fascinated in the eye and how it works and understand the kinds of things that we can now do for people's vision.

"You have to have this love for the primary care aspect of medicine."

There are also pieces of the field beside vision science, which is public health issues, care delivery issues. The burden of blindness in the world is very different than the burden of blindness in developing countries. So there are great opportunities to provide insight and actual care to underserved people.

What Nicholas didn't initially recognize was that it was the most complicated aspect of Ophthalmology and interaction between the vision system and the brain. Currently, he's interested in the diseases of the optic nerve.

"There are neurons that make up the optic nerve and there are lots of interesting and not well understood or well-treated conditions that affect the optic nerve."

The second group of patients that he sees the most are those with acquired eye movement problems and misalignment resulting in double vision. Currently, his surgical expertise is limited to realigning or straightening eyes in patients with acquired misalignment of the eyes as adults so they're seeing double.

A third of her patients he considers as challenging as they'd have to put up historical clues, exam findings, and diagnostic imaging. On the other end of the spectrum, there are patients that are packaged coming from other health conditions such as from a resected tumor that caused double vision. And then in the middle, are those people who thought they knew what they had or their doctors thought they knew what they had but had it wrong. These could also be things that were overcalled and got better on their own.

"There's a good mix of diagnostic dilemmas within ophthalmology that make it a particularly challenging field."

What's good with such field is they can take a picture of almost all their diseases so they can see what's happening, although there are still lots of nuances to consider when observing which patient is actually having such disease or which ones may require a different treatment.

For Nicholas, the complexity of neuro-ophthalmology is often best served and best done in an academic medical center. That being said, his own preference has always been to practice in the enriched and more complicated environment which you can find in an academic medical center since they have learners, research, new knowledge they're trying to apply, and the most complicated patients.

That said, there's a wide variety of things that he does making things very interesting for him with all the challenges and new learnings he faces each day.

As the chairman of an academic department of ophthalmology, he's responsible for the students, residents, fellows, faculty and all they do as researchers and educators, how their service interacts with the medical center, the community, the university. There's fair amount of fiscal responsibility as he runs a department that breaks even and is able to pay its salaries and take care of its patients at the same time.

He also facilitates the work of lots of great doctors, scientists, residents, students interested in the field. Additionally, they're also responsible for many regulatory things they need to do as part of their stewardship of the academic unit in their department.

"It's an incredible privilege to be able to be in a role where you are able to have a vision to take all these wonderful people, put them in that vision, and create something that is far better than any of us could do alone."

First and foremost, you have to have a competitive board score. Be some kind of a researcher or be affiliated with the ophthalmology department of your school earlier on.  Just be able to demonstrate that you have the capacity to multitask and that you're really interested in this and you want to learn more about the field and you've immersed yourself in a project that's relevant.

"There is a necessity unfortunately to create some type of a sorting process at everything in life."

The ability to get honors in your clinical rotations helps to distinguish yourself from the rest as well. And the board scores are important too and there is a sorting process by way of board score cutoffs or thresholds since they're only able to interview people at a certain level. That being said, they have interviewed people with average board scores and don't stand out just based on their board scores, but for certain other reasons. So don't think that just having a low board score won't get you in. It may not get you to the most competitive programs but if you continue to demonstrate that you're great and interested with high emotional intelligence and are doing it for the right reasons, then you will get good letters and get noticed by the program that knows you until you make your way into Ophthalmology. Just recently, they had their matching at their program and 87% of first time U.S. senior allopathic applicants matched.

In their program, they don't really encourage students to do electives at their institution. Nicholas adds that he actually knows more than half of the people that end up matching the programs. Either they were students at their school or he had met them while they were doing senior electives. There is an advantage in that sense.

On the flip side, if someone comes in for an interview and had done electives at three other Chicago programs that are not his, then he explains it may be obvious they're the student's fourth choice, hence they're less interested. So it could be a double-edged sword in that sense.

Mostly, students undersell themselves that they don't have the confidence they should have based on what they've achieved.

"There's a lot of misinformation out there whether it's on the internet or some website or from a buddy or from a school. They take some information and process it in a way that is not correct."

Traditionally, Nicholas admits that students from osteopathic schools don't stand out as easily. That said, if they stand out for some reason, it's harder to judge them against the other applicants. There are some osteopathic ophthalmology residencies and have a separate path to be successful ophthalmologists. It's not impossible, but it's a hard position to start from. And this is based on his experience.

"There are people that have that level of maturity about their learning and patient care that's very obvious right from the start that this person is going to be a great physician."

Nicholas illustrates that in order for a resident to stand out, there should be a level of seriousness, attention to detail, teamwork, interest beyond just getting through, and learning to do extra stuff that nobody anticipates. It's much more about how they delivered care, how they take the responsibility, how they interact with patients and have that emotional intelligence.

Nicholas advises applicants that of all the things they worry about in life right now, they may not be worried about whether they can be nice to patients or they can learn what they need to learn. But the last piece of your life is wondering whether you'll be a good eye surgeon. 95% or more will get there regardless of what you came with. And the reason the other 5% don't end up being good at it has nothing to do with their dexterity, but with something in the operating room that makes them nervous. For ophthalmology, even if they train you to be a surgeon, there are lots of good nonsurgical practices you can be in ophthalmology that only use laser and do incisional surgery.

People will know whether they're good with their hands and you're going to be a good surgeon in general. But people who have tremors would be at a great disadvantage as a surgeon. Or if your eyes are not working together, there is most likely a pathway for you but it's just going to be harder than any normal individual.

"We'll teach you. We'll get you there. And we'll make you into a good surgeon."

"Ophthalmology is the home for some of the most incredibly revolutionized treatments that didn't exist for conditions that are the most common cause of blindness."

The field now has a treatment for macular degeneration that prevent people from losing their central vision. They have also incredible advances in the technology they use to diagnose retinal problems. Nevertheless, they're making 10,000 new 65 years old a day for the next 20-25 years or so and how they're going to take care of those patients. So this is a challenge they all think about.

Ophthalmology is the first to successfully treat people with genes. They have gene therapy now that corrects hereditary form of blindness and the eye is the perfect place for gene therapy for stem cells.

On the flip side, they have diabetics who are going blind from a completely treatable condition that was undiagnosed because they didn't go to an eye doctor and there are disparity issues. How they provide care for those patients is an equally important challenge that they have to embrace in their field.

Nicholas sees a huge need for ophthalmologists in the next 20-25 years so he sees the new breed of them to be very busy in terms of the number of patients they have to care for. At the same time, they have to be comfortable working closely with non-physicians in the care of patients. There are great opportunities for synergy with optometry in terms of optometrists being excellent at taking care of the eye. At the end of the day, it's about figuring out a way to care for the population. So the future is very bright for the field of ophthalmology.

"Anybody can be taught anything with the right teacher and the right circumstances."

The thing he likes most about the field is the unique ability to recognize life-altering conditions and be able to then alter those conditions that improve people in a way that could change the way they approach their world in the future.

Conversely, what he likes the least is the necessity to have to see large amounts of patients in a short period of time than the time they would have wanted to spend with each patient otherwise.

This is an incredible specialty that you can get into it. Prepare yourself early. If it's on your list of things you may be interested in, seek out the student group in your medical school. Seek out mentors. Nudge your way in to get to know people so they'll start to see what you're doing. Know that this is an incredible time to be an ophthalmologist because of the clinical need for eye care. While we're also at the time of most exciting precipice of game-changing treatments based on clinical and translational research that is really impacting people's lives.

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