Specialty Stories

Session 80

Dr. Mary McHugh is a urologist who's been out in practice for a year and a half. She talks about her journey to urology, especially as a female, in a very male-dominated specialty.

Also, be sure to check out all our other podcasts on MedEd Media Network to help you along this journey towards finally becoming a full-fledged physician!

[01:21] Interest in Urology

Mary was exposed early on to urology when she was a second-year student during a six-week general urinary block that covered OB/Gyn and Urology. She saw how urologists were fairly entertaining who showed videos of the robot. From that moment on, she got introduced to the concept of the specialty that she had never even considered or known much about. But this sparked her interest in learning more about surgical fields.

"I just never thought about urology - period... I had always thought women didn't become surgeons."

She always thought she'd do something that wasn't procedure-based or medicine-based. That said, she didn't really experience any gender bias when she took the course. In fact, there wasn't any single female lecture in the course. Every single person that came and talked to them was a man. So it was interesting she ended up down this path.

What she really liked boiled down to medical management, procedures, and surgery. She likes the organ system, the anatomy, and that some of the problems had to deal with the quality of life. What she likes about it is that 100% of the issues people deal with is quality of life. And being able to make that impact and make it fairly quick, it leads to a lot of satisfaction to both patients and physicians.

[04:20] What is Quality of Life?

One of the biggest quality of life issues is overactive bladder urinary frequency. This would not be considered to be a life-threatening illness. However, it's something that affects how they carry out their daily activities. And some people get so bothered by this. Fortunately, there are things they can do for that to be fixed but they never even realized until they stepped into a urologist's office.

Another example is stress urinary incontinence. This is leakage, or anytime there is an increase in intraabdominal pressure. So when a woman or man coughs, laughs, or sneezes, they may leak urine. Again, not a life-threatening condition, but can be ostracizing and can interfere with things they like to do like running, dancing, horse-back riding, hiking. They have things urologists can do to help improve that.

[05:45] Traits that Lead to Becoming a Good Urologist

You have to be a good listener and a good communicator, especially that patients that come to you have very sensitive issues that deal with sensitive areas of the body. And they want to feel like they've been heard and understood. As a woman, you get a lot of male patients that are very shy when they come in. But you have to make them feel at ease and like they can open up to you and talk to you, so you can get to the root of the problem.

"Anybody who is going to be counseling patients on procedures, you really have to be a good communicator."

That being said, you have to be able to set expectations and be very clear about what's happening, what the potential risks, complications, side effects, etc. So patients really know what they're getting into when they're signing up for surgery.

Mary had other interests prior to urology such as dermatology to GI and then to peds, until eventually, she found urology after she took the course and went on her clerkships. She chose a clerkship path where surgery was second to rotation so she was able to make that decision right away.

[08:18] Types of Patients

Among her patients are those with overactive bladder, stress urinary incontinence, voiding symptoms in men due to enlarged prostate, erectile dysfunction, and recurrent infection (a big one she sees). She also sees a lot of chronic bladder pain syndrome or interstitial cystitis, stones, and hematuria workups.

Mary is in private practice in northern New Jersey and she says 70% of her patients where an OB/GYN will identify a problem and send the patients to her. Then she goes from there and does everything on her own. The other 30% are looking for another opinion or have things done or they've seen another urologist. So about 70% are common and the other 30% come with some things done.

[11:11] Choosing Private Practice over Community Setting

Mary's husband came out of his training first and finished his fellowship. He wanted a specific job in a specific location so he moved while she was finishing her last year of residency. She has always envisioned herself going into private practice. She thinks it's hard to provide training and mentorship to residents when you haven't been out in practice or out in the world. She also likes the independence of private practice as she has always liked doing things herself and at her own pace.

"It was the job market and my own style and personality that really influenced me to go into private practice."

During Mondays, Mary is in the office seeing patients. Wednesdays are full days in the office seeing patients. Fridays are procedures they do in the office such as cystoscopy, vasectomy, urodynamics, and other procedures. She also does prostate biopsies and ultrasound and injection of Botox to the bladder. Tuesdays and Thursdays are a bit more variable. As a new attending in their area where they're saturated with physicians, it can be hard to get block time. So when she puts cases on her schedule, they get added to the hospitals she's on staff at. The way you get block time is either to acquire somebody else's block or to be employed by the hospital system.

A lot of the consultations she gets sent are a lot of non-operative patients. About 20-25% of all the patients she sees end up having a procedure whether it be in the office or having surgery. This can be a little disappointing for her considering she wants to do surgery.

"You do the cases that you can and you have the best outcomes that you can and that's how you build your reputation."

She explains that one of the biggest things you have to realize coming out of training is that it takes time to build and it takes time to establish yourself and establish your reputation. Don't believe everything you see on Instagram where everyone has 10,000 cases on their first day.

[17:55] Urology as a Male-Dominated Specialty

It's just the perception of a lot of patients that only males will treat that part of the body or look at that part of the body. It has to do with traditionally, who was in the specialty looking back 20-40 years where even every specialty was even male-dominated.

That said, women are still a rarity in the field but a lot more women are being trained now which is great for both male and female patients.

[19:20] Taking Calls and Emergency Cases

Mary is in a large urology group and in her care center, there's only two of them. Their call is going to be split by whoever is in your care center. So it's every other night for her. ER calls are determined by hospitals. One of the hospitals assigns ER calls a month at a time. She doesn't describe it as too bad. But based on politics, some hospitals keep a stronghold on the call and don't want outsiders taking it which she considers as a blessing in disguise.

Some of the emergencies they see are necrotizing fasciitis of the genitals, testicular torsion, abscesses, the common ones they get consults for their scrotal abscesses, and septic stones. And retention -  a common one they get consulted for all the time. Oftentimes, they call you and patients are super uncomfortable so you have to go take care of it.

[22:13] Work-Life Balance

Mary considers having enough family-work life balance. Her husband's hours are pretty long as well. So they have that time when they go home at night where there's a couple of hours and then the weekends. Whatever weekends he's not working.

It's a lot better than training she calls it. And there are things you can do to minimize your calls your make sure everybody's questions are answered and everyone is tucked in. If you're doing a procedure on a Friday, everything is taken cared of and you don't have any worries about that when you go on call over the weekend. It's a matter of letting people know that you're available but also explaining to them what kinds of things they should be calling you for. When they're not on call for the practice, it's not as bad.

[23:35] Residency Path to Urology

Urology is its own training program. Most of the programs are five years, some are six years. Although a lot of them have gone down to five years. The first year is a general surgical internship and then usually for four or five years of urology. A lot of the programs that are six years have built-in research year.

"If you're applying, know how long the program is going to be. But it's all one program you match into the whole thing."

The urology match precedes all the other matches, after the military. But urology matches in December. It's not through the NRMP, but through the American Urologic Association. They give you a number and you do it through its own unique match.

The reason for this could be that it's a self-regulation issue. When you're in a specialty, you don't want to have so many people. This is just Mary's guess though.

Urology matching is pretty competitive. Check out urologymatch.com and find a more specific breakdown. There are not a lot of applicants but it's a 60% match rate for those applicants and they break it down in general. You have to be really high performing as a student and have good Step scores. The process could be different now as well. Mary is a DO and a lot of the programs that were DO are now in the urology match accredited by the ACGME as a single graduate medical education system. And so it's gotten a lot harder than when she matched since it was a separate match. She applied into the urology match and applied to as many programs as possible. But they've done away with programs that are just AOA accredited. Mostly, all are ACGME-accredited at this point.

[26:38] Negative Bias Against DO and Other Subspecialties

Having been on both sides of the interview trail and as an interviewer, she thinks there are biases. The Specialty Stories breaks down per specialty, MD vs DO, and Mary thinks the data speaks for itself. It can be done as a DO but that's more of the exception than the rule.

There are a lot of subspecialties you can do after urology such as oncology (2-year and 1-year fellowships), female pelvic medicine and reconstruction (2-year and 1-year fellowships), pediatrics (2 years), reconstruction and trauma (1 year), andrology and male sexual health (1 year), and fertility. Those are the general subspecialties. Urology is its own subspecialty.

[29:30] Working with Primary Care and Other Specialties

Mary says there are a lot more technology and a lot more procedures to help patients. She commends those primary care doctors for starting people on medication and working up a lot of the urinary complaints. For instance, Botox is for patients with frequency and urgency, indicated if you've failed to two or more medications. Sometimes, patients think that there's no solution or they're stuck with the medications. And people are always so surprised when they learn about their options. So just getting them into the urologist sooner and not being afraid to send in a patient to see if there's anything else they have to offer.

"Sometimes, patients think there's no solution or they're stuck with the medications. And people are always so surprised when they learn about their options."

Other specialties they work the closest with are general surgeons, OB/GYNs, family practice and other mid-level providers like PAs, NPs, etc. Opportunities outside of clinical medicine for urologists include speaking engagements, expert witness, write books, consults, etc.

[32:15] What She Wished She Knew that She Knows Now

Mary believes that one of the hardest parts of being a surgeon is that you become extremely disappointed when something doesn't go according to plan or someone has a complication. Dealing with that the most is one of the hardest parts of her job as it's emotionally taxing. So you have to learn how to deal and cope with that.

When you go out, everyone is just so bright-eyed and bushy-tailed and ready to soar, but it takes time. It takes time to develop a rhythm. It takes time to develop finesse. So there should be patience and you should respect the process.

"What you've done 10,000 times as a chief resident that you can do with your eyes closed suddenly becomes the hardest thing when you're an attending."

What Mary likes the most about being a urologist is her patients which she considers to be very awesome and this adds to her job satisfaction 100%. She comes from an urban area in her training and so now it's different there. Now, she's out in the community and the suburbs. Patients listen to her and they take their medication. They make her job very enjoyable.

The thing she likes the least is that sometimes you feel helpless in your ability to help people because you're constrained by what insurances will cover. This is an issue because people are on a fixed income and they can't afford these things.

If she had to do it all over again, Mary would still probably do it. Again, on social media,  you see these people so happy after some procedures. But what it all comes down to is to think about what complaints or complications you're going to deal with.

[37:30] Final Words of Wisdom

Stay interested. Read as much as you can, when you can. Getting exposure early is key. If you're a medical student, it's doing all the things you should do to match into a competitive specialty. Learn the people who are on the faculty at your institution. Get involved with research. Meet the residents and get that chairman's letter if you have a department. Do as well as you can and you'll succeed!

Links:

MedEd Media Network

urologymatch.com

Session 79

Dr. Brittany Davidson is an academic OB/GYN Oncologist practicing at Duke Health. She joined us to share the specialty she chose and why it’s great.

Please help up find more guests for this podcast by sending an email to [email protected] and write the subject: Specialty Stories Intern.

[01:40] Interest in Oncology

Brittany has always been interested in women's health even back in college. She then followed the path to medical school, realizing she loved being in the operating room as well as the people and the OB/GYNs she worked with. She saw how they were happy at work - something she wanted to be like.

After her third year rotation as a medical student, she was pretty cemented to OB-Gyn and didn't realize she was going to do Oncology until 2nd-year residency. Going into OB-Gyn she was thinking it was all about delivering babies and bringing joy to the world. In fact, she remembers telling her medical school tour guide that she didn't want to do Oncology. However, after first rotation as a 2nd-resident and coming back from honeymoon and a day in the clinic, she just fell in love with patients and the operating room, taken by surprise.

"There's always something and that's the fun part is figuring out what that something is sometimes."

[05:18] Traits of a Good Gynecologist

You have to be interested in being in an operating room but you also have to be great listener. By not talking and letting that patient have that time is very important. With the information you get from them, you can help potential treatment options.

"Listening is an under-recognized, underutilized field that I'm really starting to do more of myself and trying to instill that in the people that I help train."

It's hard to be quiet as silence is really awkward but that's where sometimes the best and most information comes through. As physicians, we don't learn enough about how to communicate as physicians but it's a ubiquitous skill across fields.

[07:30] Types of Patients and Treatment Process

As a GYN/Oncologist, they're referred to as oncologist below the belt. They take care of female reproductive cancers - ovarian, uterine, vulvar, vaginal, cervical cancer. They also take care of pre-cancer, the precursors to those cancers such as cervical dysplasia or vulvar dysplasia. They also get referrals for difficult or extensive benign GYN surgery like difficult endometriosis patients, although they still see some benign gynecology in their practice as well as female pelvic cancers.

Benign OB/Gyn or general OB/Gyn practitioners these days are jack of all trades as Brittany would describe it. They do a little bit of obstetrics and a bit of gynecologic surgery. But a lot of them don't operate enough these days to feel comfortable doing some of these very difficult GYN surgeries. And a lot of times, they don't have the volume to feel comfortable trying to do these surgeries.

In terms of patients coming to her already diagnosed versus those she still had to diagnose, she'd give it a ratio of 50-50. They get a lot of referrals for ovarian masses to help triage whether this is high suspicion of cancer or not. They also see cancers of the uterus. Unfortunately, with ovarian cancers, the vast majority of them are diagnosed with advanced disease. They have a lot of symptoms as well as anxieties or evidence of metastasis on imaging. In short, they see a little bit of everything.

[10:27] Typical Day and Percentage of Procedures

As an academic OB-Gyn oncologist, they have some research time. She starts clinic at 8 AM and sees about 30 patients, running the gamut of diagnosis. Mostly, she sees patients who are post-menopausal, though she does see some younger women too especially for uterine cancers.

"It's never a dull moment because each patient is different."

On a surgical day, OR starts at 7 AM. Never a dull moment as well -- she could have a whole day of cancer cases. Some days, she could have benign days. Again, it's always something different that she truly enjoys.

As to the percentage of patient ending up going to an operation room, Brittany says that one of the best things you can learn from their practice is when to decide to take someone to the operating room. Operating is not the right thing to do for everyone and sometimes, it can be really hard to make that decision especially there's a lot of grey area in the middle. Factors they consider are indications, other ways of diagnosis, and using the surgical risk calculator. And sometimes, not going to the operating room is the right answer.

"One of the best things that they can learn from their practice is when to decide to take someone to the operating room."

[13:25] Taking Calls and Work-Life Balance

Brittany is in a practice of 7 Gyn Oncologists so she's on call once in every 6-7 weekends. On her call week, she rounds on the weekends, then she goes home and doesn't take in-patient call. Being an academic OB/Gyn oncologist, she works with fellows so they take the patient phone calls, not typical of academic practice. That said, it's very uncommon to get surgical emergencies in the middle of the night.

At their institution, she takes 1-2 nights of benign gynecology call with the residents for cases like ectopic pregnancy and such.

In terms of work-life balance, it's about trying to find the right spot on the work-life continuum. Balance is really a misnomer. There are challenges definitely and there's no right answer for everyone. But she's cognizant of the fact that this is very important. Nevertheless, she loves her job and she feels very fortunate to be passionate about her career.

[16:00] Choosing Academics vs. Community

Even as a resident, Brittany has always loved teaching as she finds it very rewarding. Her favorite part of the day as a Fellow was teaching. Coming into the specialty without a strong research background, she found some amazing research mentors and have found a niche and research passion. And this was where it all developed for her. She loves hos academics keeps her on her toes both from a data standpoint but also from the clinical practice perspective.

"It's just fun to have trainees and it's one of the bright spots and one of the many great spots of my day."

[17:22] The Residency Training Path and Competitiveness

The OB/Gyn residency is four years and Gyn Oncology Fellowship is three years long. There are a few programs that incorporate an extra year of research totaling four years. You basically start your application as a 3rd-year resident then you match into your fellowship the October of your chief or last year. Sometimes, a cohort of residents doesn't realize they want to do oncology until much later on in their residency.

Residency is fairly competitive with around 80 people a year that apply for a Gyn-Onc fellowship with maybe 40 spots. In order to be competitive, it helps to have some research background to show some research effort. Basically, you have to show passion and dedication to these amazing women you get to take care of.

Gynecology fellowship is hard and the hours are long so having a degree of resiliency is important as well as flexibility. It's a different ball game compared to a surgical oncologist. So you have to be able to do that medical aspect as well.

For further sub spec opportunities, you could get into clinical trials or some rare tumors and sort it out with your colleagues or institution based on the need and what your desires are. In terms of bias seen towards DOs, Brittany hasn't really seen this. If there were some bias, she thinks this has changed considering there are really amazing osteopathic candidates out there.

[21:55] Working with Primary Care and Other Specialties

Brittany wished primary care physicians knew that they exist. A lot of larger urban centers with academic institutions, gyn/onc may be well-known as a field. But in the more rural areas, this is not the case. So if you have a concern, then have them get a referral to see GYN/Oncologists. If you're doing pelvic exams and pap smears and the like where you run into problems, they're always happy to help out and they're available.

"Patients with ovarian cancer and uterine cancer when they're cared for by GYN/Oncologists."

Other specialties they work the closest with include palliative care (by far and away). In fact, she'd joke around that she'd do a palliative care fellowship if she had to do it again, as they help them a lot throughout the entire cancer continuum. After that, they'd work with medical oncologists. They'd see a lot of patients for repressed cancers who would need their ovaries removed as part of their breast cancer treatment. There could be some overlap in terms of rare tumors so they work closely with them as well.

Unfortunately, palliative care is very under-utilized and under-appreciated while they work they do is amazing. Brittany admits it can be very hard to sell to get her patients to see the palliative care team. So it takes some convincing.

[24:55] Special Opportunities Outside of Clinical Medicine

You could join the pharmaceutical industry which they work closely with as they're trying to develop drugs to cure and treat these cancers. People have also left the field to go work in the industry. There are also some who have done palliative care training and now see patients as palliative care physicians. There are also some who have stopped operating and do strictly the medical side of it like the chemo. And vice versa, who only operate now and don't do the chemo anymore.

"There is some latitude in terms of what your practice looks like."

[26:00] What She Likes the Most About Being a Gyn/Oncologist

Brittany loves being able to take care of these awesome women who are dealing with some hard stuff. She feels like she's able to learn so much from them. And she feels it's a great privilege. She's learning new skills constantly and there's never a dull moment. She's constantly adapting and thinking outside of the box. It keeps her on her toes.

On the flip side, what she likes the least is charting, which is apparently a problem for most physicians.

[28:18] Future Changes Coming

Brittany says the treatment landscape is always changing which is a blessing as they have new therapeutic options for their patients and it keeps them on their toes. They've been fortunate in the last few years to get a few approvals for various GYN-related cancers. Surgical changes are a bit slower but they had a big study coming out this year that is going to change the practice potentially.

If she had to do it all over again, Brittany would still choose the same specialty. The one change she would have made though is doing a palliative care fellowship right after doing a GYN/Oncology fellowship. It was hard but she loves her job!

[30:10] Final Words of Wisdom

Don't let any negative feedback deter you. There's always something to be said but when you're loving your job, and you love what you do, it doesn't feel like work. Find something you're really excited about then do it and don't let the naysayers get to you.

"You've got to do what you love at the end of the day."

Links:

[email protected]

Session 78

Dr. Alex Voldman is an osteopathic (DO) physician who specializes in Ophthalmology as a cornea and cataract surgeon. Check out our latest episode to learn more. Also, check out all our other podcasts on MedEd Media Network. Please help us find a guest here on the podcast. Send me an email at [email protected].

[01:35] Interest in Ophthalmology

Alex didn't go to medical school thinking about such Ophthalmology Upon his path to being an orthopedic surgeon, presenting at a conference, he met an Ophthalmologist who encouraged him to spend a day at his clinic. Seeing their practice, he thought they're some of the happiest doctors he has ever seen in the years he spent as a student.

He thought it was an organized environment where doctors and patients were happy. And he thought they were happy. Wanting to be happy as well, he decided to jump to the bandwagon. He also found them to be working at reasonable hours. They also got surgery and played with cool toys and lasers. When he found it was competitive, this drew him even more as it was something that challenged him.

Thinking he was going to be a businessman, the father of Alex's friend called him and discouraged him from doing so. He was told that if he became an orthopedic surgeon, he was going to retire at 50 as a millionaire. It sounded great to him and thought the dad was great and living the life. So he literally switched his major and started taking science classes. He admits not really liking the business classes he was taking.

Nearing medical school, he realized that advice the worst he had ever gotten. He was glad though because it brought him to medicine but to tell somebody to go to medicine to become rich is absolutely wrong. Sure, you could do well and be rich if that's the goal but that's not the way to do it.

"To tell somebody to go to medicine to become rich is absolutely wrong."

When he got into medical school, he started exploring the orthopedic surgery lifestyle but the personalities he met didn't seem to flow with his, as he describes it. He found people to be a bit more aggressive than what he would have envisioned a classic doctor. Personality-wise, he saw he was more aligned with the Ophthalmologists who are dorkier and laid back.

[06:51] Traits that Lead to Being a Good Cornea Specialist

Alex explains you have to be very meticulous although you don't have to start being one. Instead, you'd be forced to be meticulous. All of their surgeries and procedures are visible in the patient's eye everyday. So whatever result they have, they're walking around with it. They're looking through it. And if you're off by a small fraction, then a patient sees that for the rest of their lives.

"Every calculation, whatever technology we're using... all have to be meticulously placed."

[08:00] Types of Patients

Although a cornea specialist, Alex also sees a lot of general ophthalmology. In reality, if you practice cornea in private practice, you're also more likely doing a lot of general ophthalmology because there's not that much cornea pathology to keep somebody all day long.

For instance, in a day, he may see young patients for routine eye exams. The majority of his patients are also elderly. Common cases would be cataract, glaucoma, macular degeneration. And from a cornea standpoint, there are corneal diseases related to surgery such as patients with previous eye surgeries, multiple surgeries. If you have a sick eye and has had lots of surgery, it causes damage to the cornea which often needs corneal transplant.

"If you have a sick eye and has had lots of surgery, it causes damage to the cornea which often needs corneal transplant."

Sometimes, people have infections that cause scarring and corneal disease. So he may see contact lens wearers with corneal ulcers that sometimes have scarring so they need corneal transplants. Rarely, they will see certain corneal diseases like dystrophies people are born with. And often, they'd see those with corneal ectasia, also called keratoconus, characterized by thinning or balling out of the cornea if people are born with corneal disease. Their corneas become thin and pointed so they become weak and would nee corneal care either in the form of specialty contact lenses or corneal surgery.

[11:20] Typical Day

Alex's day usually starts at 8 am as his first scheduled patient and then see between 10 and 20 patients. He's in private practice, working about half an hour from his house. He has great support at the practice. He has a scribe and technicians that work patients out for him. He'd describe it as a pretty fast-paced practice.

"To be able to get through 20 patients and make everybody happy around you, you have to be efficient."

He'd usually finish around noon and the next patient is scheduled at 1pm. So he gets to have his lunch break (although he doesn't eat but doing other things). Then he ends at 430-5 pm. This is a typical clinic day

For OR day, his first case starts at 7 and doing about 10 surgeries in a half day. He'd be done at noon, take a break, and then do clinic in the afternoon from 1-5 pm.

[13:02] Taking Calls and Work-Life Balance

In his practice, they have 7 physicians, they split their calls equally among 7 people. So he'd be called once a week and you're covering call for your practice only. It's usually light, too. Middle-of-the-night emergencies are rare and if they're happening, sometimes the person can be seen the next morning. He'd also cover call for the local university hospital occasionally where he gets to see trauma call with residents, which can be easy. They have the option to do it as much or little as they want so Alex is doing it one week a year only.

"Generally, ophthalmology private practice call is not really intrusive in your life."

When taking a call, it's very rare that he gets called in during the week since he can just see the patient the next morning. So he almost never has to go in during the week. On the weekend, he'd have a patient to bring every few weeks. So it's not very common.

Alex illustrates his lifestyle as being very predictable and he thinks this is one of the biggest draws of the specialty.

[15:22] The Training Pathway

You have to do ophthalmology residency and prior to that, do your internship. As of now, they're separated. So you do one year of internship of some kind. Most people do traditional medicine or transitional. Very rarely would you see surgery or peds. Then you do three years of ophthalmology residency. Then for Alex, he did one-year Fellowship on Cornea.

"Nothing is going to change the practice pattern so the lifestyle factor will always draw people and will make it competitive inherently because of that."

He still thinks the specialty is highly competitive until now. He points out that the nature of the lifestyle is always going to draw people to it. To be competitive in matching, like any other field, you need to really know you want it and be able to show that you want it. The only way to do that is be involved - whether in research, clinical experience, shadowing, volunteering. These are all just ways to figure out whether you like it or not. Then build connections throughout the entire process and those connections are what can help you. You'd be able to get better letters of recommendation from people you spend a lot of time with.

"You need to really know you want it and be able to show that you want it. The only way to do that is be involved."

Undoubtedly, the first thing residency programs are going to screen you on is going to be your school and Step 1 that's going to get your foot on the door. Otherwise, it could be an uphill battle - not impossible, you could definitely do it.

Next, is how well you interview. Ophthalmologists work tightly together and in a clinic environment side by side with your attending physicians, and a lot of times, with their private patients. So they want somebody they'd feel comfortable around patients. Lastly, Alex says that research always helps.

For cornea fellowship, it's not as competitive. Good programs at anything are always going to be competitive. The same reason you could say that family medicine isn't competitive. But pick the best program in family medicine and it's going to be very competitive. Ultimately, in terms of competitiveness in ophthalmologic fellowships, it's probably middle of the road.

[19:35] Other Sub-specialties

There are new ones every couple of years. But for now, there are subspecialties like a 2-year fellowship in Retina or a 1-year or 2-year fellowship in Oculoplastics, a 1-year or 2-year fellowship in Oculoplastics, 1-year fellowship in Glaucoma and 1 year in Cornea. You could also do 1 year in Uveitis, 1 year in Pediatrics. You can also do Pathology or a special fellowship for Refractive Surgery.

[20:35] Negative Bias in the Field and

Alex explains that even as a DO the bias doesn't come up among his patients. The bias rather comes up when you're trying to apply for residency programs. The program directors of MD programs are not going to look at you first. You have to do something special to stand out among the MD applicants.

"The bias undoubtedly is going to come when you're applying for residency programs because the field is so competitive."

[21:27] Working With Primary Care and Other Specialties

His advice to primary care physicians to refer early and don't just treat red eyes. The differential diagnosis of a red-eye when he sees one

"Refer early and don't just treat red eyes."

The exams he does and all the things he looks for are extensive. A lot of times, primary care docs see patients and they say it's probably a pink eye. Then they'd give somebody an antibiotic. Then send him his way.

So he urges primary care physicians to refer early. Less is more. And don't just treat. Because a lot of times, this could make Alex's job a bit more difficult when they get to him and he's not sure where to really start.

Other specialties he works the closest with include Anesthesia, Primary Care (as they manage a lot of diabetics), Neurology (taking care of patients with vision loss, cranial nerve palsies, etc.) He may also work with a Rheumatologist (autoimmune inflammatory eye diseases that need systemic management.

[23:12] Special Opportunities Outside of Clinical Medicine

One may get involved in the industry of surgical devices, doing trials, and testing new devices. You can also always be a business owner.

[24:08] What He Wished He Knew that He Knows Now

In one aspect, he has enjoyed building long-term relationships with patients. But as a practice, he is pretty tied to his geographic location because he's getting his self and name out there in building a patient base. So he can't just leave and decide in another part of the country, which is something other specialties can do such as Anesthesiologist or Emergency Medicine doc.

"The private practice of Ophthalmology is much more community-centered."

The best part of his specialty he describes is the one-day post-op where the patients come in and there's a smile in their face because they can see much better. On the flip side, one of the things he likes the least is the fact that he not infrequently does he have to talk to patients about money. For instance, he may prescribe eye drops that can't be covered by their insurance or offering different services not covered by insurance.

[26:30]  Working with Optometrists

There's a lot of uproar being seen right now with optometrists requesting and pushing for more and more ability to do procedures and things. In his experience working alongside optometrists throughout medical school up to his private practice, he thinks the majority have not been interested in getting involved in surgical intervention. He doesn't blame them because a lot of them actually went into optometry because they didn't want to be surgeons. They want their predictable lifestyle and hours and don't particularly want to go out of the scope of what they're comfortable with.

"There's a push for some optometrists to have a piece of the surgical pie and I've seen mistakes made and I've seen things that were missed."

Alex says he had seen mistakes made by optometrists. However, it has nothing to do with them being an optometrist, but it just had something to do with them not having years of surgical training and not actually knowing what you could be looking for, let alone, missing it. This makes him a bit nervous. It's scary for patients to walk in the door because half the time, they might not know who they're talking to and who's actually doing surgery on them. So for patient's safety, Alex believes it can be dangerous for optometrists to get involved surgically.

[29:23] Major Changes in the Field of Cornea Surgery

Particularly in the field of corneal transplantation, they used to take donor tissues and sew them into place. They hope that in the future, they will be able to take individual cells and replace just the damaged cells instead of the tissues. This is in the effort to have lower rejection rates, faster recovery, and better outcomes for the patients.

Other things in the cornea sphere, specifically from the refractive side (getting better vision), technology is like lens and plans they put in during cataract as well as better techniques to do cataract surgery. Currently, they're doing laser cataract surgery. Lastly, Artificial Intelligence (AI) is already in Ophthalmology to help them make better clinical decisions.

Finally, if he had to do it all over again, Alex says he would still do it. His advice to students who might be interested in this specialty, spend some time with enough ophthalmologists.

"Anybody that wants any specialty always gets in eventually. I've never met anybody that really wanted something that just never got it. Whether it took more time or a different approach or using different tools, somehow they got there. So do not give up!"

Links:

MedEd Media Network

[email protected]

Session 77

Dr. Janani Krishnaswami talks about Academic Preventive Medicine including what drew her to it, and what she likes and doesn't like about prev med. Janani is a preventive medicine physician in University of Texas, Rio Grande Valley.

To learn more about preventive medicine, check out all the available resources at the American College of Preventive Medicine. Also, be sure to take a listen to all our other podcasts on MedEd Media Network.

[01:22] Her Interest in Preventive Medicine

Janani says a lot of preventive medicine physicians basically end up stumbling into the specialty. Relatively a nontrad student, she had a background in investment banking and her background was in economics, public health, public policy, and international studies. And she has always been interested in the systems level aspect of medicine.

When she started doing her third year clerkship, she saw the same patterns of patients coming into the clinic with conditions that didn't seem to be cured as well as who got the illness and who suffered the most. So she got interested in attacking that angle.

Then she found out about preventive medicine as she was scouring through different programs during third year. She saw a program in internal medicine - preventive medicine track, which she thought was perfect for her. She loves interacting with patients but there was that systems element that she craved. Then she hunted around to find out more about the specialty and she was just amazed about it.

"I just hunted around to find out more about this specialty and I was just so amazed. I felt I had found a diamond in the ruff as it were."

[03:14] Why is Preventive Medicine So Hidden?

Janani thinks that even on a national level, we talk about prevention and we all know the benefits of it. But at an actual practice level, we just don't have those opportunities. And she thinks it all comes down to the financial incentives. The way residency programs are funded and the residents are paid is tied to a certain type of funding. In short, hospitals are paid to have residents in hospitals and not in community settings, not really doing prevention. And Janani believes this is a huge part of the problem. Their incentives are misaligned with their verbiage about prevention. And if there were more aligned incentives, Janani thinks you would see preventive medicine as one of the most foundational medicines in medical school itself.

"Hospitals are paid to have residents in hospitals and not really in community settings, not really doing prevention, and I think that's a huge part of the problem."

[05:40] Traits that Lead to Being a Good Preventive Medicine Physician

Janani says you have to be comfortable switching the big picture of population health and the individual patient, which has a bit of tension between the two. You also have to be very enterprising and proactive. Janani explains that the path is not always clear-cut especially if you want to do some combination of clinical medicine, public health, and you want to tie those worlds together.

Additionally, Janani thinks you have to be an early adopter as there's not a lot of preventive medicine physicians out there. She really believes that this is something that is a foundational discipline in the future. But we're not there yet. So it takes somebody who have that vision, perseverance, and passion for the field and its components.

"Systems change is very difficult and it takes somebody with perseverance and willingness to see opportunities."

[07:38] Being Initially Pulled Toward Primary Care

As she was going through medical school training, Janani admits also being pulled by other specialties such as family medicine, internal medicine, and all those bread and butter primary care specialties. The reason is that she just loves to connect with people. And that there's evidence now that the way a doctor communicates is integral to the health and improvement of a patient. And she was fascinated by this aspect. Ultimately, she wanted to do preventive medicine knowing that she couldn't change systems one patient at a time. So she needed to look at the big picture, apply her skills in systems based thinking in upstream medicine to really make a difference.

She was just so troubled by the idea that somebody should be living years less on average of their lives or poor quality of lives as a function of their race or income status. This was what pushed her to keep going with the preventive world.

[09:30] Types of Patients

Janani explains that different preventive medicine physicians are doing slightly different things. But with her experience, she works with a primarily indigent, underserved, highly diverse community by design. She adds that the communities that are often helped by preventive efforts actually tend to be at relatively lower risk for disease. While people at a higher risk for disease often miss the benefits of these types of preventive efforts. So even if these efforts are well-designed, you can still potentially widen the gap between the health disparities between rich and poor, or the different socio-economic classes.

As a result, she intended to come to an area with a tremendous medical need such as border communities like Texas-Mexico. So the patients she sees primarily fall into this class. The theory of who tends to bear the burden of chronic disease that is on average underserved minorities, that bears out in this region. They have epidemic rates of diabetes and obesity which are very preventable conditions - not just in terms of incidence and prevalence, but also the severity of these conditions.

Much of her work is trying to create systems to better address the social determinants of health and promote the health behaviors that are conducive to prevention and optimizing the quality of life.

[11:40] Typical Day

In her role as program director of the Preventive Medicine Residency Program, a lot of her time is dedicated to refining the curriculum, making sure they're meeting their goals of promoting health equity and health literacy. They're focusing on building the program's network, designing optimal educational initiatives for her residents, leading didactic sessions, and a lot of education. She would also see patients in the clinic, working with lifestyle medicine and addressing chronic disease determinants. So her days would be a mix of administrative work, patient care, general strategic thinking, team meetings, and a lot of education.

As an academic physician, Janani works closely with medical students. She is also the director of student wellness so she inculcates the principles of preventive medicine and spread awareness of the field at the school of medicine as well.

[13:30] Three Major Directions for a General Preventive Medicine Physician

Janani describes their residency as being an uplift version of the traditional hospital-based residency.

Typically, most hospital-based residencies, despite being primary care, residents tend to spend about 80-90% of their time in the hospital, maybe 10-20% of their time in a clinic or a community setting. Janani explains that their residency is split on that. They are 80% in the community and 20% in the hospital, like a tertiary care setting.

"What preventive medicine physicians do is intimately connect to the community."

Generally, a traditional general preventive medicine job and career pathway would involve working in public health and county and state health departments. Part of the job may be doing surveillance of the entire populations and communities at a local district, county, or state level. Janani stresses the importance of understanding how is the health of the community improving and changing at a population health level.

In an academic setting, the major role for preventive medicine is as program directors or faculty in preventive medicine residency programs. The other hat for general preventive medicine is working in hospital systems as health administrators or in quality improvement, data analysis, data management, statistical analysis, journals, and research. This being said, a lot of preventive medicine physicians she knows are operating sizable research initiatives and grants.

[16:20] Beyond Epidemiology

Janani explains that a major asset an MD will add to your training is the ability to actually understand the clinical system and have that perspective and option of caring for patients. For instance, a regional director for Texas and a preventive medicine board-certified MD/MPH will routinely get cases of people with complex tuberculosis. And as a physician, she can write their management plan. She can prescribe the medications and mandate directly observed therapy. At the same time, as an epidemiologist, she's able to understand how the case fits into the general patterns of TB prevalent outbreaks in the community.

It's a great asset in that you can also care for patients. You can understand the symptomology, the complications, as well as understand the big picture population health dynamics of those conditions.

[17:42] Taking Calls

Janani says that the one situation that is a possibility for preventive medicine is this pathway of working in the Centers for Disease Control (CDC) as an Epidemic Intelligence Officer for public health. So if there's an outbreak of an illness and you need to figure out where it starts from, your work as an officer is finding and discovering like interviewing. Then this is the situation where you might be on call because if something is happening, then you're deployed to that site. But this is a specific career path.

Moreover, public health officers, especially if you're working in a county, state, or federal government level, national disaster is another big thing for preventive medicine. They would have a lot of training in emergency preparedness. So if you're skilled in that area of national disaster, then you'd more likely be called down to that site.

"National disaster is another big thing for preventive medicine."

Janani says that a class well-loved by their residents is Disease Detection where they simulate outbreaks and figure out where they started, which is a very systematic and interesting process.

[20:50] The Training Path to Preventive Medicine

You can go into preventive medicine as a pure primary care physician. It requires one year of an ACGME accredited by the residency. It could be a transitional year or a prelim year. Then you would then matriculate into a preventive medicine residency program. Janani explains this path has its pros and cons. The pro being that it's a two-year residency so the entire year of training is completed in three years. For somebody who doesn't really want to have clinical practice as their backbone then this could be a good option.

But if you see yourself in primarily clinical practice, another way to go into preventive medicine is a second residency or a fellowship or a combined program which was what Janani did. So you can finish any residency and then do a preventive medicine fellowship or residency on top of that.

For the combined programs, either of family medicine, pediatrics, or internal medicine can be combined with preventive medicine.

Choosing the right one among these three paths depends on what you want to do with your training after you graduate. Janani says that if you see yourself doing more than 20% clinic a week and you enjoy interacting with patients and likes that one-on-one patient care, she recommends doing additional training beyond just a transitional year.

"The ability to handle complex cases can be strengthened by additional clinical training."

Janani mentions another viable path. A preventive medicine field called Lifestyle Medicine is focused entirely on clinical care. This is a scenario where you could do a one-year transitional and two-year preventive medicine and then practice lifestyle medicine.

Moreover, if you see yourself working in health policy or at a local, state, federal, or county office and you see yourself doing the big picture activities, outbreak investigation, and working at CDC, then your traditional one year transitional and two years preventive medicine makes more sense.

If you have any chance to practice a lot of clinical medicine that is not lifestyle medicine, Janani recommends doing preventive medicine as a fellowship.

[24:40] Competitiveness in Residency Training

Janani says this depends on the location. There are very competitive programs that are hard to get into. You really have to have a background in public health or be able to demonstrate some type of vision and mission for your work in preventive medicine. Other programs are not as competitive. So it depends on the geographic locale and the prestige of the institution. All this being said, preventive medicine is a small field. So program directors tend to know who the top candidates are as a group. She also noticed that the competitiveness of the field is increasing each year.

To be competitive, students must have some type of commitment. Experience doesn't have to be extensive, but you should be able to demonstrate a commitment to public health. In their program, they have a very strong emphasis on underserved medicine and health equity. So they're looking for somebody who has done work in underserved populations and is knowledgeable about the topics of community engagement, participatory research. They should be able to show aptitude in biostatistic epidemiology either through coursework or work in medical school.

"Research is a big cornerstone of what we do in preventive medicine... but the interview for us is key because that's where you can really tell if somebody understands the field."

Additionally, Janani reveals that the interview is key for them because this is where you can tell if somebody understands the field.

[27:20] Opportunities to Subspecialize

Aside from general preventive medicine, other subspecialty opportunities include occupational medicine, environmental medicine, aerospace medicine, addiction medicine, and lifestyle medicine. Many times general preventive medicine can be a stepping stone to these.

But what's interesting about preventive medicine is that a lot of times, they will take the equivalent experience to be able to certify in some of these added specialties. You don't necessarily have to do general preventive medicine first for many of these types of disciplines. Lifestyle medicine, and to some extent, addiction medicine, lends itself well to the general preventive medicine track.

If one is interested in environmental medicine, which includes toxicology, exposures, pesticides and workers, plastics in the environment, several colleagues completed a general preventive medicine residency and then gone on to do an environmental health fellowship.

That being said, the path is not that linear so if there's a specific interest, there are likely different pathways to get to that outcome.

[29:15] Working with Other Primary Care Physicians

There's an argument whether preventive medicine is primary care or not.

What bothers her tremendously as the director of student wellness is the rising rates of physician burnout, physician substance abuse, physician suicide, and the opioid epidemic. She thinks primary care physicians are burned out because they feel like they can't really help their patients to the extent they want to.

"I think, increasingly, primary care physicians are burned out because they feel like they can't really help their patients to the extent that they want to."

And the system of medicine is part of the problem and this can really precipitate the cycle of burnout. So Janani wishes that primary care physicians knew about their work. For lifestyle medicine practice, the goal is to help patients adhere to and comply with some of these evidence-based prescriptions for better health like diet, exercise, and emotional wellness. In that end, they're actually helping their primary colleagues get to the goal they want of healthier patients. But the problem is they tend to work separately. Public health systems are often quite separate from clinical systems and that makes it hard on both the public health and the primary care physician. So if they only had knowledge and information exchange between both entities, then there could be a healthier physician workforce.

"Public health systems are often quite separate from clinical systems and that makes it hard on both the public health and the primary care physician."

If people knew that this field of preventive medicine and lifestyle medicine existed and had opportunities for collaboration, you would see dramatic changes in the rate of chronic disease in the country, the epidemics of opioid addiction and physician burnout, and overall would just be a lot healthier.

Lifestyle is responsible for 80% of the disease. It's a staggering figure that even outweighs genetics. And we all know this stuff works but we just need to set up the communication channels and realize that each other exists. We must learn how to collaborate for better health for all.

[32:00] Working with Other Specialties

Janani they have partnerships in their school with the Department of Pediatrics, as well as those of internal medicine, obstetrics and gynecology, and family medicine. They work with issues including childhood obesity, child abuse, healthy pregnancy and postpartum care, and connecting women to contraception and promoting women's health and women's rights. They work with ensuring a healthy and safe pregnancy. So there's a variety of programs and specialties they're working with.

[33:15] Special Opportunities Outside Clinical Medicine

Janani says many of the public health workforces are part of the US Public Health Service Corps. These are physicians who work on promoting the health of the military, Air Force, etc. In terms of completely nonclinical, you could work at a state, local, or county public health departments. Your title is usually Regional Director or Local Public Health Officer or State Public Health Officer, or County Official. Janani describes these as very eye-opening roles for a new graduate. You get to learn so much from those roles.

Although many times too, a lot of the job openings can be in more small, rural communities scattered across the nation. This way, you can really have the ability to shape the health of your community. This is rewarding because your decisions, your understanding, the research that you do, and the initiatives you recommend can transform health.

"You really can have the ability to shape the health of your community."

[35:40] What She Knows Now That She Wished She Knew

Janani shares that she wished someone would have told her that change comes slowly and it doesn't mean your initiative is wrong or is not working. But patients would be the most important thing as a preventive medicine physician. It took two decades for smoking, which was once regarded as healthy and doctors recommended it, for that needle to shift. Now, we understand smoking as a harmful habit that creates lots of diseases. So the needle may move slowly but the evidence will come out in the end.

...

Session 76

This week, we're joined by Allison who has previously shared her story of burnout. We discuss burnout as well as the birth of MedDiaries - our newest project to help with this.

This episode is actually taken from The Premed Years Podcast since we're announcing this new project that will greatly impact premed students, medical students, residents, and physicians!

[03:35] The Prevalence of Burnout in the Physician Community

Allison talks about there are bad days as much as there are good days, which is highly prevalent in the physician community. In fact, 42% of physicians in the 2018 Medscape Report are burned out.

Based on personal experience, Allison is passionate when it comes to this topic. She also works in the field of Neurology which ranks second on the list of fields that are most likely to experience burnout, second to Critical Care.

More and more people are now researching burnout due to its prevalence in the community of physicians, residents, and medical students.

Allison describes how burnout has affected her emotional wellbeing, feelings of self-worth, and even the ability to care for herself.

"If you can't take care of yourself, you can't take care of other people well. All too often as physicians, we are sacrificing our own wellbeing so that we can take care of other people."

[05:05]  Burnout as a Sign of Weakness

In the onset of burnout, you begin to feel detached, dissociated, resigned, and separated in some way from the job you were trained to do. And even though it's a high percentage of physicians having burnout, it's not something you experience with other people. You experience it by yourself.

"Burnout isn't something you experience with other people. You experience it by yourself."

In medicine, what has been taught to us is that if you're strong enough to do it then great; but if you can't handle it, then you shouldn't do it. So if you're struggling with emotional difficulty or feeling exhausted, or if you're experiencing the human side of how difficult it is to be a physician and you talk about it or complain about it, or let it affect your work, then that's seen as a weakness and that it's not acceptable in medicine.

This is a subconscious thing, but at the same time, it's something directly taught in a lot of places. You would then have to bury that way deep down inside of you, not in the hospital or in the clinic, but someplace else. If you can't handle it, then there's got to be something wrong with you. This is all a bunch of hullabaloo, but this is what we're taught, unfortunately.

But it's not we, the people practicing medicine, who are at fault here as we are all human beings. The problem is we're surrounded by unbelievable pressures and so many different obligations, and other things that take away from the ability for us to practice medicine. For instance, these are things like clicking boxes and EMRs, filling out authorizations - things not about practicing medicine but fulfilling guidelines and nothing to do with directly looking after a patient.

"The numbers and pressures on physicians, the number of things that people are being asked to do these days just gets bigger and bigger. The list gets longer and longer."

[07:50] Premeds Experience Burnout Too!

Premeds experience the same things as well, trying to live up to the standard they think they need to live up to - being a 4.0 student, 520 on the MCAT, and getting all the extracurricular activities in - shadowing and clinical experience. You try to get into the best medical schools and best residencies and be the best doctor.

"Burnout is prevalent at every stage of the game. Unfortunately, suicide rates are high among med students and physicians."

We can't fix the systemic issues and reason we're discussing it now so as you're going through this process, you get into a position of power where you can make some of these differences. It may be not on a national scale, but on a local scale, specifically for your hospital.

That being said, we can change the discussion around burnout. This impetus behind our new project.

[09:00] Are You One of Us?

Are you a physician and feeling down or burned out? Have you had a terrible day and just need to vent and get something off your chest?

Are you a resident working 80+ hours a week in a hospital and watching your patients suffer without any dedicated space or time to talk about it?

Are you a medical student feeling the toll of studying all night after working in a hospital all day and wondering if life will look any better when you're an MD or a DO?

Are you a premed student with a dream of becoming a physician but you're feeling discouraged by a bad grade or rejection letter, and wondering if you'll ever get there?

Wouldn't it be wonderful if there were an anonymous safe place where you could speak your mind and have your voice heard?

In this time of extraordinary demands on physicians with 42% of physicians feeling burned out in the latest 2018 Medscape Report, we need a place to be heard.

All over the United States, medical centers and medical schools are trying to find ways to help physicians with burnout. Wellness groups and conferences and employee assistance programs have formed. Some residency programs have created programs to help their residents process their grief and other emotions that arise in medical training. There are islands of awareness popping up to try heal and support our exhausted physician workforce and help prevent them from self-destructing and from leaving medicine altogether.

[10:22] We All Need Support: Join the Movement!

But we cannot do this alone in silos. we need support in a way that we feel connected to all those around us, those who are feeling the way we do but never discuss it openly for fear of looking weak.

As attending physicians we are often told to meditate, exercise, and do whatever we can to "fix" our burnout. But we argue that we are not the problem. The systems around us create untenable demand that inevitably leads to burnout. EMRs and endless boxes to check, notes to write, prior authorizations, loss of autonomy, fear of litigation, and lots of reimbursement for doing the incredibly hard work this profession demands everyday.

As residents and medical students, we are told to bury our feelings deep down and just get the work done. Yet, we lose a part of ourselves when we don't acknowledge the depths, the fear, the enormous responsibility of telling a family member that their loved one is gone no matter how hard we try to save them.

While we don't know the fix for this, one thing's for sure: talking about it helps.

Welcome to MedDiaries...

When you're having a down moment, call 1-833-MYDIARY and leave an anonymous voicemail.

Speak your mind. Drop your guard. Say whatever needs to be said. You will be heard by others feeling the weight of burnout too.

This is a place to be heard. Join the movement!

[11:53] MedDiaries as Your Trusted Resource

All over the country, people recognize there's a problem with burnout. Physicians and people all through every stage of training need a place to talk, and people to talk with about how hard this whole process is. The journey never stops right until you die.

"There are pockets all over the place and there isn't a place where people can go to just have their voices be heard."

MedDiaries is creating a space where people at every stage of this journey - premed, medical student, resident, physician, or attending physician - can go anonymously and talk about what's going on.

We're not going to "fix" it but talking about it is a starting point. And this is what's really missing across the board.

Under the MedDiaries umbrella, we're going to have four podcasts:

• The Premed Diaries
• Med Student Diaries
• Resident Diaries
• Physician Diaries

And Allison is hosting the shows!

So, whether you're happy because you saved somebody for the first time. Or you're struggling because your boss yelled at you. Call 1-833-MYDIARY. You will be allotted 30 minutes to leave a voicemail.

While it's anonymous, you're also welcome to say something about yourself. But we want to keep you protected as well as who you're talking about protected.

Tell us what you're feeling. There's no right or wrong. Treat us as a diary.

There is healing in speaking what's in your mind and getting it out of your mind and out into the world.

"You will be amazed at how much what you say can benefit other people."

We're targeting releasing two episodes per week where we get your voicemail. We listen to it, play it, and Allison gives her comments. Then we're going to ask the audience to call in and leave feedback.

Again, we're not trying to fix anything. But we're all in this together. When we start sharing our struggles and successes, you'd be surprised at the impact this can make!

Links:

The Premed Years Podcast

Medscape National Physician Burnout & Depression Report 2018

Call 1-833-MYDIARY

Stay informed of the MedDiaries launch. Get notified!

Session 75

Dr. Kelsey Hopkins works in rural private practice in Southern Illinois. Learn more about rural family medicine, what he likes about it and what he doesn't like, the unique environment, how to connect with other physicians, and so much more!

If you have any suggestions for new guests to have on the podcast, just shoot me an email at [email protected].

[02:00] An Interest in Family Medicine

He actually realized he wanted to be a family medicine physician before he got accepted to medical school. Growing up in a small town in Illinois, he is the fourth of eight kids. Everybody was born at home after the first two. So there was no one in his family that was in medicine. Naive to the healthcare field in general, he didn't know there were different specialties so he just thought that as long as you went to the doctor, they give everything. Then he found out there was a rural medicine program, the RMED program at the University of Illinois - College of Medicine in Rockford. He explored this and it's where he ultimately went.

And so, family medicine turned out as what matched what he thought just a general doctor was. He didn't know you could subspecialize. This was typical in a rural setting. Kelsey describes that they would travel 20-30 minutes or more to go to the doctor. And this is true in a lot of ways.

In rural areas typically, there's not as many doctors around and certainly fewer specialties. So typically as primary care, they do more than they would in an urban area because they have less colleagues to assist them with things. So the training is oftentimes different and the role is different.

“In rural areas, typically, there's not as many doctors around and certainly fewer specialties.”

[04:05] The Decision to Go Back to a Rural Area After Training

Having been born and raised in a rural environment, Kelsey thought he was comfortable with this kind of lifestyle. He felt it was where he was most comfortable and where he would want to raise a family. So when he found the RMED program, got in, and got into the residency in Indiana, doing the rural training track, he thought all this aligned to his life goals. As he got more training to do it, all the more that he wanted to get back to a small town and stay in that environment to live. On top of this, he realized the healthcare needs so he felt it would be a very rewarding career. He considers this not only as a career choice, but also as a lifestyle. For him, he was truly accomplishing what his initial dream was. And living that out is very rewarding for him.

"I don't think I would be as rewarded or fulfilled working in a city environment."

Painting the picture of a rural setting, Kelsey has one partner who is an internist and pediatrician, the only practicing pediatrician, until recently a hospital had another part-time one in the local area. Then there are three other family doctors. One has just retired. Then there are several nurse practitioners.

They have a local hospital down a mile from his office, along with a couple of surrounding hospitals that are 20-30 minutes away in most directions. In terms of patient population, there are 7,000 people roughly in town. They call from a patient volume from around the area. He had even one patient that morning that traveled 100 miles who traveled from Missouri to come see him. They have a local niche so that patients within 20-30 minutes are able to see a doctor in the area.

[07:25] Traits that Lead to Being a Good Rural Family Medicine Doc

Kelsey says that especially if you're from rural, you seem to fit in better. You get it. You understand the lifestyle better. It's not just about practicing medicine, it's about the community. The patients' attitudes towards you may be different and their healthcare needs may be different. So understanding rural life is really important.

"It's not just about practicing medicine, it's about the community."

The University of Illinois College of Medicine in Rockford actually coined the term "rurality." This means being how rural somebody actually is. It's a way of life people understand when you're from that environment in terms of relating and communicating to your patients.

Moreover, Kelsey thinks you also need to be flexible. You have to be able to like a variety of different things. Be able to shift gears quickly and this is a key trait in that you never really know what's going to walk in your door. Their walk-in clinic is open from 8-9 where their patients only can walk in in the first hour and it's all hands on deck. Then they see however many they have come in. So be as flexible as seeing up to 16 people.

"Being able to shift gears quickly is really a key trait because you never really know what's going to walk in your door."

Being a being good communicator is critical as well. You have to enjoy teaching and talking to your patients about things that may not even relate medicine. This is key to having a good bedside manner. Just be there with the patient. Don't just see them in their disease state but see them as a whole.

[10:05] Other Specialties of Interest

Kelsey knew that going into medical school, family medicine was what made the most sense for a rural town because as one provider, you can impact thousands of patients. More than 80-85% of what they're going to come to him for, he can synthesize the info, work it up, and he can handle it most of the time so patients won't have to travel outside of town.

During his fourth year as he was doing his rotations, co-rotations, and subspecialty selections, it became crucial for him to realize that everything is related to family medicine. There's nothing that's off limits. He also takes his education track into account for having been able to at least know something about most things.

"Everything is relevant in family medicine. That's what I love about it but it also can be difficult to keep up with things. And if I don't know the answer, I know how to find the answer."

Kelsey loved OB, Urology, Cardiology - so there was nothing he thought that he wouldn't do at all. There's also a huge need for Psychiatry in rural medicine and even nationwide. This is also a big part of primary care. He does like Psychiatry. He actually did some training in that during residency and he found it has helped him everyday.

"Learning everything I could on all specialties just all continued to support the idea that family medicine is basic comprehensive specialty that encompasses everything."

[13:40] Types of Patients

Kelsey explains that rural family medicine deals with more complex disease states. You see more of the social determinants of health at play because there's a transportation issue, underinsured patients, and no insurance of patients. So you have to deal with the other things too while taking care of the person in a more social fashion than you do just the medicine.

Oftentimes, rural patients would present "later to care." It doesn't always mean that everyone who's rural is a farmer. But there's a lot of that industry in most rural towns. That said, there are several businesses there, college, and all sorts of industry around.

He'd also encounter patients like farming equipment injuries as well as those unrelated to trauma. Kelsey has observed that people tend to wait things out longer than maybe they would if they could see a specialist if they were just a few minutes walk.

"Patients tend to present later with more complicated diseases."

Additionally, Kelsey would see other cases like Neuropathy, COPD, obesity-related diseases, diabetes, hypertension, infections and allergies, etc. As well, they deal with the more complicated states. And he would still have to sometimes manage such conditions since the patients don't to leave town to go for a follow-up. Pretty much, he sees all specialties on a daily basis as well as a significant number of mental health.

Moreover. he points out the importance of being thorough in that you're not always going to get the classic symptoms written on the textbooks.

"You're going to see things that you may never see again in your career."

[17:12] Typical Day and Work-Life Balance

Kelsey's day usually starts at 7-7:15, having early clinic one day a week. The rest of the week, he starts at 8. He gets around 25-35 patients each day. They have a walk-in clinic and sees a lot of chronic disease patients with complicated check ups. And then he'd try to work up double or triple-booked people that need to be on the same day. He also works on acute cases within the same day. At the end of the day, he goes to the nursing home when necessary. Then he goes to his family with three children by 6:30pm. He puts the kids to bed then finishes his paperwork from 9-12.

"Everyday is different. I don't know what the next patient is going to be."

He basically long days in terms of paperwork. Patient care usually stops around 5:30, sometimes later if he needs to go to the nursing home. Sometimes, he might also do end of the day procedures like vasectomy. Wednesday is  typically a procedure day for him. He also does skin cancer removals and nail surgeries, and other surgical things.

In terms of schedule, nothing really goes according to plan but then again, flexibility comes in here. Overall, he likes the excitement this brings, having busy days.

Kelsey considers having enough work-life balance, especially that he's got the support of his wife. He was employed in a hospital for five years then he ended up doing private practice, which they did everything from scratch. He loves Tuesdays because he sets it for family time. He also has Saturdays and Sundays off. He makes sure he's super thorough at work otherwise he gets burned out if he doesn't take time away. So makes sure his family doesn't get to the back burner so he could still have a lot of time with his kids.

The good thing about private practice is that he could take time off. There's more flexibility in your own decision making. You might feel like there's not enough time with your family, but Kelsey assures it's definitely doable.

"Family medicine is about a relationship with patients and a well-rounded approach, but it's also about families. Family should come first, really."

[22:30] Path to Residency Training Along the Rural Track

The Family Medicine track is three years although you can opt to do more training in other subspecialties. One of them can be high risk, OB C-section track. ACGME has changed has change their core criteria in how many months of OB and the different things a program requires to have. But you can always do elective time to do more like an away rotation if you wanted to.

The rural training track is an addition to the regular training, which they did during their second year. They went to a rural clinic with no resources where they did office procedures and EKG machines.

This taught him a lot of things about decision-making when you're by yourself when there's no other help available. There's a lot of autonomy and realizing that the bottom line could stop with you.  There may not be anyone else to give you a second opinion at your beside.

"When you're in rural practice, you can practice at the top of your training ability."

After done with training, Kelsey though there's not enough time to train but the nice thing is when you've gotten extra training, you'd feel prepared for rural practice. And what's nice in the rural practice is you get to practice a lot of things on top of your training ability. You get to do a vasectomy, C-sections, etc. Things you can't normally do in an urban area. So when you've done enough of those and got trained to do that in your residency, that allows you to get credential when you're out in practice at a hospital or a clinic. You've done enough to say you're confident and you've been trained.

As opposed to urban areas where there are subspecialists, you get to do all of this in the rural area since there's no one else around. And you're the go-to person. So having that extra intensity of training really helped him when Kelsey was in practice so he could do everything he was trained to do and not just let things go by the wayside because the environment didn't fit.

[26:40] Forming Connections and the Network He Needs

Kelsey is happy that most specialists are happy to receive a phone call from him so he could call different hospitals in the area, if he needed to talk to specialists. They also have specialists that come half day a week. For instance, a cardiology comes to them a couple of days a week where they'd do a stress test, etc. They're very receptive to him and the notes are awesome. They don't have a full-time surgeon as they'd have to share the calls to other local hospitals. So a lot of cases get sent out having no full time in-house surgeon.

He also forms relationships by the quality of the institution and the group of partners and they have a good working relationship that way.

[28:30] Other Special Opportunities

One of the things he picked up long ago was a change in ownership of a local nursing home. Kelsey and his partner are the local nursing home directors. Outside of medicine, he was asked by a college to teach Anatomy. It's he something he does as a volunteer work.

This said, you could do nursing home directorships, health department board, or hospital board, things that may not be employed positions. Sometimes, family doctors can fill in as hospitalists. He did this initially which he did for a couple of weekends. Then you could moonlight in the ER or outside of town.

Others do wound care, doing more surgical stuff and just subspecialize in it. There's also sports medicine as service team doctors in small towns.

[30:22] What He Wished He Knew that He Knows Now

The one thing that comes to his mind is that it pays to be thorough and it pays to keep up on things. Just really take advantage of your training. One thing he wished he knew different was that when you're in training, you get told to get as much exposure as you can so that you're the most comfortable when you come out. He did some moonlighting in the ER. And this gave hime a ton of leg up for practice which involved quick decision making, seeing acuity, and solving a lot of primary care things.

"It pays to be thorough and it pays to keep up on things. Just really take advantage of your training."

Moreover, it really matters that you get the exposure to everything. Even when you're tired, if you have the opportunity to learn something, you should do it. When you're in private practice or even if you're employed, when you're out in practice, it's very draining financially on the company to have you get some new training that you could have received but you didn't. And telling yourself during residency that you're going to get that later, actually rarely happens.

[33:10] What He Likes the Most and Least as a Rural Family Medicine Doctor

Kelsey finds it very rewarding to see his patients and his employees from the perspective of him being in private practice. He describes this as being a family environment. There are stressful and long days but he still enjoys coming to work no matter what.

"I still enjoy coming to work no matter what. And that's cool because this is the rest of my life. I have no plans to retire."

He loves the fact he could make an impact on patients in a lot of ways. Every single day, you get to see different patients and different acuity and the different lengths of visits. So he likes how rewarding it is at the end of the day to sleep at night knowing that he did his best and some days, he saved a life. He realized that the things he was trained to do always matter. That being said, he feels very fulfilled and rewarded that he can offer a lot of services to patients. He feels very well-trained at his medical school and through residency. He loves teaching as well and students rotating with him. Two things he love doing.

On the flip side, what he likes the least is the paperwork. It's something you can't get away from so it's about reframing your mindset about it. It's important in a lot of ways and it's a necessary part. And this is also part of doing service to the patient that is a reference point for the next visit. This completes the patient's care as you're putting down on paper what you did for them and what you plan to do for them. Just look at it as an extension of the physical exam of things that it's just part of taking care of somebody. It's a necessary evil.

They're hiring some people that help them in some paperwork to help him out. They help out a couple of days a week and he sees this as great help.

[39:05] Major Changes Coming to Rural Family Medicine

He sees more hospitals merging with larger ones that gives access to more visiting specialists. The Electronic Medical Record is universal now. There may still be people using paper but this is going away. The communication in rural medicine may change but the quality of care remains the same.

"Their perception of rural medicine is that it's antiquated, doctors are not well-trained. They don't provide good care... that's generally not true."

Contrary to the misconception that rural doctors are antiquated, Kelsey begs to disagree, saying that in their office, they have the same technology that tests for influenza and strep that they could do in just 10-15 minutes.

Rural doctors are on the ball with the latest updates on things because you have to stay up on it. Keeping ideas is no different than it is in the urban areas. It's just that he doesn't have somebody to bounce ideas off when he's in the hospital or in the lounge getting a coffee. This is part of the residency that he misses. That said, it's not antiquated there.

If he had to do it all over again, he'd still do it 100%. As a doctor, you're considered a local expert on health and different things. You serve in the community. But it's not always about what he would want but what the community wants. So he wouldn't have wanted this any other way. And even beyond financial constraints, he still decided to push through with the private practice, seeing the needs of the community

"It's not always about what I would want. It's about the community. In my book, that's how I view it."

[43:00] Final Words of Wisdom

If this is something you're interested in, Kelsey recommends looking at a program both for undergraduate and residency that may provide you with that kind of training instead of just traditional training. It's worth exploring.

"It's not about the money. It's about what you want to do." 

If you have a rotation in medical school that is not what you think it's going to be but you're really interested in it, then try to explore your options. And if you want to do it, there are ways to do it. There are different options to repay your debt and be able to work in a rural area. You can have a family regardless of what specialty, just be able to know how to carve it out. Lastly, try to connect with preceptors as they can really help you.

Links:

[email protected]

Session 74

Dr. Ross Hauser is residency trained in physiatry and has gone on to train in prolotherapy. He talks about what it is and why it's the future!

Ross is very passionate about prolotherapy. If you want to learn more about this, visit his website on Caring Medical.

Also, check out all the rest of our episodes on MedEd Media Network, including The Premed Years Podcast, The MCAT Podcast, The OldPreMeds Podcast, Ask Dr. Gray: Premed Q&A, and some more coming in the future!

[02:05] Interest in Prolotherapy

In the last two months of his residency, Ross had an elective rotation which he did with prolotherapist Dr. Hamwell back in 1992. Then he joined the physician in 1993, so he has been a prolotherapist for over 25 years.

Ross describes himself as always liking old people. Thinking he was going to be a geriatrician initially, it was during his chronic pain rotation in his physiatry residency that he discovered his love of the mystery of pain. He was told by the physician he rotated with that most structural chronic pain is from joint instability or ligament laxity. And the curative treatment in a lot of people was prolotherapy. So he wanted to go for the cure instead of pain management.

[04:15] What is Prolotherapy?

The term prolotherapy was originally coined by Dr. Hackett, in short for proliferative therapy. The treatment is designed to cause the proliferation of cells, which make the extracellular matrix made up of ligaments, tendons, cartilages, or whatever you're trying to regenerate.

In the Webster's International New Dictionary, prolotherapy is defined as the rehabilitation of an incompetent structure such as a ligament or tendon by the induced proliferation of cells.

So if a person has a tendon or ligament tear, you want to proliferate the fibroblasts, the actual cells in the body that make the ligaments or tendons. You want to proliferate those cells so they can then regenerate the ligaments or tendons.

Ross goes on to explain that the body's response to an unstable joint is to try itself to limit motion. One of the ways it does is it causes synovitis resulting in a very low level type of inflammation in the joint. Since medical doctors have been trained to very quickly try to get rid of symptoms, that's why treatments have gone more toward a treatment that dissolves the pain quickly.

"Medical doctors have been trained to very quickly try to get rid of symptoms, that's why treatments have gone more toward a treatment that dissolves the pain quickly."

However, 97% of tendon tear, for instance, occur in a degenerated tendon. Under a microscope, a degenerated tendon has way less cells than a normal tendon. So there's fewer cells to regenerate for a degenerated tendon. So the best curative type treatment for this is prolotherapy.

The problem is that beside physiatry, prolotherapy is now becoming one of the standards of care for pain treatment. But in other fields like family practice, a doctor has to get training after residency. But once you get into practice, you get too busy to even get training. Ross hopes medical schools and residency programs recognize that the cause of osteoarthritis or a degenerative disease is ligament laxity or joint instability. Apparently, they have to shift to this paradigm. Otherwise, they won't be able to emphasize prolotherapy.

[08:22] PRP vs. Prolotherapy

PRP stands for Platelet Rich Plasma. Ross explains the inflammatory cascade where when tissue injures and there's bleeding, platelets rush to the area and change their shape to stop the bleeding. When they do this, they release growth factors. To simulate the way the body heal for a degenerated joint, they take the blood out and centrifuge the blood. They get the plasma out and then you're left with just the platelets, which are then injected into the injured area like the shoulder or lower back.

"Platelet rich plasma is one of the more natural solutions we use in prolotherapy to proliferate cells."

[09:33] Traits that Lead to Becoming a Good Prolotherapist

Ross explains that until that paradigm changes, until we stop trying to resolve symptoms and we start trying to treat the actual structural cause of the pain, which is joint instability, in medicine, we're going to be led astray. We're still going to use pharmaceuticals.

"There's no pain that the underlying cause is a drug deficiency. We want to be healers in the truest sense and cure problems instead of covering up the symptoms."

If you want to become a good prolotherapist, you've got to commit to it. He says that if you only do a bit of this and that, you're never going to be an expert. If you get the skill set to document the instability and treat it with prolotherapy, then the next visit, you look at the tissue. So if you find something to be true, commit to it. Treat your patients that way and document your results. That means if somebody doesn't come back, you have to call them. So you have to follow up and have to commit.

[14:15] Types of Patients and Typical Day

The average person they see is a middle age to older age that had a degenerated tendon that the tendon just tore. The more degenerated tendon means there's less and less cells to regenerate. A degenerated tendon is a lot weaker than a normal tendon. So it gets weaker and weaker until it tears.

With prolotherapy, they use ultrasound guidance to put the PRP into where the tendon tear is. They're also doing comprehensive prolotherapy into the ligament support of the shoulder. So they're resolving the joint instability and also helping the tear repair.

The've also done pubis ligament. Ross explains the more children a woman has, the looser the pubis. And a lot of people think this is a hip or back problem but it's really a loose pubis. What they do is have them put on compression shorts to keep it tight and then they do prolotherapy to tighten the ligament support. Most people also don't realize there's a disc in the pubis. Ross describes this as a strange joint, since you don't typically talk about it in medical school.

"100% of them think they know the problem the doctor gave them. But 75% of the time, they're wrong."

Ross points out that with ultrasound technology, it can locate all the nerves of the body. It's very easy by history to tell when it's a compressed nerve and what's a joint problem. But with our technology now, they can already tell whether the nerve is swollen or not and measure it. Ultrasound scanners now are so detailed. He can even now see the vagus nerve in the carotid sheath. It's unbelievable what a doctor in their own office can see.

Ross would work half a day with patients, like 5 solid hours seeing patients. He would see patients at 8 am. His staff gets the patients going although they review the patients the night before. Some are new, others are follow ups. They try to figure out whether a patient needs a motion scan. In that case, they'd have to numb the musculature in the back of the neck so the muscles can't limit the joint motion. Then they'll do a fluoroscopic evaluation of them moving their neck to see where the instability is.

So the first thirty minutes, he'd do emails and by 8:30, he'd begin seeing the patients after the staff had gotten them ready. Then he will start treating people. Whoever gets scanned, his assistant does ultrasound exams. He'll also go over some of the scans with the patients. On average, he'd see 10 patients in a five-hour stretch. The rest of the day, as the editor in chief of the Journal in Prolotherapy, he'd review studies and does his research and writing in the afternoon. He'd have some clinical trials going on with regard to surgical instability and some research projects. He's currently in the middle of a thousand-paged joint instability book as well. Eventually, he hopes this will be the gold standard.

[21:46] Taking Calls

In private practice where you do procedures on people, Ross believes you should be available after hours for them. In his practice, there are two prolotherapists and another two in their office in Chicago. So there's a total of four prolotherapists and they do calls one month at a time. They're available 24/7. But you could get one call a week, not a lot. And since they do a good job in educating patients what to expect, they get less and less calls.

"In private practice, if you do procedures on people, you should be available after hours for them."

[23:05] The Training Path

Ross thinks some of the best training is in the University of Wisconsin. The Hackett Hemwall Patterson Foundation, named after Dr. Hackett, who was at the University of Medicine for many years. They have a training in October. Ross recommends going to this. Once you go to that four-day training, they have trips all over the globe so they normally have experienced prolotherapist and you get to go to Peru, Latin America, etc. There might be 100 people with 30-40 doctors getting trained and there are charity clinics there. So you have experience prolotherapists working side by side with doctors wanting to learn prolotherapy.

"I think mentorship or hands on training is the best training... a cadaver is so much different than a live person."

If this is something you're interested in, Ross recommends getting a mentor that's in your area or go to a place overseas and do some mission work. Through the foundation, Ross went to Honduras where he did 150 cases of prolotherapy, which means he did thousands of injections. After two weeks of intensive training and all those patients, he really got to hone his skills.

There are also other organizations you can get involved in. Ross is the member of the American Academy of Orthopedic Medicine. They have training there. There's also the Osteopathic Prolotherapy Association. So go to several of these. You  may have to go through some courses. You'd also have to learn ultrasound courses and go through training in Central America or Mexico. You'd want to be training with an experienced prolotherapist by your side.

Ross also mentions the neuromuscular residency in osteopathy and in this you'd have to do a bunch of prolotherapy training. If you're going to be a family physician or a physiatrist, Ross recommends you spend your elective time with the prolotherapist like what he did for two months.

[27:30] Working with Primary Care and Other Specialties

Ross says it's really about primary care physicians understanding the degenerative cascade and that the model of just relieving information that doesn't cure people of pain has to change. As a family physician, you have the obligation to the patient to really understand why a person has an autoimmune disease or why they have chronic pain. He explains that osteoarthritis is a whole organ disease. You've got to address all the causes.

"You have to have the skillset of being able to evaluate the whole structure and correct what needs to be corrected and try to cure the person of the problem instead of managing it."

Ross stresses that pain management is not working. If you're able to address the cause of the problem instead of the symptoms, you're going to really alter the course of people's lives.

Prolotherapists work closely with chiropractors who understand that if they adjust a spine and they can't hold the adjustment, it means there's ligament laxity. To him, the specialty that thinks most like the prolotherapists are chiropractors. In regard to traditional, they'd work with other physiatrists.

[33:00] The Analogy of the Door Hinge

Ross uses the analogy of prolotherapy to the door hinge. If one of the screws is loose on a door hinge and there's a another screw and you don't take a screw driver and tighten that screw, the other screw is going to loosen too. Once the hinge is loosened, the next hinge is going to get loosened too. That's why somebody has knee pain and eventually they have ankle pain and then hip pain or neck pain progressing up and down the spine.

"Joint instability is a progressive disorder. So you can't not do something about it. You have to correct it and the treatment to correct it is prolotherapy."

[33:48] What He Wished He Knew and the Most & Least Liked

Going into prolotherapy, what he wished he knew is how much people are struggling in their daily lives. He encourages young people going to medicine that you've got to learn about what's going on with your patients. There are so many broken homes. People are struggling as human beings. We are supposed to be in health care. As physicians, we have got to know about care. And what care is you have got to ask your patients about what's going on. And one of the best questions he asks his patients is, what have you been thinking about lately?

"People are struggling as human beings. We are supposed to be in health care. As physicians, we have got to know about care. And what care is, is you have got to ask your patients about what's going on."

So he wished early on he would have really gotten to know his patients better and he finds this to be so rewarding. What he likes the most about being a prolotherapist is the Christmas card he gets that somebody has been pain-free for ten years. His office is just inundated with gifts and letters from people appreciating them.

What he likes the least is the business side of it. The average number of visits to a prolotherapist is 4 so you'd have to explain it to people. They get one visit and they're not better and then a lot of stress comes with that. If you don't help them in just one visit then they just don't return. Hence, the reason it's important to talk to them about what's going on in their lives.

When you're in the chronic disease business, things aren't going to get better typically with one visit. The hardest part is when people spend money since prolotherapy is not covered under medicare so people have to spend their own money. So sometimes, they don't come the second time.

[38:30] Reception in the Insurance World

Ross sees the trend that there's going to be more self-insured companies. And what they're going to cover is stuff like this because it's so much less expensive. It's all 1/10 of the cost when it's all been said and done. Hopefully, Medicare will also review this eventually. So private insurance they cover prolotherapy but for government insurance, it's a non covered procedure.

"More and more companies are going to go to this so it's definitely the future. And eventually Medicare will wake up and they'll really review prolotherapy openly."

[40:30] Last Words of Wisdom

Ultimately if he had to do it all over again, he'd still be a prolotherapist and he's still continually learning stuff which he really loves. He goes on that chronic pain and osteoarthritis are the most disabling of lost years working. So he encourages students to research, is joint instability the cause of that? And if it is, you have got to resolve the joint instability to cure chronic pain. And if you do give it a try in your future practice that you will see that everything he said on this podcast is absolutely correct.

Links:

MedEd Media Network

The Premed Years Podcast

The MCAT Podcast

The OldPreMeds Podcast

Ask Dr. Gray: Premed Q&A

Caring Medical

American Academy of Orthopedic Medicine

Osteopathic Prolotherapy Association

Session 73

Dr. Scott Harper is has been out of training for 8 years. He joined us to talk about his specialty, Geriatrics, and what he loves about it and more.

Scott is in an academic medical center at Wake Forest Medical School. He shares with us his journey to Geriatric Medicine, what it takes to get there, things he likes the most and least, and more!

And if you haven’t yet, please take a listen to all our other podcasts on MedEd Media!

[01:24] Interest in Geriatric Medicine

Scott traces his interest in the speciality back to when he was medical school, going through the clinic rotations. When he was working with patients he found he was most drawn to the extremes of age. He envisions his practice to include babies and kids to adults and people nearing the end of their life.

When he was in family medicine for residency, he had an almost exclusively geriatric population in his clinic practice. He didn't feel he had the skillset to take care of all of their needs so this became his goal going into Geriatrics.

During medical school, Scott recalls his grandfather entering the first stages of Alzheimer's disease and this bolstered his interest. He would visit him often and one day while he was riding with him in the car, he was stopping at every stop light regardless of the color of the light. He knew then that something was amiss. And he got to see how his disease progressed and the challenges that came along with it especially that family was not in the same town.

[04:50] Traits that Lead to Becoming a Good Geriatrician

Patience is critical to be a good geriatrician. You've got to be comfortable with things moving slowly. Most of the patients you will be taking care of move slowly and talk slowly. A lot of times, their content is very rich but doesn't come out in a rush.

You also have to be comfortable with complexity. You have to be able to navigate all these things and understand that you may never have the perfect answer to what's going with the patient. Instead, you have to be able to tweak and optimize several different realms.

"Patience, you've got to be comfortable with things moving slowly."

By complexity, it may run the gamut of acuity, but not entirely. Scott describes the neat thing specifically about his job is he gets to do a lot of geriatric primary care. So he gets to see people for anything from infected toenail to Crohn's disease, management of 10-12 co-morbid conditions. Or sometimes, they'd have acute infections and they'd have to triage them into the hospital or the emergency room.

There's other roles geriatricians play outside of primary care where you get to see different levels of acuity, which boils down to folks using medical services most often. If you're in the hospital as a geriatrician, you're going to be seeing a lot of acutely ill and complex older adults. Some geriatricians end up doing exclusively or a subset of the care in the nursing home setting or in a rehab center. Here, you'd be seeing folk who just came out of the hospital or moving in there for their final address.

[08:05] Diseases Specific to the Older Population

Scott explains this idea in geriatrics called Geriatric Syndromes, which are the end result of myriad processes that tend to commonly present in older adults. This occurs a lot in the primary care setting.

Some of these diseases include memory loss, cognitive impairment, dementia, or somewhere along that disease spectrum and acute delirium. They may also deal with dizziness, imbalance, or falls. There are also osteoporosis, vision loss, hearing loss, urinary incontinence.

"The way a person ends up with urinary incontinence may be very different than the way a different older adult ends up with urinary incontinence but the end result is the same."

[09:05] A Typical Day

Scott describes his day in the clinic seeing around 7 to 10 older adult patients in any given half day. He spends an average of 30 minutes with each of them. Most of them are there for regular check ins, where he has this process of getting their history. He'd also do a medication review. He'd usually touch on a functional assessment just to make sure there's not any significant change since last seeing his patients, otherwise he'd come up with a plan.

"I found that medication is probably one of the biggest challenges in that setting."

Sometimes, the plan is not a lot if the patient is doing really great in their current medication regimen and the current social support is optimized. In this case, they can just stay the course. Other times, it can be very detailed ad bulleted in big print, changing things and resources to mobilize.

[10:22] Taking Calls and Work-Life Balance

In terms of taking calls, the way their practice works is that they cover their own patients that are admitted to the hospital. As a group, they do the hospital care and they cover . for a week at a time. In about once every 7-8 weeks, he'd do 7 24 hours in row. During that time period, he's responsible for hospice care and covering phone calls and stuff overnight.

It's made more possible by the fact he's got nurses that work with him as well as residents to take first pass with the phone calls. So he goes from very busy patient care and long hours and then go back to having 6-7 weeks without having to take any phone call.

As to why there are no hospitalists taking care of their patients in the hospital, Scott explains their institution has chosen to keep it the traditional way. And this tends to be usual in academic settings or in rural settings.

"The "old fashioned" model tends to either be in academic settings or in rural settings."

Being an academic center, they hope residents are able to do care in a setting where they need to do hospital care. Or if they end up in a more typical primary care practice, they'd be able to recognize which patients need hospital care and be able to appropriately get them into the hospital. And that they'd be able to take the care back over from hospital care.

Currently, Scott describes that the most variable piece for him is the student education and clerkship administrations responsibilities. There are times of the year where it ebbs and flows. There are periods when they have to auto pilot in terms of figuring out what to change the next year. Or if they implement the change at the start of the new year, it can get very busy and the hours can get longer.

[13:45] The Training Path and Other Opportunities to Subspecialize

Scott outlines the training path to becoming a geriatrician. The two most typical would be to do residency in either internal medicine, which is a 3-4-year program, or family medicine, which is typically a 3-year program. Then you go on to do additional training fellowship in geriatrics. There are also programs that can run from one year to three years. The longer programs tend to include more palliative care training and more research opportunities. The one-year programs are focused on geriatric principles

"The longer programs tend to include more palliative care training and more research opportunities."

In terms of competitiveness, Scott describes the specialty as very program-dependent, but overall, it's not very competitive. One of the few instances that you can do additional training and the result is you end up with a population that's insured by Medicare which tends to pay less than private insurers. And they would also require longer visits or longer hospital stays. So there's lower volume that you can provide care for. This said, you have to have the proper mindset.

"If you feel like your goals is to do that care regardless of the financial impact, it may be a positive idea."

The specialty he sees more commonly is that people pari geriatrics with some other training to expand the scope of their care like Palliative Care and Hospice Services. So they're not just doing geriatrics, but also managing patient symptoms and end of life care. This option also has a fellowship training involved. This also opens different doors. Instead of doing primary care, you might be a hospice director or do some sort of pain management in the outpatient setting.

Second, wound care is another place older adults with like arterial disease and venous problems and diabetes, and all the things that can put you at risk for wounds on your legs.

[17:30] Working with Primary Care and Other Specialties and Special Opportunities Outside of Clinical Medicine

Scott says that there are times patients can benefit from a geriatrician. There are only a few geriatricians in a huge and growing geriatric population. But because there aren't enough geriatricians to take care of the geriatric population, most folks are not going to have access to a geriatrician for their care.

So this is actually one of the things that called him towards his academic part of his life. Even if he can't impact the population directly, at least he can provide some geriatric principles and some things to keep in mind as you're making decisions on behalf of older patients regardless of the specialty you go into. This way, he still gets to bolster the care of older adults in a much broader sense. He gets to impart nuggets of knowledge to medical students and residents that come through, so they can take it and apply it to whatever field they end up to.

"There aren't geriatricians to take care of the geriatric population. It's a specialty of which there are not a ton of. It's a population in which there are a ton of."

As to when to know when it's time to seek out the care of an older adult, Scott illustrates the two realms. First is when cognition fails. Where primary care doctors could and do provide care but it's a place where there's a lot of insecurity and patients and their families want a lot of answers. So having that familiarity with the pathophysiology and the ongoing research and local community support and resources are very important. The other instance is when there is so many concurrent problems that the patients don't fit neatly into the usual workflow in the primary care clinic.

Scott says they often work a lot with their geriatric colleagues on the internal medicine side of things. Other specialties include wound care doctors, urogynecologists, and neurologists.

There are unique opportunities outside of clinical medicine like home care positions, where you do house calls. A lot of geriatricians have some foot in one of two worlds - research is one and education is another.

[24:55] What He Wished He Knew that He Knows Now and the Most and Least Liked Things

What he wished he knew before that he now knows is that you can't be efficient and do geriatrics. There are goals you're not going to be able to achieve and you have to be okay with being inefficient. Remind yourself that your goal is to provide the best care to the patient as possible.

"Remind yourself that your goal is to provide the best care to the patient as possible."

What he likes the most about being a geriatrician is the patients. He likes having gained the relational aspect of medicine. He gets to know patients over time and be able to meet their families. He gets to have frequent conversations that are enlightening and affirming, talking about goal setting.

What he likes the least is that piece that is mentally stimulating. For him, some of those simple visits are not part of his regular practice. He would have wanted to have some visits that you can just accomplish in 5 minutes and feel you've closed the loop on the condition brought to the office.

[28:29] Major Changes in the Future

Scott talks about lens and cataract removals and the ways they can treat urinary incontinence, even in men, where they put artificial sphincters. The hearing aid technology has been successful. Technology around would dressings can also be neat. So he gets to see how these technologies impact his patient's functions.

Another shift he sees that may impact geriatric primary care is his push towards risk-based care. It's the idea that insurers are going to pay healthcare systems a set amount to take care of patients based on their cumulative risks. Being able to use that money to provide care just makes sense.

[31:45] Final Words of Wisdom

Scott says to be open to the learning opportunities. There's not going to be any shortage and you'd be interacting with a lot of older adults.

Lastly, as you hear Scott talk about the shortage of geriatricians, we need more geriatricians now. As our population ages, we need more geriatric medicine specialists out there to take care of our aging population. It may not be the most glamorous or the highest paid specialty, but it's a great, and hopefully rewarding, career for you in the future.

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MedEd Media

Session 72

Dr. Leslie Pineda is a private practice Neonatologist in Orlando. We talk about her inspiration to go to the NICU and what she likes, dislikes, and more.

I am constantly looking for physicians who would make great guests here on the show. If you know someone who might make great guests here, send them my way at [email protected].

[01:33] An Interest in Neonatology

Leslie's mom is a NICU nurse who have been doing it for over 30 years. So she was basically exposed to the field at an early age. She would go visit her at work and back when the babies were still in a nursery, she'd get to see her mom and get the babies through the windows. Through the years, she always knew she wanted to do pediatrics.

"I would branch off and think of different things but I always kept falling back to neonatology."

As to why not a NICU nurse like her mom, Leslie explains she wanted to make the "big decisions." The bedside was fun but she wanted to pursue further and get to lead the team and make the decisions as the team leader.

Other specialties that crossed her mind included emergency as she enjoyed doing procedures. As a resident, she also looked into Pediatric Emergency medicine which she also found exciting because of the procedures and the acuity. Ultimately, she realized she enjoyed working with babies the most.

What she likes about the environment is that you're able to get that long-term relationship with the patients within the hospital stay. Understand that some babies could stay there for months and so you really get to know the family. You see them everyday and take care of them all the time. So you're able to make that relationship with them and get that long-term care while also that short-term acute management you'd have to do at the beginning or when they get sick in the parts in between.

[05:25] Traits that Lead to Becoming a Good Neonatologist

Leslie says you have to want some excitement and that adrenalin rush of taking care of a potentially really sick baby. One must also like the interaction with the families since you're not talking with the baby. At the end of the day, it's about being able to tolerate all your interactions with family members and parents concerning the baby's care.

[06:23] Types of Diseases

Neonatologists often deal with premature babies. Especially up to less than 35 weeks, they will automatically come to the NICU although full-term babies may come to them as well if they're having some trouble transitioning from intrauterine life and maybe having some respiratory issues like retained fetal lung fluid.

You may also encounter some hypoglycemic full-term babies as well if their infants of a diabetic mother. You may also have meconium aspiration or if it's a very stressful delivery, sometimes a baby could get stuck because they're so big They could be into so much stress so they would have to be watched in the NICU and taken cared of in the NICU.

"A lot of different pathologies, not just the premature babies that everybody thinks of."

[07:56] Community Hospital vs. Academic Hospital

As to why Leslie chose community over academic, she admits it had a lot to do with location. Growing up in Orlando, she always knew she wanted to come back there. Why she chose private practice is there's a lot of emphasis on the educational side and research studies, which she still gets to have in her current position.

[08:30] Typical Day of a Neonatologist

Aside from mostly inpatient, Leslie says there's also outpatient follow-up in certain groups. But for her, she does 100% inpatient. Typical day for her, as she describes, is that each day is a little bit different. They cover multiple hospitals with differing levels.

In the main hospital, they come in the morning and take sign out from the outgoing person from overnight about what happened to the babies you'll be following. They huddle with the respiratory therapists and the deliver team, as well as all the neonatologists on for the day. They'd deal with the charged nurses and the pharmacists, even research nurses. They all huddle just so they all know where patients are going or if they expect any deliveries or anybody is going for a surgery.

Then they'd review all the numbers and they'd round as a multi-disciplinary team, talking to the families. They'd talk about the plans and after lunch, they'd carry out all the plans they said they would do and touch base again with the families. And then you sign out to the person covering overnight.

"We round as a multi-disciplinary team... we go to each patient's room and talk to each family, talk about the plan, talk about the numbers as a big team."

[11:03] Doing Procedures, Taking Calls, & Work-Life Balance

In terms of procedure, neonatology is procedure-heavy. You're putting endotracheal tubes in the delivery room and NICU. You're putting umbilical lines, doing test tubes, needle decompressions, etc.

For calls, Leslie takes about three-night calls a month on average. This is basically dependent on the size of the group you're with since you split it among them. That being said, she thinks she still has enough time for life outside of the hospital. Sometimes, you get to go home early and spend time with family. Other times, you may do a 24-hour call so you lose two days there. So it depends on what your schedule is like for that week or month.

[12:36] The Training Path

Leslie illustrates the training path to becoming a full-fledged neonatologist. After premed, you do four years of medical school and then you do your three years of pediatric residency. Then you do three more years of neonatology fellowship. You then take your boards after that.

At the moment, there are no further opportunities to subspecialize after neonatology. However, she says people are actually looking into doing a neuro neonatal kind of things. This is just in talks, but who knows.

In terms of its competitiveness for matching, Leslie thinks it's average compared to all the other pediatric fellowships. For a student to become a competitive applicant, just show some interest in neonatology research or some research.

"Fellowship is geared towards doing some research as part of the training program."

[14:15] Bias Towards DOs and Working with Primary Care and Other Specialties

Leslie doesn't really see any bias towards DOs in that she had co-fellows who are DOs. She has also worked with other DO physicians even in her private practice whom she describes as excellent.

What she wished pediatricians knew about what she does to help patients is that they're not trying to avoid taking the patients. Sometimes they work hard to try to keep them on the regular nursery service. This is in order for the babies to not be taken away from their moms and get to stay with their moms and bond. But they're ready in case they need to take care of the baby and hopefully be able to send the baby back to their mom (if they're a full term baby who just needed time to transition).

Nevertheless, she doesn't really see any big issues related to pediatricians transferring patients to them. They don't mind consulting on so they can decide together whether or not they can stay a little bit longer with the mom before they take them or just take them over the NICU and keep them.

Other specialties they work the closest with include neurologists, infectious disease doctors, cardiologists, pulmonologists, gastroenterologists, and practically everybody.

"We're like the primary care physician for the preemie."

[17:45] Special Opportunities Outside of Clinical Medicine

Leslie says the research route is one opportunity outside of clinical medicine. She explains why research is very hot in neonatology right now.

"Neonatology is such a fast-changing field. We just started resuscitating 22-weekers and we're just doing all these new things to improve outcome."

[18:30] What She Knows Now that She Wished She Knew Before and the Most and Least Liked Things About Being a Neonatologist

Leslie wished she knew that the hours can be a little bit stressful especially when you still have to take overnight in-house call or do a 24-hour call. It's hard since you really like you do and she enjoys everything she does as well as the patients and the people she works with. But it can just be so taxing to stay overnight or do a 24-hour call.

What she likes the most about being a neonatologist is working with the babies and the families which she finds very rewarding. And then when they see an acute patient and then when they come back and see you when they're two or three, the feeling is so rewarding. And more so, if they were a 22 o3 23-weeker who was really fighting the odds.

On the flip side, what she likes the least is seeing families in a very stressful situation and it's hard for them to understand the things happening. Leslie says how this can be stressful even for the team. Since you want to do what's best for the baby but sometimes, they're just so premature that it's hard. They're really fighting against the odds. You can see the toll it takes on the parents and she says it's just so hard to see this.

In order to handle such relationships, they have been working hard in their group to involve the families in the decision-making and in the rounds. They try to get them very involved. It's not them telling the parents what they're going to do. But it's all of them talking and making a decision. They get to hear the plan as a whole team in the room.

"Parents do get involved and that helps with communication. It helps with the stress level because they're really part of the team."

[21:27] Major Changes in the Field

Leslie says they're now able to resuscitate ages that are younger and younger. The younger and younger they go, the better they get at the older gestational ages. Plus, all the technology is always changing. Their ventilatory strategies are changing all the time and what medications they're starting to study in neonates. So they always have to learn since it's always changing.

[22:15] Would She Do It All Over Again?

If she had to do it all over again, Leslie says she would still have chosen the same as she really enjoys what she does.

"The lifestyle can be a little bit hard but it's really rewarding to work with these patients and their families."

Lastly, what she wishes to impart to students thinking about getting into neonatology is that if you're really interested in it, try to do rotations as a medical student, as an elective. See what you're really getting into. Shadow a physician and see firsthand what's going on and what kind of babies they're taking care of and how little these babies are or how sick they are. There's a lot of emotional distress that can happen to you because you really get attached to your patients and their families. So if the baby is not doing well, you feel for them too. So these are things you may not understand until you rotate through or go through the NICU to see all that happens there.

"There's a lot of emotional distress that can happen to you because you really get attached to your patients and their families."

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Session 71

Dr. Serena Sah is an academic Pediatric Cardiologist in the California area. We talk about what drew her to the specialty, what she likes about it, and more. Serena has been out of training now for three years.

By the way, do you know of someone whom you think would make a great guest on this show? Email me at [email protected].

[01:25] Her Interest in Pediatric Cardiology

Serena enjoys working with kids so she knew she wanted to do Pediatrics. She had a six-month-old cardiac patient that had an interesting physiology. Knowing nothing about cardiac disease, she was freaking out and that encounter with the patient was what really got her intrigued by the physiology of the heart. Additionally, pathophysiology made sense to her. She likes being able to figure out the causes of the disease. Going through medical school, she initially didn't have that interest in Cardiology as much as when she encountered that experience. She thought she would do general pediatrics at first but she already had the mindset of going into cardiology.

She admits her intern year was rough and thought of not going any further. But that rotation in cardiology and her interest just peaked again. She also considered neonatology which had intensive care to it. Still, she was interested in the cardiac patients.

[07:11] Traits that Lead to Being a Good Pediatric Cardiologist

Serena says you have to enjoy working with kids and being around kids a lot. Understand that pathophysiology is interesting to you. Some of these kids can get pretty sick so just having a sense of calm under stressful situations.

"You have to be able to know that you'll see kids of both spectrums of severity of illness. You have to be comfortable in that kind of environment."

[08:25] Types of Patients and Her Typical Week

A lot of the patients that get referred into their clinic are teenagers with chest pains, fainting spells, arrhythmia, or minor heart diseases. She would also have a portion of patients where she does neonatal surgery or infant surgery where patients are born with a single ventricle. They would need to have a series of operations and you need to follow them throughout their life. Basically, it's a good mixture of people who have cardiac-related symptoms, heart murmurs, and those diagnosed during their neonatal period and she just follows them through.

Of her patients who come in already diagnoses, Serena calculates it's about quarter to a third of them and she's just following them up. The next quarter to half of them are people that come in with symptoms and they diagnose it. Also, a quarter of them get screened but get discharged without any cardia diagnosis.

Serena works at an academic institution with a large group of cardiologists or pediatric cardiologists so majority of their time is spent on outpatient. Then they do a rotation of inpatient service a week at a time and it happens less frequently. Her typical week would be one to two days of outpatient clinic. She reads heart ultrasounds for 2 to 2 1/2 days of the week. She also does a couple of half day sessions of administrative time or research time.

[12:37] Academics vs. Community

Serena chose academics over community for convenience. She felt she could go either way. But she enjoys teaching trainees. In fact, she looked to both places but it just worked out that her home institution had a position that opened up so she grabbed it. And it worked geographically.

"It wasn't the only thing I was looking at, but it ended up being where I was at."

[13:40] Doing Procedures, Work-Life Balance, and Taking Calls

As a pediatric cardiologist, cardiology is one specialty in pediatrics that is a medical specialty but provides a way for you to do hands-on things. They have a specialty in catheterization and put on cats and heart stents. You can also go into cardiac ICU as a subspecialty which is a third level of training. Then you can do a lot of procedures. Doing ultrasounds is not invasive but these are two subspecialties within pediatric cardiology where you get to work with your hands.

Serena says she has a very demanding position from a clinical standpoint so there's a lot of clinical work involved. Being in a larger group, their call schedule is more spread out. So she's not on call as much versus as she were in a smaller private practice group. That being said, she still wishes she had more time for family and things outside of work.

They usually handle home calls. They do have fellows that do first call where they're screened and their just escalated to them. So they rarely go to the hospital when they're home at night. But during service, they would also cover the weekend which means going to the hospital to round and be there if there are emergency situations. Their fellows also take phone calls so they go in if they need to.

[17:07] The Training Path to Pediatric Cardiology

After four years of medical school, you match into residency for Pediatrics. Then the application cycle has changed since she applied. You have to apply in your second year so you know where you're going by the end of your third year as you graduate from residency. But they've just changed the fellowship application cycle. You apply on your second year and then match in the fall of your third year. Pediatrics is three years and Cardiology is another three years. If you want to do the subspecialty within Cardiology, the trend is to have another year or two of training. Then there's five to six different subspecialties within Cardiology - Heart Failure, Transplant, Imaging, Electrophysiology, Catheterization, and ICU.

Some are also doing a fellow, fourth year, in Hypertension so it makes six years all in all. Others do Preventive Cardiology since there's growing obesity in the younger population. There's Cardiac Genetics.

"There's seven or eight subspecialties that you can potentially train for as an extra year of training if there's something specific in Cardiology that you want to do."

Serena says the more competitive fields are neonatology, critical care, or PICU within pediatrics to match into since a lot of people want go into it. But generally, all are pretty competitive although she doesn't really have the numbers of it.

[21:50] Bias Towards DOs and Working with Primary Care and Other Specialties

Serena doesn't see any negative bias towards DO in general. As with working with primary care, she feels for the pediatricians seeing a lot of patients. When they see referrals from pediatricians, it's difficult for them. So if there's something they're uncomfortable with, then pass them onto them. But they don't mind seeing patients that need to be seen to help the general practitioners figure out who needs further care.

Other specialties she works the closest with are the ICU people, neonatology, pediatric ICU, general pediatrics, hematology-oncology, nephrology, and GI.

As with special opportunities outside of medicine, she knows of several pediatric cardiologists who have gone medical mission trips to help different places and countries. They also have people who work with developing technologies and devices. Research is also one since genetics is becoming a big field that people are interested in that relates to both bench research and genetics research.

"Genetics is becoming a big field that people are interested in." 

For nonclinical things, there are opportunities for teaching. For Serena, her job is more clinical so it's most of what her know. That said, there are people that do AI type of technology that incorporates cardiac information.

[30:57] What She Knows Now that She Wished She Knew

Serena says she has a conflicting view of things. She loves the action of intensive care but she dreads it at the same time being a stressful situation since patients have various outcomes. So she loves and dreads it at the same time. She finds herself gravitating more towards the outpatient stuff where she can be involved in the action but not as directly.

All this being said, she wished she knew more about call in general in that it can be pretty rough during residency and training.

What she likes most about her specialty is thinking through the heart diseases and diagnosing them. She likes being able to educate the family about it which she finds fascinating and rewarding. She likes being able to work the families and helping them through the process.

What she likes the least on the flip side is handling difficult cases and if there's nothing they can do for tough conditions as well as that feeling of being responsible even though you're not if the outcome isn't good.

[35:27] Major Changes in Pediatric Cardiology in the Future

Serena says there's a lot of new technology being developed within interventional cardiology and imaging. They're working a lot with 3D stuff, printing or imaging modalities. They also work very closely with bioengineers. So if you're thinking about going to medical school, Serena says having this background helps. And if you're already in medical school, just be aware of all the technologies up and coming that are potential things to explore going into it.

"There's a lot of emerging technology that will come into play very prominently in the field."

Although she loves medicine and the intellectual stimulus of it, but if she were to go into medicine again, she would still be in pediatric cardiology. If she didn't go into medicine, she would probably be into graphics design or any design-related field.

Finally, her advice to those who are considering this specialty is to be persistent as cardiology training is difficult. Persevere and maintain your motivation and persistence, Have an attitude of learning everything as much as possible within your training time. It's a great field and a very interesting and fulfilling and rewarding field. The process is long but there's a lot of rewards that come out at the other end.

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