Specialty Stories

Session 29

Dr. Renée Darko is a community-based OB/GYN. In our podcast, she talked about her path to OB, what you should be thinking about during med school, and some tips as you're going through the process of deciding whether OB/GYN is right for you. If you haven't yet, please listen to Episode 127, I dove into the residency match data for OB/GYN.

[01:30] Community Setting Practice

Renée practices in a community setting. Although at one point, she considered an academic setting while she was in residency but shortly before she graduated from residency, she started realizing that she needed to explore a little bit more of the setting she wanted to be in so she began doing Locum Tenens in terms of practice rather than joining a group or an academic center. During the time she was doing Locum right after she graduated from residency, she also did a Health Policy Fellowship to give her a little bit of time to think of what she wanted to be and what she wanted to do. Renée graduated from her residency in 2010 so she has been practicing for seven years now.

[02:44] An Interest in Pediatrics to OB/GYN

Renée did not want to be an OB/GYN when she first entered medical school. In fact, she says it was the last thing she ever wanted to do. She actually wanted to be a pediatrician. The she did her pediatric rotation in her third year of medical school and she hated it, not because of the kids or the parents, but she just didn't enjoy the medicine of pediatrics and realized it wasn't for her.

During the last rotation of her third year was OB/GYN and knowing it was the last rotation and knowing she wasn't going to like it, she thought she didn't know what to do. But upon her first week of OB, she absolutely loved it. She loves the versatility of it as well as going to the OR, doing the deliveries, and doing the procedures in the office. She then realized considering an OB/GYN more seriously.

Renée's experience in pediatrics was somewhat a repetitive cycle which she didn't like. She didn't enjoy it because she didn't think she was very good at it mainly because it didn't interest her. Whereas she found OB to be a lot more versatile even as a generalist. They were doing things that could be potentially considered as subspecialties like surgery. She basically likes the fact that she can work with her hands and do a bit more to keep herself busy.

Before she started her path to OB/GYN, Renée had not considered a procedure-based practice. She never really thought about the procedures being a major part of what she would be doing as a physician. She thought that if she liked a particular population, being a new mom and that she loves kids, then that's the population she wants to work with. She realized she needed more than just the population. She needed something that was going to motivate her, keep her busy, and something that she was going to enjoy. So to her, the practice of OB/GYN was just of more interest to her. This is another example of keeping an open mind going into medical school.

[07:15] Traits that Lead to Becoming a Great OB/GYN

One trait that leads to becoming a great OB/GYN is being a good listener and allowing the patients to feel comfortable with you. When Renée was in residency, one of the things her attending used to say to her is that you're not your patient's social worker. Part of the reason she was being told that is because she would go in doing more than just prescription or procedure. She would actually sit down and listen to patients as they tell her their lives and all things that affect people outside of just looking at their differential diagnosis. Hence, Renée recommends thinking about the things affecting your patient's health. She adds this is a very intimate type of specialty so you need to go in thinking that and realizing that the patient is going to tell you intimate details and for you not to shy away from listening to those details otherwise you might miss things.

[09:22] Keeping an Open Mind

Renée was so dead-locked on being a pediatrician that she didn't let herself open to looking at other specialties. Apparently, she was so hooked to pediatrics until their peds rotation when she realized she didn't like it. Again, it was only till the end of his third year that she did an OB rotation so she felt she missed a lot of other opportunities and that she should have considered other specialties. That said, Renée loves OB/GYN and she says she wouldn't trade it for the world.

[10:25] Types of Patients and Typical Day

As an OB/GYN, you deal with patients on the OB (obstetrics) side composed of pregnant patients and the Gynecology side consisting of non-pregnant patients ranging from teens to the elderly. Aside from pregnant patients, she also sees patients trying to conceive, those with fertility issues, menstruation issues as well as women going through menopause. Basically, she sees a wide variety of patients and this is what makes her job more interesting instead of just one diagnosis she sees constantly throughout the day.

Renée's typical day would be going into the office at around 8:45 and sees about 10-12 patients in the morning and around the same thing in the afternoon. The first patient may be a pregnant patient and if it's her first visit, she has to assess all of her risk factors - her age, previous pregnancies and/or complications, genetic disorders (including the father), medical conditions. The she does an exam on her to make sure she's doing okay and measure the size of her uterus. If she's far enough along, Renée can listen to the baby's heartbeat. Then they make a plan as to how the pregnancy is going to go, things to expect, follow-up appointment, and what to expect for next time. Every patient may be a different diagnosis and coming for a different problem. The next patient may be an elderly woman having the hot flushes. So her patients vary everyday in terms of the number and versatility of patients she sees.

[13:58] Taking Calls

For Renée, she doesn't take a lot of calls although previously, she had to take calls three to four times a week which can get pretty hectic. Basically, the number of calls you take as an OB/GYN depends on how many people you have in your call rotation. Calls vary as well in that there are different models of OB. One of the more popular ones is the Laborist model where you're in the hospital and that's all you do so you typically won't see patients in the office. Renée didn't practice this in the past.

However, if you see patients in the office and take calls at night, you can either take call from home if you live close enough. You can take call in the hospital where you have to stay in the hospital overnight or you can take call from home and do something called second call, the most recent kind of call she has taken, which Renée describes as when someone else is taking the primary call.

For example, the family practice doctors who practice OB (common in a rural setting) are the first line of call so they take care most of the pregnant patients that come in. But if they ran into a problem such as a complication or the patient is more high risk than they anticipated or if the patient needs a C-section, she will then be called and she will come in from home into the hospital.

[16:40] Work-Life Balance

Renée says she has work-life balance right now but she has significantly changed how she practiced. She is currently doing independent contracting so she gets to choose when to work and when not to work which is not a typical model most OB's would follow. But she describes her previous model as difficult and cumbersome to balance your home and work life, bringing work at home a lot of times or staying at work late to finish things. In fact, sometimes when appointment ends is when work has only begun such as notes to catch up on, accumulating messages in her inbox, and looking at lab results coming in which she ordered days before for her previous patients. Renée typically goes home at around 7:30-8:00 pm. She still has to put dinner and decompress then go to sleep and do it all over again when she's not on call.

[19:50] Path to Residency

OB/GYN residency takes four years. Typically in your first year of residency, you're doing mostly general OB and GYN rotations. For Renée's residency, she did OB rotations in different hospitals as well as a GYM rotation along with GYN ER where she saw patients in the emergency room as an OB/GYN resident. In your second year, you're going more into the subspecialties such as MFM (Maternal Fetal Medicine) or high risk obstetrics dealing with not just pregnant patients but also those with high risk issues, Gynecologic Oncology dealing with women's health type of cancers, and Urogynecology which entails a lot of surgical experience. In your third year, you're expected to take on a little bit more of responsibility. By your third year residency, you're considered a senior resident and you may have a team that you're actually leading. Your team may be made up of a second year and a first year resident and you're leading that team.

Throughout your residency, you're also doing "night float" which means taking night call maybe from 6 pm one night to 6-7 am in the morning. You're doing this for four to five days out of the week. Again in your third year, you're taking a little more responsibility with your OB rotations so maybe you're making more decisions and the same thing with gynecology in the OR doing a more advanced type of procedures. Whereas in your first year, you may have been doing minor procedures like tubal ligations or LEEP. In your third year, you might be doing a little bit more of hysterectomy (removal of the uterus). Then your fourth year is even more responsibility. You're leading a team and doing night float but you're doing OB, GYN, and potentially maternal fetal medicine. All these are broken up into rotations so you're not going to be doing these all at once but you're doing it four to six weeks at a time. Renée describes it as a pretty busy residency but you get so much out of it.

[23:45] Matching Into OB/GYN and Choosing a Program

Renée says matching into OB/GYN can be competitive and she recalls her year to be a pretty competitive year. She adds the importance of going into doing audition rotations like your sub-internships pretty early in your fourth year and seeing where you want to be so you're not blindly picking where you want to go. It's a surgical specialty so you want to be sure that wherever you go, you're going to be in a place that does enough surgery. Delivering babies is fine but if you have a program that is so obstetrics-heavy and not enough gynecology, especially surgeries, Renée suggests reconsidering going into that program. At the end of the day, you have to really know how to work your hands to do surgery. You will learn how to deliver a baby wherever you go but doing hysterectomy, particularly vaginal hysterectomies and other types of gynecological procedures, you're going to really want to get good training in that. So when inquiring about the program or doing a Sub-I or interviewing, be sure to ask about it and get a sense of what your training is going to look like, particularly your surgical training.

[26:30] Bias towards DO's

Renée is a DO and applying to residencies, she actually never experienced any bias. She did the MD match and chose to opt out of the DO match because at that time, there weren't enough programs in the region she wanted to be. She is from New York so she wanted to come back to the New York/New Jersey area and there weren't enough DO programs at that time that she was interested in. Anyway, she didn't experience any type of bias. In fact, their program chair specifically told her she wanted Renée to be in the program.

[28:20] Subspecialty Opportunities

You can just do OB although Renée recommends that if you're just coming out, you probably want to do OB/GYN. You can also just do GYN. Other subspecialties are Maternal Fetal Medicine (high risk obstetrics dealing with pregnant patients with high risk issues) which consists of a three-year fellowship, Urogynecology (an additional three years and very surgical-heavy), Gynecological oncology (dealing with cancers, another surgery-heavy specialty which is also an additional three years), and Pediatric Gynecology which is one year. There is also the Reproductive Endocrinology and Infertility, which Renée was originally interested in and where you deal with infertility patients and other endocrinology disorders which is another three-year fellowship.

[31:00] Working with Primary Care

Renée explains that depending on what organization you talk to, OB can be considered primary care. But she doesn't think it's primary care in the sense of how they look at it. I personally think it's primary care for women's health but there's still a primary care physician for a woman's overall care. Nevertheless, she wants primary care physicians to understand that they are the first line for women's health so it's important they have a relationship with primary care physicians with regard to women and women's health.

Renée sees some women going to their family practice doctor and they've seen them for years but they haven't had a pap smear or breast exam in years. She adds family med doctors are pretty good at doing mammograms but the breast exam is still recommended. As an OB/GYN, Renée stresses that the clinical exam is still extremely valuable in evaluating patients. These are the kinds of things she wants for the primary care physicians to keep in the back of their minds to always ask their women patients if they've seen their OB/GYN or if they've already had their pap smear. This is even important with teenagers because Renée says there are a lot of instances where they could have treated or prevented issues but they've missed the boat on that.

[34:30] The Laborist Model

What she wished she knew about OB/GYN which she didn't know going into it is how flexible it actually can be. The Laborist, also called the OB Hospitalist Model, is currently getting popular. As a laborist, you're primarily in the hospital rather than being in the office and having to take calls and having to do everything in one day. Now that she knows that, Renée is actually taking more advantage of it and seeing it as her saving grace being a new mom and so it's really important for her to spend time with her baby. She gets that flexibility of being able to work in the hospital alone and set her schedule in the hospital where she gets all the work done in the hospital so she doesn't have to bring her work home and be able to spend more time with her son.

[36:35] Most and Least Liked Thing

What she likes most about being an OB/GYN is talking with patients. She is very candid with her patients so they would feel comfortable talking with her especially about sensitive topics where they may feel ashamed of so they're trying to hide it such as domestic abuse or sexual abuse or postpartum depression. Sometimes, they're not comfortable telling a perfect stranger but Renée sees it as a privilege for someone to be able to say that to her. So it's all about the trust her patients put into her that she's carrying for them.

On the flip side, what she likes the least about being an OB/GYN is when it gets too busy where she feels like she doesn't have the time she needs to either talk with her patients or have the time she needs with her family. Another thing she doesn't like is having bad outcomes especially on the obstetrical side when you're dealing with either miscarriages or stillborn which is heartbreaking. These are the things Renée says you never get used to such as bad diagnosis of, say, cervical cancer.

[40:10] Changes in the Field

Renée explains there is always something coming down the pipe. In particular, she sees genetics to become really big where there are a lot of genetic technologies coming down the pipe for OB. Most recently, cell-free DNA has come out which can give a lot of information about a fetus during pregnancy, something we didn't have in the past. Policy-wise, Renée sees the fight with women's health so it's interesting to see what policies are going to be emerging with regards to women's health in the next few years.

[42:30] Final Words of Wisdom

Renée gives her last pieces of advice to medical students looking at OB/GYN as a future career. First, don't underestimate it and don't not consider it. Don't tunnel-vision your way. She was lucky that when she did OB, she liked it. If you like using your hands and you like using your brain, OB/GYN is something where you can help a lot of women. You may never see a male patient again which Renée humorously sees as a blessing but they do circumcisions as OB. Nevertheless, you're going to help a lot of people. One of the things Renée and her husband learned during their medical mission about women's health is that women are typically the gatekeepers to their family's health which is very important. When you take care of a woman, there's a very good chance you're taking care of their entire family. If they prioritize their own health, they will do the same for their children, their husbands, their mothers, their sisters. They are the people who tend to keep the family healthy. Renée says it's very important to consider that when you're considering OB/GYN, you're not only helping that person sitting in front of you but you will also be helping potentially their entire family which is a beautiful thing.

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Locum Tenens

Specialty Stories Podcast Session 127: A Deep Dive into OB/GYN Residency Match Data

Session 28

Dr. Nii Darko is a community-based Trauma Surgeon. He's also an Osteopathic physician. Listen to his journey and what you should be thinking about. Dr. Darko has also been on The Premed Years podcast back in Session 196 and he is the host of the podcast called Docs Outside the Box.

[01:05] An Early Interest in Trauma Surgery

Practicing for almost five years now, Dr. Darko knew he wanted to be in two points of his life. As a seventeen-year-old, Nii had the opportunity to shadow a trauma surgeon in Newark, New Jersey, with his first exposure to trauma case was a person who got shot where they evaluated the patient and seeing a whole chorus of nurses and different medical staff helping the person. The trauma surgeon he was shadowing was at one corner of the room conducting the stuff, which to him seemed like an orchestra or rather a concerted type of chaos. The patient was taken into the operating room and when the doctor came out, he talked with the family. The doctor comes out of this operating room as a big superhero and saves the day. From then, he got hooked.

Fast-forward to residency around ten to twelve years later, Nii noticed that general surgeons were doing everything including trauma and found himself moving towards operating on the unknown which to him was the fun part about trauma. You don't know exactly what's injured so you have to use all of these different detective-type qualities to figure out exactly what's going on. So Nii felt trauma surgery was the best mix for him in terms of taking care of patients who need things like appendix or the gall bladder and at the same time use his superman qualities in high-adrenaline and highly stressful situations.

[04:40] Traits that Lead to a Good Trauma Surgeon

Nii cites patience as a very big trait considering that oftentimes, with trauma, you don't know what's going on  and a lot of things are going on at the same time. Another important quality is leadership. You need to understand that it's a very highly stressful situation. You have the ability to take a step back, be patient and at the same time, have the qualities where you direct people respectfully. Nii stresses the fact that no man is an island, particularly in medicine and although you'll be making decisions on your own, you are leading a team and if you can lead them effectively, it's always going to end up, for the most part, with good results for the patients.

Nii initially wanted to be obstetrician being greatly inspired by Bill Cosby of the Cosby Show who played the part of an obstetrician who was a positive African-American doctor figure. In fact in medical school, Nii was the first year representative for the OB/GYN club and he quickly realized afterwards that it wasn't for him. Orthopedic surgery was also in the running for a very short period of time for him but everything fell by the wayside when he did a rural general surgery rotation in the middle of Kansas and then knew from then on that general surgery was for him.

[06:58] A Typical Day and Types of Patients

Nii gets into the hospital by seven in the morning and a sign out period occurs where they talk about all the patients on the list, anything major that occurred the night before and then they talk about the plan for the next 12-24 hours. From 8 am to 7 pm, Nii handles different duties whether it be patient evaluation at the trauma bay or someone on the general floor. By 7pm, they do the sign out process again and whoever is on at night handles any situation that needs to occur at night and then do it all over again.

Nii typically treats patients from all walks of life, children and elderly patients as well patients in their late teens and 20's. As a trauma surgeon, majority of patients he sees are patients in their teens to mid-late 20's and 30's, which he describes as the "invincible years" where people think they're invincible so they do more of the reckless stuff. Additionally, he sees a huge boom of geriatric patients consisting of the baby boomer generation who as they get older are more prone to falls and different types of mechanisms, making them the second largest patient population he deals with.

70% of his job consists of true trauma cases such as car accident, gunshot wounds, stab wounds, and critical care while 30% goes to general surgery. Only about 10-15% of his patients that come through the trauma bay get taken to the operating room for various operations such as removing a spleen or fixing a liver laceration or a washout of an exposed bone. A very small percentage of patients get taken to the operating room which is a significant shift from trauma surgery that our generation knows from most TV shows in the 70's and 80's. Because of how advanced technology now is, those days are way behind us. Now, you can study someone and take a look in their, say abdomen or chest, and have more information before you take them to the operating room.

[12:08] Calls, Work-Life Balance, and Burnout

In terms of taking calls, Nii works in a two-week-on-two-week-off type model which is basically a shift work where he and another surgeon alternate call for two weeks and he gets another two weeks off. No administrative work, no hospital work, no patients. So Nii works hard in Central Pennsylvania for two weeks and then he's able to get home for a week to see family. This makes it attractive for people who really care about being able to travel or being able to do things with their families that they may not be able to do in a regular type of job. But that said, Nii describes his two weeks on as tough. You can do it but it's not for everybody. However, Nii finds those two weeks off as very valuable.

When his patients come back during the two weeks he's off, they have this agreement among all surgeon where it's no longer his patient but their patient. Hence, other doctors take care of him or treat him during his time off. Nii sees this as the wave of the future. It may not be necessarily two week in a row and two weeks off but more and more specialties are taking on this type of work model with varying number of days on and off and where they're working as a team. Considering the amount of work or the amount of patients one person has to see and to be able to have the lifestyle with the new generations coming up, millennials and GenX, he sees lifestyle as coming into center stage and as a result, this type of schedule is becoming a lot more attractive.

Nevertheless, Nii still feels he has enough time for family since he's working very hard for two weeks and prior to this year, he was in a situation where he spent 24 hours in the hospital and another 24 hours afterward is for backup in case he's needed to come in. he ends up convincing the OR to give you time to operate early in the day which doesn't happen much due to elective cases filling in. So you may be spending an additional five to six hours in the hospital. Again, Nii stresses how tough those two weeks are and oftentimes, you may still not be able to see loved ones during that time, but during the two weeks off, you may still catch up. But it's not for everyone. Nii has still missed a lot of important life events and he honestly says there are times he's questioning if this is all worth it but in order to be human, you have to have that type of thought process at one point. Nii is not complaining but this is real talk. This is bringing to light something people have not talked about before and it may have been manifested in bad behaviors in the operating room. So it's important to have this type of discussions now.

[17:35] Residency, Fellowship, and Competitiveness

Nii did five years of general surgery residency which includes training in a whole bunch of various areas of surgery such as general surgery, surgical oncology, ENT, neurosurgery, a little bit of orthopedic surgery, but less focused on general surgery. Afterwards, he was allowed to practice general surgery and decided to do a one-year fellowship where he did additional training at University of Florida's Ryder Trauma Center. He got as much experience in trauma as he could as well as critical care experience. After his training, he became board-eligible to practice trauma surgery and critical care surgery as well as general surgery.

Nii describes trauma surgery as not a very competitive residency for a host of reasons. For one, a lot of people are little bit nervous about the hours you work with trauma. Second, it's very stressful. Third, a lot of programs offer trauma so it's not as competitive as in the realms of vascular surgery or any other type of subspecialty such as laparoscopic surgery or bariatric surgery. For the most part, people may think of trauma surgery as not being too competitive but it's very hard to get into the top trauma centers like the University of Miami, Grey Memorial Hospital, USC in California, or Shock Trauma in Maryland, these hospitals.

[19:55] How to Be a Competitive Applicant

From a medical student's perspective, Nii cites the the key things for becoming a very competitive applicant to general surgery. First, set the groundwork by being an excellently trained general surgeon. Show your interest in general surgery whether it be going to conferences or shadowing a general surgeon. You're going to be doing a general surgery rotation so you may want to do an additional rotation as a third or fourth year doing a sub-internship in general surgery or trauma surgery. Get excellent letter of recommendation and do well on your board exams.

Once you become a general surgery resident, make sure to have an open mind. Make sure you're giving every rotation that you're doing enough attention and being as open as possible to basically learn as much possible. Be open to the idea that maybe you thought you wanted to do trauma surgery but you're actually really interested in surgical oncology or what have you. At this point, which usually happens during your second or third year, start getting yourself involved in research or doing some additional trauma surgery rotations if you like or get yourself involved in co-authoring a chapter in a textbook if you're at a large institution that does that. As for Nii, University of Miami has opportunities for not only medical students but also for general surgery residents to attach themselves to one or two general surgeons who are making probably a 25-30-chapter textbooks. There are plenty of opportunities to get yourself ready but focus on getting into a general surgery residency and as a resident, start putting your hands in different ways to show your commitment to trauma surgery.

[22:40] Tips for Choosing Your Program

Nii says he wouldn't have done anything differently with how he chose his program. The way he did it as a fourth year surgery resident at Grey Memorial Hospital where there was a lot of trauma done, there were multiple trauma surgeons who train at various places and they've come to work at that hospital. What he did was querying all of those surgeons, going to various people and asking them about their program and why they think it would be good for him to train there. Aside from getting advice from them, he went online and looked up more about those different programs and even calling up the program directors where some of them accommodated him.

Nii wants people to understand that medicine is an extremely small world but as you start to get into more sub-specialties like trauma surgery, it's a very, very small world. For instance, their chairperson knew the trauma director at Miami and they ended up getting introduced in that way so he got to talk to him and told him about the program. So he applied and ended up working for him.

Additionally, when you apply you get the opportunity to interview at these places if given the interview, which is an opportunity for you to showcase how well you speak and think or how you are in person, outside, separate from a piece of paper. Also take it as an opportunity to interview them. Ask them in how well they train their residents or fellows and in doing well on their board exams, how much experience do they get operating in x or y, how much time do they get off.

[25:00] His Hustle to Allopathic Residency as a DO

Nii is a DO but he went to an allopathic residency program for general surgery. Based on the NRMP Match Data for 2017 for Surgery programs, out of 1,276 positions filled, only 64 were filled by osteopathic students.

When asked about how it was for an osteopath to get into an allopathic residency, Nii explains how much he hustled which means grabbing an opportunity and not waiting for someone to give you an opportunity. He knew he wanted to do general surgery and was open to doing a general surgery residency at an osteopathic program. He went through the rounds of interview at all these different DO programs and at the same time he decided to interview at all different places. He got a phone call from three or four general osteopathic surgery programs that they have matched outside of the match, which was part of their culture. They at times will just agree to take in a certain person before the match.

So Nii had no other places available to him to get into a DO general surgery residency. But since he got to interview also at allopathic programs, he still had that chance within that allopathic realm. He ended up doing a last-minute sub-internship at Morehouse School of Medicine in the Medical Intensive Care Unit (MICU). When he got there, he made it very clear that he was doing the MICU rotation because he tried to get into the SICU (Surgical Intensive Care Unit) rotation but it wasn't available. He actually got lucky he had a very good pulmonology critical care physician and he honestly told him that he enjoyed intensive care unit but at the same time he was really interested in being a surgeon but he took the opportunity since it was the only thing available to him. Then every now and then he would request to round with the trauma surgeons and then he eventually maneuvered that into seeing what they do in the trauma. He basically got his foot on the door and hustle his way into making sure they know him.

As a result, he got accepted into their program. It wasn't until his second year that he had the opportunity to talk to the chairperson who accepted him because they saw his ability considering they have never ever taken an osteopathic medical student before. By the time he graduated from the program, he was the best resident that has ever come through that program. Nii's advice is to make sure that if any osteopathic medical students are ever interested in their program, you have to take them more seriously. Think that we're all going through the same trials and tribulations and stress. Nii thought they may think that because he's a DO, he's different but he went above and beyond and he crushed it. Back then, they didn't treat him any differently or did anything to make him feel that way, but it was the thoughts he had at that time. His advice to medical osteopathic students out there is if you want to get it then go get it. And if you have to get into a general surgery in the allopathic world, then go and be as aggressive as possible and take the opportunities that may be presented to you. Kick the door open and don't wait for someone to give you an opportunity otherwise you're going to be on the outside looking in.

[31:40] Subspecialties, Other Specialists, and Special Opportunities

As a trauma surgeon, your subspecialty is called Trauma Critical Care. You can go and get some additional education like other specialties can like take additional courses in ultrasound. This is very useful if you're trying to figure out if someone is bleeding in their abdomen or has blood anywhere else. Using it is cheap, quick, and it doesn't require moving the patient to a CT scan where their pressure can drop or end up dying of a collapsed lung. You can get additional training in mostly anything. It won't get you additional certification but Nii explains it's always good to have that additional training in your back pocket because you never know when you're going to use it. Moreover, if you want to get any type of additional training that would get you certified in something else, you may have to do an additional fellowship aside from trauma surgery such as laparoscopic surgery or plastic surgery.

In trauma, Nii always works with an orthopedic surgeon for broken bones, neurosurgeons for head and spinal cord injuries, plastic surgeons and oral and maxillofacial surgeons for broken bones in the face or missing teeth, broken nose and broken sockets. Other specialties they work a lot with include cardiothoracic surgeons.

Other special opportunities outside of clinical medicine for trauma surgeons can be EMS. For example, if EMS is called to a scene and a patient is found down, if there's enough training, and EMT may bring that patient to the ER and allow the ER to work that patient up. But if the patient has a bunch of bruises on the head or anything on the rest of the body that may suggest they've fallen, if a trauma surgeon did the education and ER comes together, they may be able to educate EMS as to what to do first.

You can also create your own type of experience. You can do a podcast like Nii where he interviews ordinary doctors do extraordinary things. And as with any other specialty, the world is your oyster. Nii further says that as a doctor, whatever you do, you just have so many opportunities to do anything you want. There are so many ways that you can branch off and go into.

[36:38] What He Wished He Knew Going Into Trauma Surgery

Nii trained in Atlanta, Georgia and from his experience, he found trauma surgery as a burden in their hospital since majority of trauma patients at their facility were indigent populations. Other services are expensive  so if a patient with polytrauma comes through and they don't have insurance, it could be a huge expense for the hospital since a lot of that care has to oftentimes be written off. This normally occurs in areas where you have patients who don't have a lot of insurance or indigent populations.

When Nii ended up becoming a trauma surgeon and going into areas where people have car insurance or people have other health insurances to pay for this, he didn't know that trauma surgeon could be as lucrative for a hospital as well as for the providers. And at the hospital he's currently at, trauma surgery is not a burden and instead is the biggest money maker for the hospital just because there are so many tenets of care.

He wished he had known this before because he used to often get physicians who tried to turn him away from trauma surgery whereas in his current situation, trauma surgery is not seen as a burden and the administration can't get enough of trauma surgeons and want more of them.

[39:00] Most and Least Liked Things About Trauma Surgery

The thing Nii likes the most about trauma surgery is being the jack of all trades. He enjoys stressful situations and being trained in all different areas knowing you've got to stay calm. You get to orchestrate a lot of people and run a team and you're seeing someone literally from the door as they come in and all the way to when they're discharged and you're in charge of all facets of the care. He finds this very fascinating reason that the went to trauma surgery in...

Session 27

This week I'm breaking down and reviewing the match data for OB/GYN. There are a handful of surgical specialties thought to be a good mix of medicine and surgery specialties. OB/GYNE is one of them along with ophthalmology, urology, and ENT. If OB/GYN interests you, take a listen to this episode to see what you need to do!

[02:30] Match Summary

Table 1 of the NRMP Main Match Data 2017 shows the summary of the match and OB/GYN is listed separately from everything else having its own category. There are 241 OB/GYN programs. Compared to other specialties, Surgery has 267 programs, Internal Medicine has 467 programs, Emergency Medicine has 191 programs.

While OB/GYN has 241 programs, there only 1, 288 spots available compared to Emergency Medicine with 191 programs but there are 2,047 spots. That's almost 800 more spots even if there are 50 less programs. Hence, there are less spots per program in OB/GYN.

Out of those 1,288 spots, there were 1,202 U.S. Senior applicants. This means there are less of them applying than there are spots available which is a good thing. (For our conversation, U.S. Seniors based on this data specifically talks about allopathic medical students. The NRMP is the match for allopathic medical schools.)

There are a total of 1,753 students applying. Aside from U.S. Seniors, there could be physicians in another country applying for OB/GYN residency here in the U.S. They could be Caribbean grads, DO students, etc. Only 81.4% of the U.S. Seniors matched so out of 1,202 U.S. Senior applicants, only 1,049 matched and 153 did not match. There could be a number of reasons students are not matching for residency. Maybe they weren't competitive enough or they interviewed poorly. Or maybe they didn't apply to enough residencies or performed poorly on their audition rotations.

[05:45] SOAP and PGY-1

For OB/GYN total, 100% of spots were filled. If for some reason you're trying to Scramble, which is now called SOAP, for OB/GYN in 2017, there were no spots available.

There are only 19 PGY-1 OB/GYN spots, Typically, for OB/GYN spots, you have medicine, surgery, or a transitional year which is a mix of medicine and surgery. It's pretty interesting that OB/GYN has a prelim year. This is for the students that need to SOAP and the students that didn't match maybe they were able to get a PGY-1 spot. However, there is no discussion about OB/GYN having any PGY-2 positions. I'm wondering what happens to these students once they finish their PGY-1 spot.

So there were 19 programs and 23 positions offered, which seems to be just an extra spot for interns, and then 8 programs went unfilled. 142 U.S. Seniors applied and 202 total applicants and only 6 U.S. Seniors matched. As to why this is the case, they probably applied to both categorical OB/GYN spot and the prelim spot so you get a lot more applicants to the PGY-1 spot that hopefully matched in the categorical and didn't need to go onto the prelim year. If that's the case, they wouldn't have matched in terms of how the algorithm works because they are two different programs.

[09:00] Specific Applicants and Trends

Table 2 shows who matched in the specialty. For OB/GYN, there are 1,288 spots for the categorical programs and all spots were filled. 1,049 were filled by U.S. Seniors so 81.4% of all spots went to U.S. Seniors who are those still in school. 11 of those spots went to U.S. graduates who are students that went to an allopathic or MD school who aren't in school anymore that possibly reapplied or took a year off to do some research. There are 123 osteopathic/DO students matched into an allopathic OB/GYN categorical spot.

Outside of the U.S. allopathic and osteopathic students, 64 U.S. IMGs matched into an allopathic OB/GYN categorical spot and 41 non-U.S. citizen IMGs matched. So 105 graduates from a non-U.S. medical school matched.

Table 3 shows the growth of programs year over year (2013-2017). For OB/GYN, it's been growing around 4.5-4.7% every year and this is a good pace.

Table 8 shows the percentage of applicants filled by U.S. Seniors from 2013-2017. 81.4% of those that matched were U.S. Seniors in 2017, 77.5% in 2016, 79.8% in 2015, 76.5% in 2014, and 76.2% in 2013.

Table 9 shows how popular OB/GYN is compared to all of the other specialties. 4.7% of all applicants who matched, matched into OB/GYN. To give you an idea of what that looks like, 7.4% matched into Emergency Medicine, 4.1% into Anesthesiology, 5.4% into Psychiatry categorical.

Table 10 looks specifically at U.S. Seniors who matched by specialty. 6% of all U.S. Seniors matched into OB/GYN. This is a good number. Table 11 shows osteopathic students who matched into OB/GYN.  4.2% of all osteopathic medical students matched into OB/GYN.

Table 12 shows foreign-trained physicians (international medical graduates) and only 1.6% of IMGs matched into OB/GYN. This makes sense since more of the subspecialties are harder to match into as an international medical graduate. Now compare this to 46% of all IMG's matching into Internal Medicine.

Just to give you a comparison here for students who matched into Internal Medicine, Osteopathic students make up 23.5% (Table 11) and 25.6% for all applicants (Table 9) and 18.6% were U.S. Seniors. 25.6% of all applicants is kind of held up by the International Medical Graduates leaning into Internal Medicine.

[14:36] Applicant Choices by Specialty, Matched and Unmatched

Table 13 shows the applicant choices by specialty. For OB/GYN with 1,288 total positions available and all of them matched. 968 of U.S. Seniors that matched only ranked OB/GYN programs. 198 U.S. Seniors ranked OB/GYN as their first specialty and they had a different specialty after that. 36 students U.S. Seniors had a different specialty before OB/GYN. This is common but I personally can't understand ranking more than one career. This is your residency training. This is your specialty. While yes, it is possible to change careers at some point, don't you only want to do it once? I wonder how it feels like to open up your envelop seeing you matched into the specialty you didn't rank first. My advice is try to narrow it down to one program because the data shows that when you rank more than one program, it starts to work against you. There's probably some psychology working in there but it's interesting information.

Table 14 shows the ones that actually matched who ranked their specialty as their only choice. For OB/GYN, there are 890 that matched out of the 968 that applied as their only choice.

Figure 6 shows the percentages of unmatched U.S. Seniors and independent applicants who ranked their specialty as their only choice. OB/GYN is near the bottom for total unmatched percentage at 15.4%. This is pretty good since we covered Physical Medicine and Rehabilitation before and their unmatched rate is 27.5%. Family Medicine is 25.3%.

The majority of those unmatched applicants are the independent applicants. Unmatched U.S. Seniors is very small at 8.1% for OB/GYN (Pls. refer to Table 14). Compared to other specialties, this percentage is on the higher end of U.S. Seniors unmatched. Anesthesiology is only 0.9% of U.S. Seniors, Internal Medicine is 0.5%, PM&R is 7.1%. So even though the total unmatched rate is 27.5% for PM&R and OB/GYN is 15.4%, the U.S. Seniors unmatched is still pretty high at 8.1%.

Table 18 covers SOAP information for 2016-2017 and as mentioned earlier, the 1,288 spots available for OB/GYN went completely filled. When you look at this, Table 1 shows you all of those that matched pre-SOAP and if there are no programs available based on table 1 then obviously, no programs are available for the SOAP. With the OB/GYN prelim year (PGY-1), there were 8 programs, 9 spots available and 8 of those spots went filled.

[20:27] Charting the Outcomes 2016

Looking at Chart 5 of Charting the Outcomes 2016, the students that did not match were equal to or more than the number of different specialties ranked. Those that did not match rank more specialties in their match list than those that did match. So you're focusing your efforts on too many different places instead of honing in on one and putting all your cards on the table for one specialty. Based on the data, it shows that those who spread out too thinly and applied to more programs didn't match whereas those who applied to fewer programs actually matched. Hence, focus your energy on one specialty.

First, note that there is an overlap with a lot of different specialties. For example, diagnostic radiology can be very similar to interventional radiology.

Chart 8 shows the mean number of research experiences from U.S. Allopathic Seniors and OB/GYN is higher for those that matched at 3.2, a decent number right in the middle of the pack. Orthopedic surgery is at 4 and Otolaryngology (ENT) is at 5.1. Those that did not match for OB/GYN had 2.8 so not a lot fewer.

Chart 12 shows the percentage of U.S. Seniors who are members of the AOA (Alpha Omega Alpha), the honor society for medical students. For OB/GYN, 15% matched while 2% of those that did not match were AOA.

[23:25] Contiguous Ranks, Step 1 & 2 Scores, Top 40 Schools

Moving down to the OB/GYN specific information Table OB-1 (Page 123), the mean number for contiguous ranks that matched was 12.5. If you've listened to any of these deep dives before, you will know that this is one of the key indicators of who's going to match and who's not. You are more likely to match when you rank more programs. Those did not match had 6.7 mean number of contiguous ranks. So those who matched almost doubled than those who did not match.

For those that matched, the mean Step 1 score of those that matched was 229 versus 214 for those that did not match. Mean Step 2 score was 244 for those that matched while 230 for those that did not.

The tenth on the list indicates the percentage who graduated from one of the 40 U.S. medical schools with the highest NIH funding. I get a lot of students asking if it matters where to go to medical school and the I always tell them it doesn't matter unless you have aspirations of being a top academic person at Harvard or Stanford and then think about going to some of those more elite schools. But for OB/GYN, specifically, 31.2% of those that matched came from one of those 40 schools. This goes to say that most of the students are coming from somewhere else. You don't have to go to an elite school to match into OB/GYN. On the other hand, 29.8% of those that did not match went to one of the top 40 U.S. medical schools based on NIH funding. To me, this doesn't tell anything about the quality of schools, it just means the school does a lot of research and it's good at writing grants for money.

[26:25] Medscape Lifestyle and Compensation Reports 2017

Looking at the Medscape Lifestyle Report, it tells us that OB/GYNs are pretty burned out, being the second highest on the list at 56% next to Emergency Medicine at 59%. Slide 3 shows the severity of burnout and OB/GYN is near the top at 4.3 in a scale of 1 to 7 (where 1 equals "It does not interfere with my life" and 7 equals "It is so severe that I am thinking of leaving medicine altogether.") When you look at all of the specialties listed here, none of them dropped below 3.9 so it seems everybody is on the way out. This is one of the questions for premeds out there, why do you want to enter this? You have to be ready to answer that question on your interviews. Slide 18 shows which physicians are the happiest, OB/GYN is right in the middle at 69% happy outside of work and 32% happy at work.

Moving on to the Medscape Compensation Report 2017, OB/GYN is near the middle but lower than half at $286K as the average annual physician compensation. Orthopedics is first at $489K and Pediatrics at the very bottom at $202K. Slide 18 shows which physicians feel fairly compensated and OB/GYn is near the bottom at 48%. Whether they would choose medicine again, OB/GYN is second from the bottom at 72%, just above Neurology at 71% while Rheumatology is on top at 83% followed by Psychiatry at 82%. Whether they would choose the same specialty again, OB/GYN is pretty near the bottom at 76%. It looks like not a lot of OB/GYNs are happy with their chosen specialty.

[29:30] Final Thoughts

With a lot of OB/GYN not very happy with their career, more so, not choosing the same specialty again. But information is power. Knowledge is power. So take this information and use it to your advantage. A lot of people go into specialties not knowing enough about the specialty or what their life is going to be like and this why we have this podcast. Take this information and use it so you can best make an informed decision.

Links:

NRMP Main Residency Match Results and Data

Charting the Outcomes 2016

Medscape Lifestyle Report

Medscape Compensation Report

MedEd Media Network

Session 26

There are many things to think about when you are deciding your future career. In this episode, we discuss how you should start that process.

The goal of this podcast is to speak to specialists from every field, both community and academic. But I want to rewind a little bit and talk about the whole process of just thinking about these specialties and the questions you should be asking yourself, and what you should be thinking about as you're going on this journey so that as you listen to these interviews, you will have a better sense of what you're thinking about and your goals in career and life in general.

[02:10] Keep an Open Mind

A large percentage of premeds that go into medical school know what they want to do. But keep in mind that most medical students change their minds. They may get in a specific field after exposure and research but as they get more involved in the field through rotations and doing a lot more clinical work as a medical student, they realize it's not for them. So realize that your preference can change. Don't hold onto your convictions of wanting to be a certain specialty. Let go a little bit of that and keep an open mind as you are going through this process.

[03:38] Academic/Community, Urban/Rural Settings

Understand that with that, what you see as a medical student is typically urban, academic medicine. For DO students, that's not always the case because most DO schools are not associated with large academic medical centers. You have to go around to different hospitals. Some are academic while others are more community-based or more on the suburbs or more rural, wherever the hospitals are that you rotate at based on the schools you go to.

Understand that what you see day in and day out as you're a first year, second, third, or fourth year student doing your rotations and doing your preceptorships and your pre-clinical years, the medicine you're likely seeing is not how the majority of medicine is practiced. So when you're out shadowing a cardiologist in a large urban, academic medical center, the life of that cardiologist could be 180 degrees different than a community-based cardiologist or a rural-based community cardiologist.

As you're setting up rotations for your sub-internships and getting more involved in some of these electives (cardiology is not the best because it's a fellowship you do after medicine), try to mix up academic and community settings to give yourself an idea of what you want for yourself. Do you see yourself as an academic person? Do you want to be around residents and medical students? Or do you just want to work as a physician and practice? Do you enjoy teaching? Do you enjoy doing research? Research is usually big in the academic world. You can do plenty of research in the community too but in the academic world, research is more mandatory. Or do you want to have a hybrid setup? We talked to Dr. Topf back in Episode 16. His is more of a community-based nephrologist but is also involved in academics and running a fellowship program for nephrology. So you can have a little bit of the best of both worlds.

Start thinking about those settings. Start thinking about where you want to go to residency. Have those ideas in mind regardless of the specialty.

[07:00] Introvert or Extrovert

Think about what kind of person are you? Are you an introvert or an extrovert? I, myself, am an introvert by nature. When I go out and interact with people and when I used to interact with patients all day before medical school and during medical school, when I was interacting with clients all day while I was a personal trainor, I would be completely drained at the end of the day. Working with people drains me. Even being at conferences drains me. If I would have taken that into account and it was significant enough that at the end of the day, I was completely wrecked and couldn't do anything, maybe I would think about a specialty that is a little bit patient-focused. If that's the type of person you are, think about it.

There's also that opportunity to fake it till you make it. I put on a big smile on my face during work and at conferences and just deal with it then at the end of the day, I get tired and would need lots of alone time. I need to be by myself to recharge my batteries.

Or you may be the type of person that recharges being around other people. If you're a people-person, look into those fields that are more people-heavy like psychiatry or some of the general primary care specialties.

For the introverts, when you try to get away from people, possible specialties include radiology or pathology. We did an interview with Dr. Judy Melinek back in episode 24. She is a forensic pathologist and she interacts with the deceased's family members whom she calls patients. So she's still interacting with people as a forensic pathologist.

[09:30] Stressful Situations

Think about what kind of stressful situations do you like to be in? Are you ready for anything at any notice and life and limb and death in your hands? Maybe the emergency department is right for you. I personally liked the emergency department but not the sort of intensity. I wouldn't want to work in that sort of stress. I originally wanted to be an orthopedic surgeon. Complications happen in the operating room and you need to be able to handle that. But you're already in a controlled environment. Hopefully, you're thinking through these situations as you're going through it. You're always thinking three steps ahead. In the emergency department, anything can come in at any time so you always need to be prepared and really be able to handle that.

[10:38] Length of Training and Variety

A couple silly questions I don't think are valuable in asking is what time frame do you have or how long do you want to train? Neurosurgery is seven years versus pediatrics which is three years. But if you really want to be a neurosurgeon and think it's too long so you're just you're just going to settle for pediatrics, you're making a huge mistake. Don't settle on something or don't avoid something just because the training is going to be longer than you hope for. It may seem a long time at the beginning of your career, but it's actually not a lot when you look back at it. So don't use this as your criteria for deciding what specialties you're looking at.

Another question you should ask yourself is do you need a lot of variety? Maybe the emergency room is good for you. I interviewed an emergency medicine physician back in episode 02 and he said majority of the day is spent dealing with a lot of the same stuff over and over again. All the other stuff is just a small percentage of what you see. Everything you do as a physician will get monotonous so you need to really love the monotony. Don't go into emergency medicine because you want to treat gunshot wounds all day long because that's not what your career is going to be like. You have to like all of the other stuff.

[12:50] Blood and Guts

How much you can handle blood and guts and how squeamish are you is a silly question. As we've heard from Dr. Melinek, again back in Episode 24, as a forensic pathologist, she deals with a lot of nastiness. With crime scenes and accident scenes and everything else, you're dealing with squished heads and blown up bodies. She said you just get used to it and get desensitized to it. It's something that happens all the time with your training. Right now as a premed or medical student, don't think that you don't like blood and guts because as you progress through your training, you will become more and more accustomed to blood and guts. Maybe you're different, but use that criteria right now and put that aside.

[13:55] I Am Not Good with My Hands!

Surgical skills can be taught so don't worry about that. If you feel you don't have that much manual dexterity, a lot of that stuff can be taught. Don't write off surgery just because you don't have the manual dexterity. Practice and get better. There's still lots of time.

[14:35] Medicine or Surgery

These are the general things to think about as you're starting this search and as you're hearing these episodes. When you're starting down this path and you're getting into the weeds and thinking what you're interested in, there's this huge divide. You have medicine and surgery. Medicine is going to be pediatrics, neurology, radiology, and internal medicine docs and a lot of those subspecialties. You're going to deal with a lot of the bread and butter.

To get started, go to the AAMC Careers in Medicine website to check out a huge list of medical specialties and what is available for you. This is where you start looking as far as what's out there.

On the other hand, F.A.C.S. (Fellow of the American College of Surgeons) recognizes fourteen surgical specialties. But surgery is surgery. Do you like the O.R. or not? Again, do not think about it as whether you like blood and guts or you get queasy around it because this is stuff you will get used to every time. Don't worry about it from that perspective. Personality-wise, the O.R. is a little bit different. The environment is different as well as the pace. Do you like that sort of environment? You don't know until you get in there.

There are four specialties typically named that are a great mix of medicine and surgery. We had this in last week's episode with urology (Episode 25). Urology, ophthalmology, EENT, and OB/GYNE are considered a really good mixed specialties that have medicine and surgery. So if you find yourself stuck in the middle of wanting to be in the O.R. but wanting to do a lot of medicine as well, take a look at those.

Do you like procedures? Dermatology is huge with procedures.  I've talked with Dr. Chris Sahler back in Episode 13 about Physical Medicine & Rehabilitation and how there's a lot of procedures in that specialty. Are you interested in working with your hands and doing that sort of thing but don't really want to be in the operating room?

There's a great ScutMonkey Comics by the blog site The Underwear Drawer that presents The 12 Medical Specialty Stereotypes, which I think are pretty spot on and funny. Take a look at it too as well as a couple of fun algorithm charts out there or a flow chart of how to choose your medical specialty.

[18:37] Final Words

Things you don't want to look at when it comes to choosing a career is income. It should be last on your list as far as what you're hoping to do in the future. Don't look at potential income as you won't be happy. You may get lucky but more than likely, you won't be happy if you're in it for the money which is the wrong reason.

Don't think, either, that just because you're choosing a certain specialty in an academic setting, you're stuck there for the rest of your life. Once you have your specialty, you can go move to a community hospital.

So these are the things I want you to think about just to get you in that mindset of what you should be thinking about when you're listening to these physicians talk about their specialties. I ask these doctors what traits do they think are good for this particular specialty, and when you listen to those, they are very much always the same. Nephrologists seemed to be the odd men out with one specific thing that you have have to love attention to detail. But everybody else says you have to work hard and you have to want to help people, be a lifelong learner, and all those generic things.

If you have something else that you want to add to this list to help choose a specialty, shoot me an email at [email protected].

Links:

Specialty Stories Podcast Session 16: A Private Practice Nephrologist Who Also is in Academics

Specialty Stories Podcast Session 24: What is Forensic Pathology? Dr. Melinek Shares Her Story

Specialty Stories Podcast Session 2: What is Emergency Medicine? A Community EM Doc's Story

Specialty Stories Podcast Session 25: An Academic Urologist Shares His Thoughts on the Field

Specialty Stories Podcast Session 13: What is Physiatry? (Physical Medicine & Rehabilitation)

AAMC Careers in Medicine

Fellow of the American College of Surgeons

MedEd Media Network

The MCAT Podcast

The Premed Years Podcast

The OldPreMeds Podcast

ScutMonkey Comics

[email protected]

Session 25

Academic Urology is a mix of medicine and surgery. Listen to Dr. Peter Steinberg discuss what drew him to the specialty, whether you and your personality would suit in this field, and what you can do to be a competitive applicant given that urology is one of the more competitive fields out there.

[00:50] Academic Practice

Dr. Steinberg chose academic practice over a typical community practice for two reason. First, he wants to have a more sub-specialized focus in his practice available in most community practices. Second, he enjoys working in training residents. He has been practicing for seven years now.

Peter started residency training in general surgery, which at that time most programs would require you to two years of general surgery prior to four years of urology. So he decided during his intern year to do urology, which was his second rotation as an intern and it was he deemed would fit him and his personality rather than general surgery. It took a while to get into a urology program but he kept doing general surgery and did the two required years before switching.

[02:05] A Better Fit to His Personality

Dr. Steinberg cites a few things that make him fit to be in Urology. First, the types of problems you encounter in urology involve a greater variety of issues compared to other fields like general surgery (at least as a resident where they often encountered issues that are extremely serious, extremely acute, and very challenging.) Urology, on the other hand, has a very broad spectrum of different things they dealt with ranging from simple issues to very serious and life-threatening and everything in between, something Dr. Steinberg was looking for.

Secondly, he noticed the personalities of the residents and the attending physicians matched his personality a lot better than a lot of the surgeons in terms of having a healthy work-life balance, good sense of humor, being jovial and collegial. And this speaks to the issues they're dealing with which are a little bit less stressful. He add that because of the nature of some of the problems, you have to deal with them with a little sense of humor with issues relating to people's sex lives and genitals.

As to getting a sense of what community general surgery was, Dr. Steinberg actually did a community general surgery rotation towards the end of his second year as a trainee, where he spent three to four months at a community hospital. They dealt with issues like hernia, gall bladder issues, and some serious issues occasionally. But  he saw a different pace as opposed to an academic center.

Dr. Steinberg stresses that the Venn diagram of overlap between training and practice can be very small depending on what you're interested in doing. He reminds med students and residents that in whatever job or field you're in, you can get it.It may not be exactly what you want, but whatever you want to construct in the medical field, someone somewhere will let you practice it. So seeing the community general practice was eye-opening for Peter where they seemed much less stressed and doing quick procedures with not a lot of complexity.

[05:49] Traits Leading to a Good Urologist

Dr. Steinberg describes Urology as a mix of medicine and surgery like EENT (Eye, Ears, Nose, & Throat) and that you need to have a couple of different aspects to your personality. You need some of that surgeon mentality of seeing problems that can be fixed and dealing with them rapidly and decisively. You also need a little bit of that family practice doctor type mentality where you're going to be dealing with people longitudinally where you have to get used to having rapport with people, building some trust, and dealing with them over time.

For instance, Dr. Steinberg does a lot of kidney stone work and a lot of nephrology where he deals with people with tinkering medications and their diet where he has to deal with them over the years. He also deals with them who have acute and surgical issues. You can have a multi-year relationship with someone where you go from doing some basic things to operating on them and dealing with them over time or they get another urologic problem over time.

Dr. Steinberg says you need to have a little bit of the longitudinal kind of primary care doctor personality and interest in dealing with the medical side of things but also some of the traits that go with being a surgeon in terms of being decisive and knowing when to and when not to operate on people.

Other traits he thinks would make a good urologist is having a good sense of humor that helps with everything in life, being loose, and being used to hearing things like sex lives and how they go to the bathroom. You need to have some degree of not taking things too seriously otherwise you'll have a hard time dealing with just how people describe their chief complaints and histories.

[08:40] Types of Cases, Typical Day, and Calls

Dr. Steinberg describes his mix of cases and patients with about two-thirds of his practice consisting of kidney stones, falling into general urology. The third is straight up general urology, encompassing issues like those having trouble urinating, blood in the urine, urinary tract infections, prostate issues, and other urinary complaints. He also deals with pain or complaints related to the penis and the testicle such as trouble with the foreskin, pain in the genitals, pain and swelling of the testicles, etc. This is the big bulk of general urology.

A typical week for a general urologist is somewhere between two and four days in the office and then one and two OR days. As with Dr. Steinberg, he will have a day consisting of office in the morning, a two to three-hour procedure in the afternoon, or in the office all day seeing a mix off new and returning patients and doing some office-based procedures such as stethoscopy or endoscopic checks of the bladder, vasectomies, biopsies of the prostate under ultrasounds. Some days he will be in the OR all day doing 30-60-minute outpatient kidney stone procedures and other endoscopic procedures, where he will do five or six of those in a day.

He sees around 1,500 patients a year and he does around 150-200 operations. He is a referral provider for other people sending in complex things. So it's a small percentage of the people he sees end up getting operated by him.

In terms of taking calls, Dr. Steinberg describes urology calls not to be horrendous. Most of the issues can be dealt with by emergency room physicians or some basic techniques known to other types of providers. In the group he's in, there are five of them taking calls so they are on call basically one week night and they have a larger group of people that take calls over the weekends so they're on call one weekend a quarter, a little less on the weekend than an average person but it really depends on the group size. Peter thinks most times, urologists are on call. If they do get called, they can have things the can deal with over the phone or things they need to be dealt with urgently or straightforward, as opposed to calls in other fields where calls deal with a lot of operations and doing a lot of stuff in the middle of the night. Basically, calls are very heavily phone, triage-based.

[14:37] Work-Life Balance

Dr. Steinberg says he has a good work-life balance. First, he takes all his vacations. Secondly, he enjoys going to medical meetings and he has found a good way to attend a variety of different meetings each year, about three to four of them which allow him to get away from work. Their national meeting is usually around May and regional meeting in the Fall. the subspecialty meeting is close to the end of year. He likes to ski so he also finds a ski meeting he goes to in the winter. So on top of going on vacation, he also gets away from work to go to meetings which he finds relaxing.

During his free time, he does things he enjoys such as skiing, sailing, and surfing. And living in Boston, he works around a lot.

[15:50] Residency Training Path and Competitiveness in Matching

Urology residencies have increasingly gone into five-year programs, which now include one year of general surgery internship and then four dedicated years of urology. More urology training goes to fellowship now because a lot of times, they're not getting all the skills they want in a particular subspecialty during their undergraduate training.

In terms of matching, Dr. Steinberg describes Urology as a very competitive field to get into. There are a couple of things unique about it. One, it has its own separate match and not part of the conventional match. It's one of the early match programs such as ophthalmology and plastic surgery and it's run by the American Urological Association. It's highly sought after now because of the work-life balance a lot of people find within the field. A typical urology applicant nowadays has a strong resume in terms of academic achievement in college and the basic science part of medical school. They have good marks on rotations like surgery and medicine and often get very good board scores, which is often the screening tool that programs use to pick out who they're going to interview. A lot of people have research experience or some other type of unique clinical experience such as doing an underserved clinic or traveling to the third world to bolster their resume.

Additionally, something very critical in matching into urology is doing away rotations at programs you're highly interested in matching in and performing well there. Most of these are pretty standard in terms of competitive programs having students come from other medical schools and you function as a sub-I on the service. Generally speaking, you're graded on a couple of things such as your performance day-to-day. Most programs make you give a big sum-up talk at the end of your rotation, a big area you're graded upon. Dr. Steinberg thinks most programs pretty heavily weigh people's performance on those types of away rotations as far as their rank list goes. Lastly, letters of recommendation go a very long way in this field because it's a small field. There are only so many training programs.

[20:03] Bias Towards Osteopathic Physicians

This was a big debate about a decade ago, having concern at the higher levels of organized urology about things like extending board-certification to osteopaths. But his has mellowed and there's been much more embracing of osteopaths within the field. There are some osteopath-specific programs out there such as Michigan State. Peter is not seeing any huge bias towards it but he thinks most osteopaths still currently congregate towards a couple of the more osteopath-specific training programs. This may improve in the future but for the time being, a lot of osteopaths going into the field end up in the more osteopath-oriented residency programs. Although Peter doesn't have osteopathic physicians as colleagues at their academic center, he thinks this is somewhat regionalized. He went to medical school in Philadelphia and PCOM (Philadelphia College of Osteopathic Medicine) was around so they were used to having osteopathic colleagues on rotations and as residents and faculty because there were so many PCOM graduates in Philly. He remembers the best anesthesia resident he ever worked with was a PCOM grad. So Dr. Steinberg thinks it's still somewhat regionalized given the fact that osteopathic schools tend to be regionalized. So a urology training in Philadelphia or Michigan is still that way to some extent.

[22:25] Message to Primary Care Physicians

Dr. Steinberg has actually been waiting for this to be asked for three years now. He sees three things that are routinely issues and backed up by the data people have acquired. He sees tremendous reluctance on the part of house officers and even attending physicians in practice to not do a genitourinary exam, a pelvic exam, or a rectal exam. They teach this to the second year medical students at Harvard where they do a half-day session on these skills. He finds it remarkable how often they get consulted and there's no documented genitourinary exam in the chart. The same goes with outpatient referrals.

He emphasizes that you have to learn how to do those exams as they're not that complicated. In fact, any urologist would be happy to show you how to do these things if you don't know how.

Secondly, Dr. Steinberg says that people need some basic skills in medical school and residency to put a Foley catheter in. You're not always going to have a urologist close by where you're going to be. It's not that complicated. There are times when you need a urologist to help you do it and there are certain things to look for there but it's a very important basic skill for everyone to learn.

Diagnostically, he thinks it's almost embarrassing how he feels like people have lost sight of how to do some basic work ups of common problems we see such as hematuria, kidney stones, working up an elevated PSA, a urinary tract infection, and just the basic things. If you're confused about the basic work up, especially when it comes to imaging for certain problems, the American Urological Association and other associations have tremendous guidelines on how to deal with basic problems. Dr. Steinberg recommends seeking the guidelines from some of these subspecialty areas to get some basic information on evaluation of hematuria, kidney stones, etc. So just know some basic things about what imaging tests you need, doing a good exam, and being able to put a Foley catheter in would go a long way and this would put you at the cream of the crop of internists in terms of dealing with these things.

[25:10] Working with Other Specialties and Subspecialty Opportunities

Dr. Steinberg is a bit unique in a way that he does a lot of complex kidney stone work so he deals with interventional radiologists and this is true for a lot of radiologists doing a bigger practice. Interventional radiology and radiology in general is going to be one area where you work very closely together.

Other specialties a urologist might work with include Pathology (if you do a lot of prostate biopsies, prostate cancer, bladder cancer, kidney and testes issues), medical oncology, gynecologic oncology, gynecology, obstetrics, colorectal surgery, nephrology, and pelvic surgery.

Moreover, fellowship opportunities are rampant within Urology including oncology, endourology, minimally invasive surgery and robotics, pediatrics (a separate board-certification now), female urology and incontinence, voiding dysfunction in men, reconstructive urology (urethral stricture disease), sexual dysfunction, andrology, male infertility and doing vasectomy reversal. Obviously, there is a variety of areas of subspecialization you can pursue.

In addition, if you go into practice and your group is big enough, usually people will tend to subspecialize to some extent. Even with urology, just residency training, there is tremendous ability to carve out your niche in the team like you could be the incontinence person in the group or the kidney stone, etc.

Dr. Steinberg explains that gender re-assignment is extremely subspecialized and that most of the male to female full reassignment is done by plastic surgeons. Some urologists will do male to female surgery because it's less technically demanding and does not require microvascular or microsurgical skill but that tends to be pretty heavily done by plastic surgeons. There are a few urologists involved in that and if you did want to get into that as a urologist, there is tremendous opportunity out there to be involved with that. Peter thinks it's a very under-served area without a lot of people with good skills. He adds that If you did reconstructive fellowship, you will immediately have a two-year wait list for operative patients if you went out into practice.

[29:05] Special Opportunities

Dr. Steinberg says there are ample opportunities to do things that are not direct patient care such as research in an academic setting or in any industry. There are tons of innovation within urology especially devices like for kidney stone, robotic surgery, incontinence surgery and pharmacologic work on things like the bladder, prostate, and in oncology.

There are tremendous opportunities in hospital administration and a lot of leadership opportunities within urology. You can do legislative work and advocacy. They have a political action committee called UROPAC. There's a congressman in Florida who's a urologist.

You can also do consulting to work with investment firms to figure out would certain areas be good investments. You can be a typical healthcare consultant. You can also do medical legal work as an expert witness.

[30:30] Most and Least Liked about the Job and Major Changes in the Future

What he likes most about his job is taking people who are feeling really unwell and getting them back to normal health. The least think he likes about being a physician in general is a lot of metrics in bureaucracy is making daily patient care more challenging. The focus of large healthcare organizations is getting slightly off-track from patient care and physician empowerment. Although Peter thinks the pendulum is going to swing the other way a little bit on this but it's his biggest gripe.

Dr. Steinberg thinks we've been in a drought for the last five to ten years and he thinks we're due for something. He's not sure where it's going to be but he thinks Urology is definitely due. Another big thing is the change in how care is delivered within the specialty in terms of people becoming employed by hospitals, larger groups forming, fewer small, private practices, and the consolidation of physicians together.

If he had to do it all over again, Dr. Steinberg would still have chosen Urology as the field suits him very well and he thinks it's an excellent choice for people with his personality and interests.

[33:50] Final Words of Wisdom

Dr. Steinberg leaves us with an advice that if this something you want to do, you will find a way to get into it. If you've got some deficiencies in your application in some ways, it's very easy to make up for problems with low board scores or some bad rotations. You can make up with it very easily with a strong research program, picking a program where you want to go and becoming a known entity there through research and away rotations. Don't be discouraged. With some embellishment of your CV, by being affable, and by being a good team player, it can be achieved if that's what you really want to do.

Links:

MedEd Media Network

UROPAC

American Urological Association

Session 24

Today's guest is Dr. Judy Melinek, a New York Times bestselling author and a Forensic Pathologist based in California. She documented her journey through her fellowship training in her book, Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner.

One important thing to note is that Pathology isn't actually a required rotation in medical school, one reason that it's not commonly under the radar of most medical students. Listen to our discussion about the field of Forensic Pathology and how you can explore if this is something you're interested in.

[01:20] Working as a Forensic Pathologist

Dr. Melinek does some academic work. She is currently affiliated with UC Davis as a Research Associate. Forensic Science students from their Master's and undergraduate programs shadow her but she isn't presently on staff at any academic institution.

Most forensic pathology jobs tend to be for government agencies, either a coroner/medical examiner's office. Any academic affiliation usually tends to be in the clinical instructor's status teaching residents and medical students.

Dr. Melinek did her fellowship in Forensic Pathology from 2001 to 2002 and then she did another fellowship in Neuropathology from 2002 to 2003. In 2001, she started working as a Forensic Pathologist because even during fellowship, she got paid doing autopsies being part of the coroner/medical examiner's office, specifically working for the New York City Medical Examiner.

[02:49] The Road to Forensic Pathology

Dr. Melinek only figured out she wanted to become a forensic pathologist until later since she wasn't exposed to it as a specialty in medical school. She stresses this is something we need to further discuss and explore because it's a real failing in our medical education that pathology is relegated to second year academic discourse but there is no required pathology rotation in medical school like there is for internal medicine or general surgery. It's only something people have to discover on their own.

Dr. Melinek got exposed to Pathology in second year medical school just like all medical students and then they offered this post-sophomore fellowship in pathology, which is an extra year you take in medical school between second and third year and work in the pathology department. You're just like a resident and you get paid but you're not just a resident or MD yet. But it's an opportunity for them to expose people to pathology in a more hands-on level.

She basically did this post-sophomore fellowship in Pathology having wanted to take a gap year between college and med school. But she got in off the waiting list and she was afraid she would lose her spot if she decided to defer. So she found this as an opportunity to take a break but still be doing medicine and working at the same hospital she was training at. Dr. Melinek describes it as a great experience having been exposed to multiple different rotations in pathology including the blood bank, autopsy, and surgical pathology. Also during that time, she was allowed to do research and she actually decided to do research with the liver transplant team. That's when she fell in love with surgery and decided she wanted to be a surgeon. But everybody in Pathology convinced her to be a pathologist.

Upon finishing medical school, Dr. Melinek matched in Surgery and went to a General Surgery residency and lasted for only six months until she collapsed from exhaustion and decided she wanted to be a Pathologist realizing it was a better fit for her personally and professionally. Because of her impressive work, the pathology department at the UCLA Medical School had saved her a spot outside the match so when she quit surgery, they gave her a spot to start in July. Dr. Melinek claims it was the best decision she ever made.

[05:40] Post-Sophomore Pathology Fellowship and Demand

This type of fellowship is sponsored through ACGME and the American Board of Pathology. The organizations that accredit pathology residency programs allow a year of pathology while you're still in medical school and it accounts towards your residency. This existed when Dr. Melinek was still in medical school. (Upon checking on the internet, some institutions that offer this program today include UCLA, Stanford, Duke, and West Virginia University. Check with the institution you’re interested in getting into if they offer such program.)

Of the six post-sophomore fellows they had during her time, three ended up in Pathology. Dr. Melinek says this program helps people who are interested in the field to pre-select and also it cements their interest. It's an easy way to get people interested in it.

She adds that Pathology is easy to recruit for once you're exposed to it. It's such a wonderful field. It's so intellectually stimulating. People are really nice. It has pretty decent work hours and not as physically or emotionally grueling as some of the other specialties can be, especially surgery. Dr. Melinek thinks it's easy to recruit but the problem is it's not a required rotation in medical school so it's not in the radar of a lot of students. It's not something they think about.

As a result, there are only about 700 or so board-certified forensic pathologists practicing in the United States, which is half of what they need for the demand. She sees job openings that are open for months and even years because there is just not enough forensic pathologists to fill. Dr. Melinek therefore highly recommends the field for medical students to consider in terms of job security and opportunities.

[07:51] Surgery versus Forensic Pathology

Dr. Melinek got drawn to surgery because of it's hands-on nature and you get to fix things, as a practical person that she is. However, she wasn't attracted to the field's lifestyle and found it to be too exhausting. She was on call every other night and she had to watch her attending physicians cycle through multiple marriages and being there late at night for long hours, sacrificing their family times and their own mental health in exchange for the career, which she thought as unnecessary. She believes it's a financial burden and a cultural problem in the field and that you really don't need to train surgeons this way as there are more reasonable programs in general surgery.

What Dr. Melinek likes about pathology is the reasonable hours. She basically was drawn to it primarily because of that exposure she had in medical school though at that time she didn't have the passion for it that she had for surgery. She felt disconnected from patients and that she wasn't being a real doctor. People do criticize that which of course Dr. Melinek thinks is such a crap. Anyway, she felt disconnected from patient care and from the action and excitement that surgery had until she did her forensic pathology rotation at the New York City Medical Examiner's Office.

[09:22] The Work of a Forensic Pathologist

When she was a resident in Pathology, they did rotations in different fields and she went to the New York ME's office for a one-month rotation. There she fell in love with the field, being able to go to crime scenes, testify in court, and interact with police officers and with family members of those who had died. She finally got that variety and excitement she was missing.

Dr. Melinek wants people to understand that this is the pathology work. You're not just in a lab doing autopsies and looking at microscopic slides all day. You do a lot of field work, going out to scenes as well as a lot of work interacting with a lot of families on the phone. You testify in court at least once a month on average for her. You also interact with lawyers as you try to explain the science to them. Basically, you're built in as an academic and a teacher even though you're not officially in an academic environment. Dr. Melinek finds herself educating family members about the disease process that killed their loved ones over the phone. She finds herself teaching juries about science so that they can make a good decision about guilt or innocence about civil liability. She considers herself a teacher, just not in formal academic setting.

[10:55] Traits of a Good Forensic Pathologist

You have to be curious and to be the kind of person who digs more into something when it doesn't make sense or it sets off your BS meter. A lot of medical specialties are not going to have all the answers and you have to take the best pass forward given the limitations of your time and financial resources. But in forensics, you have time. They have an expression in forensics that is kind of tongue in cheek, "They're still be dead tomorrow." On the plus side, it means you can work on a case the next day and not have to rush it. The other aspect of that is you can put this off 24 hours and think about it. You can look up another article or contact your colleagues and wait. There's no rush in those cases for you to come up with conclusion. What's more important is for it to be rigorous, accurate, and defensible.

[12:12] A Day in the Life of a Forensic Pathologist

Dr. Melinek currently works three days a week at the Alameda County Sheriff/Coroner's Office and sometimes fill in on Mondays or Tuesdays if other people are sick or on vacation.

Her typical day at work is waking up at 6:00 to 6:30 am and gets a text from her boss informing her of the number of cases she has. She gets her kids off to school and then driver to the office which is a 40-minute commute for her. She gets in at around 8:40 am. She reviews the cases and paperwork generated by death investigators from the office who are deputy coroners and they're the ones who went out to the scene and collected the dead body. They have a clinical summary about what happened to the deceased, whether they were ill or drug abusing, or when they were last seen alive, when and how they were found, the condition of the body. All of these are in the report. They review the reports and then split it up among themselves. In her current office, there is one chief forensic pathologist and four assistants who stagger their schedule so there's usually two or three of them on a given time. From 9am to noon, they go in the morgue doing the autopsies. A typical autopsy takes about an hour or an hour and a half at the most if it's a homicide case. Some cases can take multiple days where she would do two hours one day and two or three hours another day or splitting them up over several days. But majority of the cases can be done in an hour to an hour and a half.

In the afternoon, she does paperwork, field phone calls, talk to lawyers, and also does her consult work. In addition to working for the coroner's office, she is also an independent forensic consultant so she can get hired usually by attorneys and sometimes family members to do a second autopsy or give an opinion in a case of wrongful death, whether civil or criminal cases. She looks at paperwork and reports and gives them her opinion. Sometimes, she gets called to testify for court.

[15:00] Percentage of Cases

For the bodies that she's doing an autopsy for, their causes of death are a mix. About 10-20% of her cases are homicides, which is disproportionate compared to what you see on television. The remaining 80% is a mixture of natural deaths, people who are elderly or young people with natural disease but haven't seen a doctor. They either died at home or en route to the hospital or in the street and they don't know why they died. Then when she does the autopsy, she finds natural diseases, heart disease being the most common as well as lung disease from smoking and complications of obesity on the natural death spectrum. Another equal percentage of cases comprise accidents which are predominantly motor vehicle fatalities and overdoses. They can make it to the hospital and survive for a period of time but they'll still come to their office because any case that is sudden, unnatural, or violent gets evaluated by the medical examiner. A smaller percentage would be suicides. Dr. Melinek reckons it's 20% homicides, 80% split up between natural, accidents, and suicide.

[16:35] Call Schedule and Crime Scenes

In her current position as a contract pathologist, she doesn't take calls. The only person on call is the chief forensic pathologist and she estimates that he gets called out to scenes maybe once or twice a month at the most. In the previous job she held at the San Francisco Medical Examiner's Office, there were four of them who would split up calls. So they'd be on call for one week at a time, which means you just get called out at night to crime scenes and she gets called out about once a month. It would be unusual for her to called out twice in the same week, and it's usually once a week.

Most people may think that when you're being called out in a crime scene, they'd imagine CSI, Bones, or Dr. House. In reality, Dr. Melinek says it depends on the case. When she was In San Francisco, they get called out just for homicide, which are clear cut cases or those where they suspected a homicide. If she went out to a scene, it would have already been cordoned off by the police with a lot of police activity and the medical examiner would be the one would come in underneath the line. First, you have to sign in so they have a log of who comes in and out of the scene. You have to have your personal protective gear, gloves, booties, depending on the condition of the scene. The first thing they do when they get there is get basic information from the police officers at the scene about what happened, how was the body found, were shots fired, what did people hear or see, what are witnesses telling you. Then they go over to the body. They don't move it until after it's been photographed. A lot of time on the scene is typically spent waiting for the crime scene unit photographers to do their work and document everything with photography and video. And only then can they move the body, take a look, and assess the injuries so they can give the homicide detectives at the scene an idea of what they're seeing on the body and some leads about things they can question witnesses about.

When asked about how she gets used to seeing these crime scenes, Dr. Melinek explains that all of medicine is a desensitization process. She remembers the first time she came in and got introduced to a cadaver on her first year of medical school and she freaked out. She knew she would be dissecting a cadaver because that was part of medical school and she's always been fascinated in human anatomy and how the body works. She says there's always a gross out factor but you still find yourself getting drawn to it. You actually get desensitized over the course of medical school, the first time you see a delivery or an autopsy or you do surgery and you see somebody's chest wide open with a heart beating. It's shocking yet you're trained sufficiently to do your  job and follow the lead of the people with you in terms of learning how to cope with the stresses of the job.

Dr. Melinek finds that forensic pathology is actually less stressful than taking care of living patients for which she has done both. When taking care of patients, there are demands of the patients and families which can be unreasonable. They're in pain and suffering. They're not happy. So she found it more stressful given that and it was harder for her to separate from that and forget about it once she gets home than it is for her dealing with the horrible things she sees on the daily basis because she knows they're no longer suffering and out of their misery. She deals with this by thinking it's her job to make sense of this chaos and give some closure to the family and answers to the legal system that can help repair the mess that a few seconds of impulsivity created.

[21:05] Postgraduate Training for Subspecs

After finishing medical school, the minimum is three years of anatomic pathology residency and one year of forensic pathology fellowships. That's a total of four years of postgraduate training before you can go and work at a medical examiner/coroner's office.

Dr. Melinek did surgery first and then when she went to pathology, she didn't know she wanted to do forensic so she did both four years of anatomic and clinical pathology. Anatomic and clinical pathology combined make you more marketable for working in a hospital setting. Clinical pathology involves laboratory medicine so it involves managing the laboratories at the hospital, the blood bank, the hematology lab, the toxicology lab, the microbiology lab. It involves learning how the test work, the assays work, and how to supervise and manage the equipment and the technologists who work there.

So instead of the minimum three, Dr. Melinek did four years of residency and then two years of fellowship, one in forensic pathology and the other one is forensic neuropathology, which was a program that her fellowship placed at the New York City Office.

A typical neuropathology involves working in a hospital setting where you're diagnosing tumors and doing surgical pathology. It's a two-year program where one year is spent examining brains and doing surgical pathology while the other year is spent doing research in order to be board-certified. Instead, Dr. Melinek just did one year of examining brains in a forensic setting. It's both brains and spinal cord taken out of the autopsy in cases where the death is sudden or violent, sometimes they have gunshot wounds, sometimes history of seizure disorder, sometimes without any history and the pathologist out of prudence, saves the brain and spinal cord for a more thorough analysis by a neuropathologist. They would slice the brain and spinal cords and then look them under the microscope to make a diagnosis of things like Alzheimer's disease or chronic traumatic encephalopathy (CTE) which is injury caused by repeated concussions.

[23:41] Competitiveness and Testing the Waters

Dr. Melinek says it's not competitive to become a forensic pathologist, in fact, it's easier compared to other specialties and subspecialties. She adds that a lot of pathology programs don't fill. This is actually surprising to her because it's a great, fun job, especially now that she's hitting middle age and a lot of her friends and colleagues that have gone into other specialties are hitting burnout but she's not tired at all. She actually has colleagues in their early 80's and are still practicing because they love what they do. Everyday is something new. Everyday is challenging.

If this is something you're interested in or you just want to test the waters, Dr. Melinek recommends that you do well in your histology and pathology coursework in first and second year of medical school. Then start talking to your teachers, most of them are in the pathology department at your hospital. Find out about doing rotations with them and see if you can shadow them. Go down to the surgical pathology division and find out when they have their rounds or when they have their teaching cases. Sometimes they have resident conferences where they sit around the microscope and they look at slides. They always have extra room for medical students. She further...

Session 23

Our episode with Dr. Chris Sahler was one of our most popular episodes. I decided to bring you the PM&R residency match data since many of you seem interested!

[02:33] NRMP Main Match Data for 2017 - PGY-1 & PGY-2 Positions

Table 1 shows the match summary for all the different specialties and Physical Medicine & Rehabilitation only has 32 programs under PGY-1 positions. This is also one of those specialties where you can match into a PGY-2 spot and you have to separately apply for your internship. This table shows there are 62 programs for PGY-2 positions and that gives you a total of 94 programs. Just be careful when looking at data since some specialties may have they PGY-1 built-in while some do not.

Looking at PGY-1 spots, there are 119 positions. This is a relatively smaller program with almost 3 and 3/4 per program. And out of those spots, only one program went unfilled. There are 294 U.S. Seniors applying out of 595 in total who applied. (Remember for the purposes of this podcast when talking about match data, U.S. Seniors refer to U.S. allopathic students so these are students who are still in medical school going through the normal timeline so they're not taking any gap years after medical school.) This implies that more than half them applying for these spots are U.S. Seniors. Interestingly, only 74 U.S. Seniors matched for Physical Medicine & Rehabilitation out of 118 that matched.

Only 62.2% of the students that matched were U.S. Seniors. Comparing this to other specialties, 78.2% of those that matched in Emergency Medicine were U.S. Seniors, Neurosurgery at 83.9%, Neurology at 50.6%, and OB-GYNE at 81.4%. There is a very wide spectrum of what percentages of students matching are U.S. Seniors.

For PGY-2 Positions, students also need to rank and match into a PGY-1 spot, whether it's a surgery year, a transitional year, or an internal medicine year. So these are three different prelim years you can choose from. Out of those 62 programs, there were 294 spots available so it's almost 4 and 3/4 per program. This is a little bit bigger compared to PGY-1 position programs. And out of those 294 programs, none of them went unfilled. Out of 633 total applicants, 306 were U.S. Seniors and only 61.16% of those that matched were U.S. Seniors.

[07:28] Matches by Specialty and Applicant Type

Table 2 of the 2017 NRMP Main Match Data shows us where the other people are coming from. For PGY-1 positions, 33 were osteopathic students out of 118 physicians that matched in PM&R. This is 27.97%

Compared to other specialties. Emergency Medicine had 283 matches for osteopathic students (a pretty big number for non-primary care) out of 2,041 total students. That's 13.9%. So PM&R is 14% higher than that which is very interesting.

Looking at this data, you can't say osteopaths are at a disadvantage because less osteopaths are matching into some of these surgical positions. But if a student goes to an osteopathic medical school because they believe in their philosophy and manipulation, then going into surgery maybe doesn't make sense and so is going into pathology. So you can't just look at the numbers. You have to look at what's the reasoning behind the numbers.

It's easy to hypothesize that osteopathic medicine fits very well with PM&R, which is basically, non-surgical orthopedics. You're dealing with people who have aches and pains and joint issues as well as other things and osteopathic medicine works with that. So these PM&R programs seem to be very open to osteopathic students. In fact, Dr. Sahler talked about this in Episode 13 that PM&Rs are very open to osteopathic physicians.

For PGY-2 spots, all 294 positions went filled. 181 were U.S. Allopathic Seniors, 5 were U.S. Grads (these are students outside of the normal timeline), and 83 were osteopathic students, which means 28.2% of osteopathic students actually matched. So if you're an osteopath and are interested in this stuff, you have a good shot to get a spot here. Moving on, 17 were U.S. International medical graduates, 8 were non-U.S. citizen international medical grads.

[11:40] Positions Offered, U.S. Seniors, All Applicants, Osteopaths (2013-2017)

Table 3 tells us how the the number of spots is growing and looking at PM&R, it's growing slowly over the last four year at 0.4% every year for PGY-1 while for PGY-2, it's been growing much faster at 11% in 2017 from 10.9% in 2016. If you're interested in it, it's obviously a growing field for you.

Table 8 shows the percentages filled by U.S. Seniors versus all applicants from 2013-2017. It basically shows us a trend of what programs are doing, whether they prefer U.S. Seniors or U.S. Graduates or other students. Looking at PM&R for PGY-1, 62.2% in 2017 were U.S. Seniors, 61.16% in 2016, 60.7% in 2015, 56.3% in 2014, and 59.8% in 2013. So it has gone up pretty steadily over the last couple of years with more preference towards U.S. Seniors. For PGY-2, 61.6% U.S. Seniors matched, 52.8% in 2016, 45% in 2015, 53.7% in 2014, and 51.7% in 2013. There was a huge dip in 2015 which is really interesting.

Table 9 shows all applicants that matched by specialty. 0.4% of all students matched for PGY-1 spots matched into PM&R. Compared to other specialties, Surgery is 4.6%, Internal Medicine is 25.6%, Family Medicine is 11.6%, Anesthesiology is 4.1%.

Table 11 shows us osteopathic students matching into PGY-1 spots with 1.1% of all osteopathic medical students are matching into PM&R. Comparing that with the previous table of 0.4% by percentage, more osteopathics actually match into PM&R than allopathic students. This is very interesting yet it still goes with the fact that it does fit with osteopathic medicine.

[15:12] Unmatched and SOAP

Figure 6 of the 2017 NRMP Main Match Data shows the Percentages of Unmatched U.S. Seniors and Independent Applicants Who Ranked Each Specialty as Their Only Choice. PM&R is near the top of the list for total unmatched students at 27.5%. Internal Medicine (Prelim) is the highest followed by Dermatology, Psychiatry, and then PM&R. Majority of these students are independent applicants which means they are not U.S. Allopathic Seniors. You have osteopathic students, U.S grads who are already out of school and international medical graduates making up this number. This is a little scary since PM&R is higher on the list. Remember there was only one unfilled position so it's highly sought after for a specialty.

Table 18 is all about the SOAP (Supplemental Offer and Acceptance Program). Again, there was only one unfilled spot in all of PM&R. So for the SOAP, there was also only one spot available and as expected, it was filled through the SOAP.

[16:48] Charting the Outcomes 2016

Based on Charting the Outcomes 2016, Table PM-1 (Page 168 of 211) shows the number of contiguous ranks, Step scores, research, work experience, AOA, etc., to give you a picture of what these students look like for those who matched and did not match.

For U.S. allopathic Seniors, the mean number of contiguous ranks that matched are 14.2 programs while those that did not match were only 5.6. I can't stress enough the need for you to rank enough programs in order to match.

When you submit your rank list, you actually don't have to apply to only one specific residency program. You can apply to General Surgery and Orthopedic Surgery programs. For Physical Medicine & Rehabilitation, the mean number of distinct specialties ranked is 1.6 for those that matched and those that did not match were 2.2. Those ranking more programs are not going to be able to verbalize and communicate to these programs why they specifically want to go into PM&R because maybe they're out there ranking other programs.

Back on the data, the mean Step 1 score is 226, mean Step 2 score is 238. These are not terribly high Step scores. Those that did not match are 210 and 221 for Steps 1 and 2 respectively.

They have data for osteopathic students as well. Looking at Level 1 score for those that took the COMLEX, they have a 551 for those that matched and 492 for those that did not match, 563 for Level 2 that matched and 491 for Level 2 that did not match.

Charting the Outcomes 2016 Table PM-1 also looks at work experiences and volunteer experiences. AOA members comprised 6.2% of those that matched while 0% for those that were unmatched. (AOA in the allopathic world is for Allopathic medical students)

[21:10] Medscape Physician Lifestyle and Compensation Reports

Normally, I would also check on the Medscape Physician Lifestyle and Compensation Reports but PM&R is not included in the data probably because it's a smaller field so they didn't have enough respondents for it. So we do not have enough feedback to have the data here.

Links:

Specialty Stories Episode 13: What is Physiatry? (Physical Medicine & Rehabilitation)

MedEd Media Network

2017 NRMP Main Match Data

Supplemental Offer and Acceptance Program (SOAP)

2016 Charting the Outcomes - NRMP Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

AOA

Session 22

Aerospace Medicine is a subspecialty of Preventive Medicine and very unique usually to the military, though there are civilians equivalents.

If you are a premed student and you're getting ready to prepare for your medical school interviews, check out The Premed Playbook: Guide to the Medical School Interview. Its paperback version will be released on June 06, 2017. Preorder the book at Barnes and Noble now and you will get about $100-worth of free gift including a 1-month access to our brand-new mock interview platform (only currently available to those who preorder) and a 13-video course on the medical school interview. Text PREORDER to 44222 to get notified with instructions on how to get on this.

Back to today's episode, I will be interviewed by Ian Drummond, a fourth year medical student and the host of The Undifferentiated Medical Student podcast. Ian interviewed me back in Episode 24 of his podcast about aerospace medicine and I'm playing a part of his interview with me specifically relating to aerospace medicine.

[03:29] What is Aerospace Medicine?

AAMC's Careers in Medicine didn't actually have a description of aerospace medicine although it was listed under Preventive Medicine. Ian, however, will refer to this description provided by the Aerospace Medical Association and we will take it from there.

"Aerospace medicine concerns the determination and maintenance of the health, safety, and performance of persons involved in air and space travel. Aerospace Medicine, as a broad field of endeavor, offers dynamic challenges and opportunities for physicians, nurses, physiologists, bioenvironmental engineers, industrial hygienists, environmental health practitioners, human factors specialists, psychologists, physician assistants, and other professionals. Those in the field are dedicated to enhancing health, promoting safety, and improving performance of individuals who work or travel in unusual environments. The environments of space and aviation provide significant challenges, such as microgravity, radiation exposure, G-forces, emergency ejection injuries, and hypoxic conditions, for those embarking in their exploration. Areas of interest range from space and atmospheric flight to undersea activities. The environments studied cover a wide spectrum extending from the microenvironments of space to the increased pressures of undersea activities. Increased knowledge of these unique environments of “Spaceship Earth” helps aerospace medicine professionals ensure participants are physically prepared, physiologically safe, and perform at the highest levels."

[05:28] Building Trust and Relationships with Patients

I agree with all of it as a great representation from the organization. One of the biggest things missing which is unique to aerospace medicine is the relationships with patients. In fact, it is a huge factor in aerospace medicine which I think deserves its own call out there.

I will speak specifically to the Air Force although it's pretty similar for the army and navy which also have civilian flight surgeons. There are AME's (Aviation Medical Examiner) out in the real world that do physical exams for pilots. There is a civilian equivalent, just a little bit different for the military.

For the military, specifically for pilots, they usually go and see the flight surgeon for a few things. One is the mandatory annual physical examination (crossing their fingers that nothing is found). Second, if something is really wrong and they need help.

Typically, a pilot doesn't want to go and see the flight surgeon outside of those two things because every visit to the flight surgeon is an opportunity to lose their wings, which means they would no longer be able to fly. Because a flight surgeon has that control to make sure pilots and other people interacting with aircraft are safe operating the aircraft, it's their job to make sure that if they have any medical condition, we have to determine if they should continue flying or not.

As a flight surgeon, I was a rated flyer where I got to wear a flight suit and had wings. I was required to fly four hours a month to be part of the air crew to build that rapport and build that trust. I went for an MRI one day because I was having some symptoms and I got diagnosed with MS so eventually I was no longer allowed to go up in an airplane for the Air Force. Because of that fine line between being allowed to fly and have your career or you're not allowed to fly out anymore, it's such an important relationship to have that trust and rapport. It's one of the best parts about being a flight surgeon. There could be cases they're lying and hiding things from us, like a cat and mouse game, because they want to fly. They love their jobs and they love the camaraderie that comes with it and everything else so it's a large part of who they are.

Personally, I thought it was a stupid rule that I got grounded. MS is one of those weird things for aerospace medicine. The Israeli Air Force lets their pilots with MS fly. Ours is less progressive so they worry more about the cognitive decline since 75% of MS patients have some sort of cognitive deficit and that's what worries them. I did argue for a while but I lost.

[11:32] Flying the Plane

There are a couple of caveats here. In the navy, flight surgeons go through some of the pilot training courses. The army may do it like the air force where you go through a little bit of ground pilot school. For instance, they get to ride in a small Cessna plane and fly to see what it's like. The whole point of the flight surgeon is to make sure that pilot and other people can do their job so you have to understand what they're going through. Then you get to see how much there is to do.

I have my private pilot license. I have always been fascinated with airplanes so when I had the opportunity to get my private pilot license, I jumped on that.

As a flight surgeon where I had to fly four hours a month, it meant being part of the aircrew. So the majority of aircraft that I was in were bigger airplanes so I would just hang out in the back or in the cockpit but not actually controlling anything. Sometimes I would talk on the radio and help them with the radio stuff. The one time I got to fly something was in the backseat of an F-16 because the controls are right there.

When you have wings, it means you're in some way affiliated with the airplane. So it's not just the pilots, but also, load masters, navigators, flight surgeons, etc. having wings is just a designation that you're like a "real" Air Force and you're part of the plane considering there are other jobs in the air force that have nothing to do with planes (ex. bus driver, cook, etc.)

[16:08] Civilian Physician vs. Air Force Physician

When you're, say a Primary Care physician, there is almost never this thought about what job a patient does or can they continue to do it. It's usually the patient that asks for some time off because they don't want to work. But as a flight surgeon, that's always the first question at the top of my mind. I have to know what your job is and whether or not you can continue to do it. So if you're a pilot and you come in with a knee pain and I know that if an engine goes out and you need to push full rudder to keep the plane straight and land it, you're probable not going to be able to do that with how bad your knee is. So you can be grounded for a week or two to make sure your knees are better and then come back and see me to reevaluate.

*There is no such term as a "flight surgery" but it's an old name that's been held out for a long time. The actual practice is aerospace medicine and there are aerospace medicine residencies but you are a "flight surgeon" as an aerospace medicine specialist. There is flying but there is no surgery and there's definitely no surgery while flying. 

[18:44] A Typical Weekly Routine and Patient Types

A typical week for a flight surgeon is an ambulatory setting where you're seeing patients depending on what based your stationed at as an active duty flight surgeon. In some bases, you see dependents (the family members of the active duty member) while in others, you see retirees. So the types of patients you're seeing vary but you're seeing normal clinical stuff.

You're seeing a lot of occupational health visits. When a pilot comes in for their annual flight physical exam, it's an occupational physical where you check their vision, hearing, and other things making sure their healthy. But a lot of them are occupational-based which means making sure they meet the qualifications for continued flying. If seeing dependents and retirees, flight surgeons are basically a family practice physician so family members are treated for normal aches, pains, and colds, etc.

Depending on where you're at, 50% is seeing patients and another 50% is hanging out with air crew and building rapport, doing "shop visits." As a flight surgeon, you're an occupational health physician so if your base has airplanes and you're visiting the flying squadron to make sure things look good there and the facilities are clean. You go to the maintenance squadron and make sure people working on the airplanes are keeping a clean environment and not working with lead-based paint and bring it into their offices and where they eat. You're simply making sure the base stays healthy. So you're basically outside of the clinic a lot of times and interacting with the rest of the base population which keeps things varied and you get a lot of diversity.

When you go to site visits, it's like carrying a clipboard with a checklist like making sure they keep separate wipes for their masks or have separate sinks for different things. So a lot of the things are structured that way while some of it is just using your intuition and question-asking skills. Usually, you go out with a team consisting of public health or bio environmental engineering while you're focused on the health side So it's a very collaborative team-based approach.

[23:16] Flight Surgeon as a General Practitioner

50% of the time, a flight surgeon is basically a practitioner except of the military. Also, a large majority of flight surgeons are general practitioners which means they're only internship-trained. This is the way the Air Force gets flight surgeons wherein a lot of them are fresh out of their internship. There are also a lot of flight surgeons with residency training, like OB/GYN, Orthopedics, Family Medicine, or Internal Medicine. You can actually have any specialty and be a flight surgeon if you choose to. And if you have specialty training and become a flight surgeon, you have to go through all the aerospace medicine training before becoming a flight surgeon because it's unique and different.

Aerospace medicine is a subspecialty available to everyone in the military. They usually need flight surgeons so there are several physicians that jump ship from their specialty and subspecialty and come over to the aerospace medicine world.

[24:50] Patient Outcomes

Typical outcomes would be just like a family practice doctor where you're seeing people with their aches and pains, sniffles, and flu so you're treating an acute thing for a week or two and grounding them for a week or two and then they come and see you and things are better.

Although there are also some unique things that could happen like somebody losing their vision or has a random new diagnosis. There are a lot of bad things that can happen to cause somebody to lose their wings. As a flight surgeon, you also take care of firefighters, which is another big occupational health job.

The outcomes are usually normal healthy people but when you get those random diagnosis, it's a life-changer.

[26:23] Most Exciting and Most Mundane about Aerospace Medicine

The most exciting is being able to go out and be part of the aircrew and fly around the world or fly an F-16 or do all sorts of missions, experiencing what the rest of the base is doing. Conversely, the most mundane part is dealing with normal aches and pains like dealing with blood pressure management or diabetes management, basically the boring normal doctor stuff.

[27:10] Wish I've Known About the Specialty

When I got the call to say I was going to be a flight surgeon, I didn't know what it was. When I was in it and now that I'm out of it, I don't think there's really anything that I had wished I had known about other than I wish I would have known about it.

Consider doing aerospace medicine especially those who are on an HPSP scholarship. It's an amazing job and there are so many things you can do. Even if you're interested in a specialty, go be a flight surgeon for a couple of years and then go live the rest of your life. The stories I can tell now, having been a flight surgeon, are going to stay with me forever.

[28:40] What is HPSP Scholarship?

HPSP refers to Health Professions Scholarship Program that offers about 150 scholarships a year where you get into medical school and you apply for the scholarship. Once you get accepted, they pay for medical school and then you owe them a year for a year of scholarship, where you can do a 3-year or 4-year scholarship.

[29:28] Combat, Non-Combat, and AME's

Because it's more of a military-based career, I will divide this into a non-combat and combat.

As a non-combat flight surgeon, depending on where you're stationed, you can be stationed anywhere throughout the world. You can be stationed at a place without planes. But majority of your job is to make sure that the population of that base is healthy. It's always an ambulatory setting. There would be no need for an in-patient hospital-based flight surgeon.

When you're deployed in a combat setting, you can run different parts of the medical evacuation triage tents and stations along the way. When somebody gets injured in combat, they're evaluated and triaged to see if they need to be evacuated out to a bigger hospital or if they can just be treated where they are. As flight surgeon doing that evaluation and determining what kind of aircraft they need to fly on, meaning is this an injury that is going to get worse at altitude or do they need at low altitude, do they need to be in a helicopter and stay low or stay in an unpressurized aircraft at a low altitude. So you're basically doing a lot of cool triage in trying to figure out what's best for the patient based on aircraft, altitude, and other things.

An AME is an Aviation Medical Examiner, a designation where you get certified through the FAA. As an AME, you're usually a family practice doctor or an internal medicine doctor or somebody interested in aviation. It's a cool job because it's usually a cash-based business. You can see Class 1, 2, and 3 pilots which need a certain number of physical exams depending on the class. You have to go through FAA training which is free. The population of AME's has significantly decreased over time so it's now getting more difficult for pilots to find an AME and get their physical exams. An AME is very similar to a flight surgeon where there are strict guidelines that determine whether or not you're able to fly and bases your evaluation on those guidelines and makes recommendations based on that. FAA training is not the same as an aerospace medicine residency. It's a week to two-week long course that the FAA puts on.

You can be a flight surgeon at NASA. I've been down to the space center in Houston and visited the world's largest swimming pool where the astronauts do all their training for weightlessness. And as a flight surgeon in the air force, I did see people that wanted to be astronauts and I would do their initial physical exams before they would go down to Houston to get their full physical.

[36:15] Pilot Physician

Moreover, you could be a Pilot-Physician of which the Air Force gives 20 spots. A student I'm working with is in the Air Force right now and wants to go back to medical school but she's also a pilot, not in the Air Force but she is a private pilot with 600 hours and she flew with the academy on their stunt team.

They typical path for a pilot physician is you're a pilot and if for some reason you get interested in medicine and you go to medical school and you still want to be in the military, you become a pilot physician. So you're a physician first but you have the pilot training and usually, you're doing a lot more higher level things than just seeing patients in a clinic but you're looking at a lot of the regulations being written, research into new technologies, etc. Since there are only 20 slots in the Air Force, it's a highly sought-after position and because there are not enough pilots are going on to be physicians, they're looking for physicians that may be interested in going into pilot training through the air force to be pilot physicians. I did look into this but I didn't pass the age requirement. I was too old to start since 29 is the oldest to start the training and I was already 30 or 31.

The Air Force is taking any physician but you obviously have to go through their aerospace medicine training at some point. The unique thing a pilot physician offers is the research and more of having the deep knowledge base and foundation of having both careers under your belt and being able to make those regulations and see things from both sides.

[39:56] The Biggest Challenge and the Future of Aerospace Medicine

One of the biggest challenges of aerospace medicine is that a lot of people don't understand us so there is much pressure for us to start doing more and seeing different types of patients. Apparently, there is a lot of misunderstanding from the greater Air Force of what our job is.

What the future holds for aerospace medicine in 10-20 years would be that as we go to more and more autonomous aircraft, where we have drones, majority now are remotely piloted. They are not unmanned aircraft, they're manned, just in a different location. Because of that, interest in aerospace medicine will go down. Part of the lure is being able to go fly and so why would you be doing it if there is no plane to fly. There could also be unique psychological challenges that come into play for drone pilots. We're going to fighter planes (F-22 and F-35) that are only single-seat planes, which means the flight surgeon can't go up there and the less experience they get. There will be the heavier aircraft like the C-5 and C-17 and re-fuelers.

[44:35] Final Words

Aerospace medicine is an awesome and great job! Although pretty much specific to the military, there are civilian residencies for aerospace medicine. For this podcast, I'm not going to dive into all medical specialties in the military for two reasons. First, the practice of Pediatrics in the military is not very different than...

Session 21

General Surgery is gaining in popularity, which shows in its competitiveness for residency. You need to be on the top of your game to match. And similar to Internal Medicine, it is the gateway to a lot of subspecialties.

As we're presenting the data here, remember that this is not just for those looking to be general surgeons their whole life but those who are looking into other subspecialties which we will be featuring here on the podcast in the future such as Surgical Oncology, Colorectal Surgery, Surgical Critical Care, Minimally Invasive Surgery, etc. There are certainly a lot of things you can go on and do after your general surgery residency.

The 2017 NRMP Main Match Data is now available since the match happens in March of every year.

[01:45] Total Number of Programs and Applicants

For General Surgery, there are a lot of physicians available with 267 programs around. There are 236 Psychiatry residencies and 204 Pediatric residencies so that gives you an idea that there are more general surgeons than pediatrics. There are 241 OB/GYN residencies so there are a lot of surgical residencies.

General Surgery has two categorical residency programs. A categorical program is one where you apply to the program from medical school and that's where you're going to do your five years of General Surgery residency. Then there are prelim surgery positions and there are more prelim surgery positions than there are categorical.

Somebody doing a surgical prelim can do it because they're going into a surgical subspecialty straight out of medical school and they're required to do their PGY-1 year separate from their categorical residency.  In this episode, I will only tackle the full five-year categorical surgery programs consisting with 267 programs for categorical surgery.

Out of 267 programs, there are 1,281 spots. There are almost 5 spots at each program. Interestingly, there are not a ton of U.S. Seniors applying for these categorical programs. And out of these spots, there were only 1,383 that applied and 2,388 total applicants. For the purposes of this data, U.S. Seniors equals Seniors at an allopathic (MD) medical school. Hence, this does not include graduates of an MD medical school. These are only students who are still in school. Those who took some time off to do some research or didn't match the first time are not included in the U.S. Seniors data. There were 3 unfilled programs which means a lot of of people are matching with 99.6% of the spots filled.

I want to briefly mention that if you don't match in a categorical spot, it's typically pretty easy to do a Supplemental Offer and Acceptance Program (SOAP), which used to be called Scramble. There are only 61.7% of those spots were filled. So it's very easy to do a SOAP into a program if you don't match in a surgical program.

But assuming your stats are decent and you're a good person, you're probably going to match because it's not overly competitive for U.S. Seniors which is interesting.

[06:55] Types of Applicants

Table 2 of the 2017 NRMP Match Data breaks down the types of applicants for each specialty. For categorical surgery, there were 1,281 positions and there were 1,276 were filled. So there were 5 empty spots and 3 programs that went unfilled.

Out of the 1,276 filled positions, 1,005 were U.S. Seniors while 74 were U.S. Grads (students that either didn't match the first time or didn't apply because they were doing research or something else. Total number of U.S. Seniors (allopathic MD students) was 1,079 out of the 1,276 positions. The rest of it was filled by 64 osteopathic students and 62 U.S. International medical graduates.

Something that is highly debated in the premed world is whether to go to a U.S. DO school or an international MD school, specifically Caribbean schools. If General Surgery is something you're interested in, there were 64 students that matched from U.S. osteopathic schools and 62 from international medical schools.

Moving along, there were 71 Non-U.S. International medical graduates that matched into General Surgery. For me, this is a peculiar number and is not something I would have thought to see. It just goes to show that there is still a high demand for General Surgery spots so they're taking as many possible and the most qualified and a lot of those happen to be non-U.S. citizen international medical graduates.

[09:47] Trends in Positions Offered and U.S Seniors (2013-2017)

Table 3 of the 2017 NRMP Match Data illustrates the total number of physicians offered from 2013 to 2017.

This is the fourth time I've looked at the Match Data and the numbers always seem to very consistent. Surgery is no different at 4.4 to 4.5 every year, going at a a good, steady pace and hopefully it continues that way.

Table 7 shows the number of U.S. Seniors being accepted compared to all applicants over the course of the last five years. As the number of seats in each program has increased all the way up to 1,281 for 2017, the U.S. Seniors are increasing as well. This is a good thing in that more U.S. allopathic students are going into General Surgery to fill this increasing need for spots. It's not necessarily a good thing for DO students or U.S. International medical grads because the demand is rising among U.S. Seniors as there are more spots.

Table 8 shows the actual percentage of U.S. Seniors for each of the programs. There were 80.8% of U.S. Seniors in 2013 and it dropped down to 76.5% in 2014, back up to 80% in 2015, back down to 76.4% in 2016, and then up again at 78.5% in 2017. This suggests that maybe the demand is not as high also looking at the data in table 7.

Table 9 shows the percentage of applicants that matched into a given field compared to the rest as a whole. 4.6% of all applicants that matched in all fields matched into Surgery (categorical). So it's up there. Internal Medicine is huge at 25.6%, Family Medicine at 11.6%, Emergency Medicine at 7.4%. This gives you an idea of where Surgery lies. Interestingly, Psychiatry (categorical) is at 5.4% which is more than Surgery and Pediatrics at 9.7%.

[13:25] Osteopathic Students, Unmatched U.S. Seniors, Independent Applicants, and SOAP

Table 11 looks specifically at Osteopathic students who have matched into PGY-1 spots as a whole. This is similar to the last table but this one looks specifically at osteopathic students. As expected, General Surgery has a lot less total number of osteopathic students percentage-wise. Looking at all specialties adding up to 100%, Surgery only made up 2.2% of all osteopathic students that matched into an allopathic General Surgery (categorical) program.

Students may think it's harder to go to an MD General Surgery residency as a DO student and if this is what they want to do, then they should probably only apply to MD programs. My different perspective on this is that if osteopathic schools are doing a good job at recruiting students that meet this "osteopathic" philosophy and are looking at recruiting and attracting more students that are interested in Primary Care, then there should obviously be a lot less that are matching into a surgical program.

Figure 6 of the 2017 NRMP Match Data shows the percentages of Unmatched U.S. Seniors and Independent Applicants (outside of the U.S. Seniors which, for these purposes, are considered U.S. allopathic students who are still in school). General Surgery had one of the higher unmatched rate at 20.7%, which is 9th on the list. Majority of those are unmatched, independent applicants (non allopathic students, non MD Seniors). The unmatched U.S. Seniors was only 9.6%. This is still high compared to a lot of the other specialties. It seems it's getting more and more competitive and this is a trend that I've heard from speaking to others that General Surgery is becoming more and more competitive as there are more options available for these subspecialties and fellowships afterwards.

Table 18 breaks down the SOAP process and looking into Surgery (categorical), there were 3 programs that needed to fill 5 spots and all 3 programs filled those 5 spots through the SOAP process.

Looking at the National Matching Service Data for 2016 for the different program types, there were 49 programs for General Surgery for osteopathic students and 155 positions. 149 positions were filled and 6 went unfilled.

The data given is not as robust at the NRMP so I'm uncertain if there were a lot more applicants than these 155 spots and a lot went unmatched or if there weren't just that many applicants.

[17:43] 2016 Charting the Outcomes - NRMP

Based on the 2016 Charting the Outcomes for the NRMP, Chart 3 shows the match rates and there was an 83% match rate for U.S. Allopathic Seniors for General Surgery. Looking at other specialties, Dermatology at 77%, Neurosurgery at 76%, Orthopedics at 75%, Plastic Surgery at 77%, and Vascular Surgery at 71%. So General Surgery is right there with all of the other surgery subspecialties.

Chart 4 shows the Median Number of Contiguous Ranks of U.S. Allopathic Seniors. For students that matched and those who didn't, the chart shows you how many programs they ranked on their rank list when they submitted. Those that matched ranked 13 as a median number while those that did not match ranked 5. If you are picky about where you go or if you didn't get an opportunity to apply or to interview at a lot of spots, then you have a lot less chance of matching.

Chart 12 shows the percentage of U.S. Allopathic Seniors who are members of AOA (the Honor Society for medical students showing good academic success in medical school). For those that matched only 17% of the U.S. allopathic Seniors were AOA whereas 52% for Plastic Surgery and 53% for Dermatology. So General Surgery is in the lower end for a surgical specialty.

Looking at the Summary Statistics (Table GS-1) for General Surgery, those that matched have a decent Step-1 Score at 235 and those that did not match at 218, which shows a big difference in Step scores. This is one of those things where you need to be very realistic with your chances of matching. If you don't match, why? Could it be that because your Step score is not high enough? The mean Step 2 score is 247 for those that matched and 231 for those that did not.

[21:20] Burnout, Happiness, and Compensation

The Medscape Lifestyle Report 2017 and Medscape Physician Compensation Report 2017 are two separate reports that Medscape releases every year.

For the Lifestyle Report, more than 14,000 physicians over 30 specialties have responded in the survey. The numbers are not necessarily the best data-wise because it's a survey so just take this with a grain of salt.

Who is the most burned out? General Surgery is lower on the list at 49% which is more than halfway down the list. This is good. But looking at how severe is the burnout, surgery is higher up on the list at 4.3 from a scale of 0-4.5.

Which physicians are happiest at work and outside of work? General Surgery is higher up on the list with 35% happiness at work and 69% happiness outside of work. So it's on the higher end of the scale.

Moving on to the Medscape Physician Compensation Report 2017, General Surgery is higher up on the list with an average annual salary of $352,000. Above it is Anesthesiology and below it is Ophthalmology. So it's a decent living as a general surgeon. Although if you think about the lifestyle and everything else, it's harder. So you're compensated for that harder lifestyle.

Looking at the rate of increase year over year,General Surgery had a 9% increase which is pretty decent. The number of physicians who feel fairly compensated for General Surgery is lower at only 48%.

Whether a specialist would choose medicine again, General Surgery is right in the middle at 77%. While only 82% said they would choose the same specialty, which is a little in the lower half of all the specialties there.

[24:50] Final Thoughts

If you're not sure what you're interested in yet, go through these numbers. It's eye-opening to see what is going on in the world when it comes to matching and physicians that are happy and making money and those that aren't.

Links:

MedEd Media Network

2016 Match Data NRMP

Supplemental Offer and Acceptance Program (SOAP)

National Matching Service Data for 2016

Charting the Outcomes - NRMP Medscape Lifestyle Report 2017

Medscape Physician Compensation Report 2017

AOA

Session 20

Dr. Stephen Grupke is an attending Neurosurgeon at the University of Kentucky. In our episode today, he discusses the residency path to neurosurgery, what makes you a competitive applicant, his typical day, the types of patients and cases he serves, what he likes best and least about his subspecialty, and more.

Stephen and I went to New York Medical College together. Currently, he is a neurosurgeon in an academic facility and a new faculty being an assistant professor at the University of Kentucky.

[01:30] Choosing the Specialty

Stephen knew he wanted to be a neurosurgeon when he was in graduate school. Being a chem major in undergrad, he was working in a lab in grad school. A neurosurgery resident at New York Medical College did a research under his belt and took Stephen under his wing doing experiments and showing him different amazing stuff and he was just taken by it right there. That was actually the first time he saw what it's like to be a neurosurgeon and it was something he would love to do. That was what sold him to be a doctor.

[04:33] Traits that Lead to Being a Good Neurosurgeon

Stamina is a major key in being a good neurosurgeon since taking out a brain tumor can take hours and hours and that can be very physically and mentally taxing. You can have long clinic with a lot of people and a lot of varied problems so you have to think every one of them through, giving genuine, concerted effort to every single person considering they have very different pathology. Emotionally, the level of acuity in what they see is profound, having several highs and lows in one day. You could see pretty horrible things like abused children coming in with brain traumas and people being diagnosed with brain tumors. Then you have to relay this information to the family. On the same note, you can bring somebody from the brink of death in the operation and give somebody function back with a simple spine surgery that enables them to live without pain. In short, there is a lot of emotional highs and lows and to just deal with that day in and day out is kind of tough. You just have to focus on the highs in between and move on to the next thing and do the best you can for every person that comes to your door.

The longest case Stephen has been in was a brain tumor case as a resident that went fourteen hours. Although they've also had spine operations that ended up being broken up in a couple of days such as a long, complex scoliosis case in multiple levels.

Besides Neurosurgery, other specialties that crept into his mind was Neurology, being cerebral and focused on the central nervous system and everything that entails. He likes having to think of esoteric pathology you need to figure out. Internal medicine is another specialty of interest for Stephen, as it shares a lot of things with Neurosurgery in terms of the complexity and diversity of the cases you see. There's a lot of detective work involved and you get to see a lot of different specialties.

One of the things that led Stephen to Neurosurgery is knowing a lot of varied information in a lot of different specialties such as Endocrinology for pituitary tumors or traumatic brain injury cases. You have to be adept at critical care management as well as fluid and electrolyte maintenance. There is so much intermingling of other sub-specialties since the brain is ultimately involved in every other system of the body.

[10:10] Types of Patients and Typical Day for an Academic Neurosurgeon

As a neurosurgeon, Stephen sees all sorts of pathology. In his practice, he tries to focus on cerebral and vascular neurosurgery like cases of aneurysm, arteriovenous malformations, etc. But when you're on call, you have to be willing to take whatever is thrown at you and treat everybody from premature babies all the way up to the very elderly, people from all different socioeconomic classes and all kinds of pathology from taking out a tumor in the peripheral nerve and spine surgeries to open surgeries and endovascular surgery. Because of its variety, it keeps things interesting.

Stephen's typical day would be getting into the office at 6 in the morning to give him a breathing room to go over some of the labs and images of the patients from the day before. He spends one day of clinic a week from 8am to 5pm, which consists of seeing new patients and operative followups. A couple of days in a week would be spent in the operating room treating patients. Another couple of days in a week would be spent in the endovascular suite doing things like diagnostic cerebral angiograms or treat aneurysm cases or angioplasty and stenting to treat coronary stenosis or treat arteriovenous malformations with glue embolization.

As a resident, Stephen has done several hundred cases as part of an enriched curriculum that focuses essentially on endovascular treatment of cerebrovascular disease. Now, he's doing another year under the tutelage of a group of physicians at the University of Kentucky who also serve as his mentors so he can get a certification in cerebrovascular intervention. So Stephen does this for two days a week.

Some specialties like interventional radiology and neurology are also doing these fellowships to become adept at this intervention. Stephen doesn't really see any turf war going on in his institution especially that one of his mentors is an interventional radiologist and is grooming him to be a partner in his practice. In general, however, he is seeing a little bit of turf war across industries that are trying to get in on it. Moreover, there is a move for interventional surgery to standardize fellowships to make sure that everybody that comes out from these other specialties that they're giving an essentially comparable product.

[15:15] Taking Calls and Procedures

As far as interventional call, Stephen takes one-third of the call which they do a week at a time. This is much less rigorous than primary neurosurgery calls. Things they would have to come in for would be endovascular treatment for aneurism or stroke. Thrombectomy for stroke has taken off since February 2015 when several studies released showed its efficacious intervention. As a result, it has opened the door for a lot of people that may not have been candidates in the past to have a mechanical thrombectomy. For that, they end up getting called in the middle of night. Being a comprehensive stroke center, they've always got somebody on call to do that. Generally, they don't get any call every single night by any stretch but primary neurosurgery calls would be every 6 or 7 nights which is totally manageable and doable.

Considering he spends one day a week for clinic, only a small percentage of those patients are being brought to the operating room. Some people are keyed up to come in that have been sent to him from pain clinics and anesthesiologists to have interventional pain procedures done. These are people that have already been worked up and already know they're getting a surgery. But for ten people he sees for back pain, a common thing that primary care doctors send to them, one-tenth of them or less is something worth going to the operating room given that conservative management has been done first (ex. physical therapy, eat, rest, ice). In general, 20% of the people end up getting into surgery and the rest involves counseling in terms of pathology and management. For most cases, he tries to be conservative with.

[18:56] Work-Life Balance

Stephen doesn't think any neurosurgeon does since neurosurgeons have this workaholic stereotype he sees as true to some extent. He has a nasty habit of bringing work home with him. He has three small children and he's happy he gets to spend a lot of time with them. He his fortunate to have a program that emphasizes a good home-work balance since their chairman wants to make sure they are happy at work and a big part of that is making sure you have a good balance in life. Nevertheless, there are many nights spent on signing notes, reading upcoming cases, or writing papers at home. Still, he makes it a point to take time out of his day to do as much family time as he can.

[20:52] Academic vs. Community Setting

One of the biggest benefits Stephen sees being in an academic center is being surrounded by a great group of residents. He gets to play a part in teaching them and helping them to become the next generation of neurosurgeons and being able to walk them through the same steps his predecessors did for him so it's his way of paying back.

Additionally, it puts him in the forefront of what's going on academically in neurosurgery which is a wide open field. There is so much that's not known about the brain and there's so much research going on and it's really exciting to be on the forefront of that and seeing that happen in real time. They get to a lot of these interventions before the community even gets to them being involved in the big multi-institutional research projects. They get to see a lot of unusual pathology being sent to them since only a big university that have resources and experts such as theirs that can deal with that.

[23:00] Neurosurgery Residency and Matching

The ACGME requires a certain number of these different categories of procedures under your belt while being a resident and you have to do so much time in the ICU and such.

For Stephen, he graduated from medical school and spent the year doing an internship that is part general surgery subspecialty and part neurosurgery and neurology. (Today, they're now more focused on neurosurgery and neurointensive care.) Then Stephen had to go through six years of neurosurgery residency. As a junior resident, he did a lot more of the carrying the call pager, dealing with the ER, seeing new consults, helping staff clinics, and helping taking care of the patients on the floor and in-patients. As he went on, he spent more time in the operating room and spent more time doing academic stuff. He spent more time on the lab and molded his curriculum in a way he could enrich himself in certain subspecialties once he met his prereqs. As he got on towards the fifth to seventh year, he took on more of the administrative roles, working with scheduling of junior residents and juggling taking care of the operating rooms, being the chief on call, and helping junior residents on the floor and be the resource for the younger ones. Typically, it was a total of seven years of residency training for neurosurgery.

Neurosurgery is basically competitive when it comes to matching and Stephen imagines it getting more and more competitive having met some really smart, capable, qualified folks over the last couple of years that unfortunately ended up in the scramble. It's relatively competitive since there are not that many spots and there's a lot of very smart, capable, and qualified applicants. Stephen thinks that despite the specialty being a very tough and rigorous lifestyle and residency, there are a lot of people that are up to meet that and take that as a challenge and want to face it head on.

[28:00] What Makes a Competitive Applicant for Neurosurgery

As somebody who has been a chief resident and as an attending who has been in the committee that goes over all of the applicants, Stephen sees that everybody that gets on his table has great boards scores and good grades but that's not what seals it for you but being able to show in the interview that you're a reasonable person. There are smart people that are capable of making a hostile work environment so you want a good esprit de corps and you want everybody to get along that makes life nice and that's what their resident group has.

Having said that, their match system is difficult in that they interview applicants for a day, similar to speed dating. Stephen says one of the best ways to see if you would fit is to go to place you're interested in and do a sub-internship there whether a month of medical school or just a week. Go back for a second look after you've done your interview to spend some time with them. Any residency program can really put on a good face for a day so it's important to be able to see how everybody is on a day-to-day basis. What makes a good applicant for Stephen is them being able to trust that they're going to get along with you.

[30:58] DOs, Subspecialties, Primary Care, and Other Specialties

Unfortunately, Stephen doesn't know a lot of DO neurosurgeons probably because he has not just been out of the academic world for a long time and he went to an allopathic school as well as throughout residency. Although he knows there are some designated DO neurosurgery programs, but he doesn't know enough about them to comment on this.

After seven years of residency training, subspecialties available include Pediatric Neurosurgery or Cerebrovascular Neurosurgery. Today, physicians can get CAST or Certificate of Advanced Surgical Training where they do an enriched program, meeting a certain amount of criteria, and do several cases to qualify for this. Then you get a certification that you've done something above and beyond, whether that be for spine, epilepsy, peripheral nerve, and a lot other subspecialties for neurosurgery that you can focus on.

To be able to do this, Stephen suggests being in an academic center where you have other folks that can cover the rest of the subspecialties. such as functional neurosurgery like deep brain stimulation. While you want to subspecialize in something else, they have a good complement of attendings in their group.

Stephen has a good relationship with primary care physicians in their area, them knowing that neurosurgeons are there to help. The important thing is for them to know that neurosurgeons are always available to help them with things, even the non-surgical stuff, such as back pain and neck pain which are sometimes better dealt with physical therapy or a physiatrist. It can be hard to make heads and tails of which one is surgical or which is not, and they're more than happy to go over that with a patient and let them understand what's going on. This makes people feel they're being carefully looked at or things are fully being explained to them.

Other specialties neurosurgeons work the closest with include Oncology (for tumors in spinal cord and brain or peripheral nerves), Physical Medicine and Rehabilitation (for brain pathology due to stroke), Hospitalists, Vascular Surgeons, Carotid Artery Pathology, Trauma Surgery, Endocrinolgoy (for Cushing's disease and pituitary tumors) Neurologists are their closest colleagues, sharing management on stroke patients and epilepsy. They end up being closely involved with a lot of different departments.

[38:40] Special Opportunities Outside of Clinical Medicine

You can take part in academics and research in the lab. You can take things from the bench off to the bedside since you have access to the patient base. Some neurosurgeons also end up doing stuff in the administrative side of things. Otherwise, many of them are clinically and academically busy between teaching, writing, and doing their clinical duties. Other than those, you can do pretty much anything according to Stephen.

[40:12] The Best and Least Liked Part

Stephen explains he would reassure himself that he'd still love what he's doing even after all the grind. A lot of times, things could get tough and it wears on you physically and mentally. But literally being able to take care of people in their darkest hour and be there and be involved in the most important part of a lot of people's lives is hugely fulfilling. The same goes academic-wise, it is very fulfilling in that you can do detective work while you get to teach the next generation of smart and eager neurosurgeons. He gets tired but he never felt that feeling of dragging yourself off to work and just to work for the paycheck. Stephen finds his professions as very fulfilling.

When asked what he likes the least about being a neurosurgeon, Stephen says there could be bad days like having a streak of patients you're not able to help or you think you did a case by the book and did everything right but the patient gets a bad outcome so there's that feeling of hopelessness. You present that case in M&M and you still study and that if you had the chance to do it again, you'd probably have done it the same way but if it still turns out poorly, you think about it and it keeps you up at night.

[43:46] What is M&M?

M&M stands for Morbidity and Mortality. It is a conference where you and your colleagues are in a room and every time a patient has a problem or die or has a complication of some sort, their case is presented and is picked academically by other colleagues. This is done systematically to try to prevent errors in the future and see where in the care and management of the patient did something break down or how could have it done prevented and whether a change in protocol is needed in the future. Then you come up with a solution. It's stressful and it's rough on you if it's your case being presented. but it's important to make sure everybody is treated appropriately in the future, for accountability, and for teaching the residents.

[45:30] The Future of Neurosurgery

There is so much more that is not known about the brain or the central nervous system that leaves a lot opened and some exciting new things are going on such as neuromodulation  or deep brain stimulation for all sorts of different pathologies right now. It's commonplace for Parkinson's disease and tremors but there is a lot of potential utility for it in the future. There are also implantable devices help detect seizures and extinguish them before they become a problem.

Stephen sees a lot of interesting technology on the horizon as well as new utility for old technology such as stimulators for spasticity and stroke and stem cells implanted for stroke, Parkinson's disease, and neurodegenerative diseases in general. This is another way they're going to be involved with their neurology colleagues as they come up with ways to potentially intervene and help patients that were once thought to just have progressive neurodegenerative disorders that have promising interventions such as treatments for traumatic brain and traumatic spine injury and neural computer interface for moving appendages. With a little fine-tuning, he doesn't see it being too off before it becomes something that you're able to use an artificial limb and perform complicated maneuvers. It's close to being a thing so we're in really exciting times.

[48:00] Final Words of Wisdom

If he had to do it all over again, Stephen would still have chosen the same residency as he had a great time making friends for a lifetime and had great teachers. The field of neurosurgery itself is still what he keeps by his bedside as something to read on. Even in lay media, it's what he picks up and what he's drawn to. So he definitely still has a fire for it and it's been great so far.

If this is something you're considering but quite unsure, Stephen recommends to look in yourself and make sure it's something you want to do. And if it is, then you should do it. It's rewarding and interesting. There maybe some tendency for folks in the early medical school community to want to be a neurosurgeon but not necessarily do neurosurgery and that's a wrong attitude to have. TV may glamorize the specialty probably inappropriately more so than other surgical subspecialties which require just as much scholastic...