Dr. Al Berg

by William Burnett

Alfred O. Berg, MD, MPH, is a professor at the Department of Family Medicine at the University of Washington in Seattle.  He is board certified in Family Medicine and General Preventive Medicine and Public Health.

Dr. Berg’s research has focused on clinical epidemiology in primary care settings.  He has served as chairman of the United States Preventive Services Task Force, co-chair of the otitis media panel convened by the Agency for Health Care Policy and Research, chair of the CDC STD Treatment Guidelines panel, member of the AMA/CDC panel producing Guidelines for Adolescent Preventive Services, member of the Institute of Medicine’s Immunization Safety Review Committee, and chair of the Institute of Medicine’s Committee on the Treatment of Post-traumatic Stress Disorder.

He currently chairs the CDC’s panel on Evaluation of Genomic Applications in Practice and Prevention.

He recently spoke with the Student Doctor Network about evidence-based medicine and health care reform.

You have been associated with the concept of “evidence-based medicine [EBM]”. Would you explain the term, and its relevance to the current debate on health care and health insurance reform?

The average person imagines that medicine has always been “evidence-based”, but there is quite a difference between the older ways of thinking about evidence and the systematic approach to evidence that is now considered the state of the art.

In the past, if you were a medical student, resident, or practicing physician trying to find answers to a specific problem, and your attending or your consulting physician said “this is your answer” you assumed it to be true.

What has changed is that we now ask who or what is the authority for the evidence. We are now more systematic about deciding when something is authoritative.

The most important characteristic about the new approach is that the evidence is scrutinized in standard ways, leading to more accountable and transparent clinical recommendations.

Unfortunately much of current medical practice still uses the “it’s true if I say so” approach, so a lot of medical practice is not evidence-based by current standards.

EBM is one of the “under the radar” features of the current health care reform debate. Would you see it as a major change, if it ends up in any form of the final legislation?

EBM could have a huge impact on reform. It could lead to more transparent and accountable practice, and would change the ways things are done now.

One of the likely outcomes of health care reform, in whatever final form the legislation takes, is that clinical practices and outcomes will be monitored and behaviors that depart from evidence-based standards of care will not be acceptable.

Over time, evidence-based practice has potential to reduce the huge variations in procedures and interventions we have now when there are no medical reasons for the differences.

You have been a member of and chaired advisory bodies on EBM for both the Institute of Medicine [IOM] and the U.S. Department of Health and Human Services [DHHS] over the past two decades.  How did you come to be involved with these advisory bodies?

My interest began as a fellow in the Robert Wood Johnson Clinical Scholars Program where I first learned basic epidemiology, health services, and biostatistics.  I made some connections with one of the DHHS committees that existed in the late 1980s, in which I had expressed skepticism whether a guideline released for treating asthma was supported by the published evidence – there was too much expert opinion.

In 1989 I was appointed to the Preventive Services Task Force, my first real assignment in this area. I was then asked to chair the Centers for Disease Control committee that published the 1993 Sexually Transmitted Disease guidelines, and co-chaired a committee for the Agency for Health Care Policy and Research on otitis media with effusion.  I have gone on to other committees on vaccine safety, genetic testing, post-traumatic stress disorder, and genetic tests, sponsored by various agencies.

What qualifications led to your appointments to such a diverse group of committees?

Being a generalist on clinical topics and a specialist in critical appraisal and systematic review has led me to be involved in a variety of clinical questions. As a non-specialist on any given clinical topic, I do not come into the process with preconceptions about what our conclusions should be.

And, because of the experience in reviewing the basis of evidence in dissimilar clinical areas, I have developed some general expertise at managing the committee processes that are designed to reach clinical and research conclusions.

You are a member of the Institute of Medicine.  What does it do?

It is an organization of around 1,700 elected members, part of the National Academy of Sciences which was chartered by Congress during President Lincoln’s administration, although the IOM formally began just in 1970. It receives no direct federal appropriation, but does accept contracts from federal agencies when an agency wants answers that are unbiased and evidence-based.

For example, the VA commissioned the IOM to do a study to advise them what interventions work in treating PSTD — a controversial topic where some might have questioned the conclusions if the VA had done the study on their own.  The agency negotiates the contract with the IOM, but once the project begins the IOM works independently. The IOM accepts broad input but its internal processes are confidential. The IOM also takes extraordinary steps to limit conflict of interest on its committees so that the conclusions are not tainted.

How does one determine what kinds of medical interventions are “evidence-based” and what kinds are not?

Medical students, residents, and physicians need to be moving towards asking that question more often. I have become wary of what I call the “journal club approach” to medicine where a single article is discussed hoping that it might be a “silver bullet” that will change practice. From where did the article come? What were the clinical questions asked? Are the questions relevant to my own practice?  Where does this fit in the body of evidence already available?

Medical schools are beginning to do a good job of teaching how to evaluate individual studies, but there is a parallel list of questions on how to evaluate evidence-based clinical practice guidelines. I believe this skill is as important as being able to evaluate a single research article.

How much of a problem are health care disparities in your opinion?

The folks at Dartmouth have shown how the same condition is managed in different ways at different costs in different parts of the country, when there is no apparent reason for difference.  If we were following evidence-based practice more uniformly, a patient with the same characteristics would be managed the same way in rural Texas as in New York City.

A New Yorker article (”The Cost Conundrum“) looking at the highest Medicare costs in the U.S. showed that over-treating and over-diagnosing have negative consequences. If one wants to maximize health, the “sweet spot” is when you use only as much health care as you need. When you use more medical services than you need it can lead to poorer outcomes.

If we have high standards for evidence-based practice, we could decrease costs and make health care more rational, regardless of who you are, who your doctor is, or where you are.

How do you assess President Obama’s health care reform efforts?

I believe his heart is in the right place. What I think he is finding is that EBM is important. He is also finding that science is not what is driving the system, but rather the economic benefits enjoyed by lots of people in the healthcare industry. EBM threatens the profits of some very powerful special interests. I believe that all the special interests are willing to bend on some issues, but their second best position tends to be keeping the status quo.

I hope the public will figure out that they are getting neither good value nor good health from its money, and we’ll finally be able to move ahead.  EBM has potential to help in that process.

Are there models in other countries of how EBM would work?

Much of the rest of the developed world is ahead of us on EBM. In many countries, there is a process for deciding when there is enough evidence about an intervention’s efficacy to make a product or intervention available to the public at public expense. Interventions considered experimental or not achieving a level of confidence in the outcome are generally not paid for with public funds. The U.S. is quite unique in that evidence of an intervention’s proven effects can take a back seat to other concerns.

Can you employ EBM techniques to determine if less invasive therapies work, such as those advanced by, for example, holistic health practitioners?

Of course. We should move toward a single standard of evidence that is blind to the kind of therapy being promoted.  We should be able to objectively assess the balance of benefits and harms of any test or intervention, whether performed by an MD or a naturopath.

How do you see the future widespread use of the Electronic Health Record (EHR) interfacing with the idea of EBM and federal funding of evidence based preventive care?

That is something I’m working on at the moment. One of the issues of EHRs is the proliferation of products that cannot talk with each other. The business incentives are not aligned to make this easy. The feds have been trying to come up with a list of common data elements, but EHR vendors are dragging their feet. At the University of Washington, we would like to develop ways to use EHRs across practices for disease management and prevention within the practice and for collaborative research regardless of the particular EHR being employed.

What are things do you believe have a chance of going right?

President Obama has made it clear that he is interested in science and objectivity. I have faith that in the long run being open and transparent about evidence supporting medical practice will result in desirable change. There are many examples of where the EBM approach has made a difference in the outcomes of patients and where it has nudged the funded research agenda. People like me continue to hope that focusing on the evidence will eventually improve the public’s health. 

Charles Q. North, MD, MS

Students may not be aware of the variety of opportunities available within the Indian Health Service (IHS).

To learn more about IHS and the volunteer, scholarship, and employment opportunities available, the Student Doctor Network recently spoke with Dr. Charles North, retired Chief Medical Clinical Officer for Indian Health Services.

Charles North attended medical school at the University of Pittsburgh and completed his residency at the University of Minnesota.  Currently, he serves as Professor of Family and Community Medicine at the University of New Mexico School of Medicine.

Would you explain what the Indian Health Service is?

Gladly. The Indian Health Service (www.ihs.gov) is an agency within the United States Department of Health and Human Services (HHS). Since IHS is designated as an agency or “Operating Division” within HHS, it is a parallel organization to the Centers for Disease Control (CDC), the National Institutes of Health (NIH), the Food and Drug Administration (FDA) and several others.

The IHS was created in 1955 when Congress transferred responsibility for health of American Indians and Alaskan Natives from the Bureau of Indian Affairs to the federal department that preceded HHS. The IHS is the principal federal health care provider and health advocate for Indian people.

The mission of the IHS, in partnership with American Indian and Alaska Native people, is to raise their physical, mental, social, and spiritual health to the highest level.

The goal is to ensure that comprehensive, culturally acceptable, personal and public health services are available and accessible to all American Indian and Alaska Native people.

The foundation of the Indian Health Service is to uphold the Federal Government’s obligation to promote healthy Indian people, communities, and cultures and to honor and protect the inherent sovereign rights of Tribes. It is charged with providing direct medical care in the broadest sense, elevating their health status to highest level possible.

Congress passed the Indian Self-Determination and Education Assistance Act in 1975 to provide Tribes the option of assuming from the IHS the administration and operation of health services and programs in their communities, or to remain within the IHS-administered direct health system.

The IHS has around 15,000 employees and Tribes probably employ about an equal number of tribal employees. Over 70% are Indian or Alaska Natives. There are about 1,000 physician positions in the system, about half of whom are primary care physicians.  As of July 2009, 21% of the physician positions were vacant.

There are 35 states that have significant Indian populations and/or reservations, mostly in the western United States and Alaska. About half of the health care for Indians and Alaska native populations is administered by the tribes and reservations themselves and half by the “feds” (i.e., directly by the federal IHS).

The Indian Health Service might be an appropriate career path for certain health professional students. Is this mainly a program for students who are from Native American Indian communities, or is it open to any qualified health professional?

The IHS’ first priority is indeed to the Native students themselves. We have a scholarship program for Native students and Indian preference for all federal positions.

But there is a shortage of qualified Native students, with not enough people in training to meet the projected need of the rapidly growing population. Even though there has been a steady increase in numbers, we do not expect that Native students will be able to meet the human resource needs of either the IHS or tribal programs in the foreseeable future.

What type of background do you look for in the IHS and whom do you think would find this an appealing career?

The most successful students are those oriented towards working with service to underserved populations, who enjoy cross-cultural and “transcultural” experiences, who have a special appreciation for an American Indian or Alaskan Native community or who want to work with indigenous people.

If you have a background working in the Peace Corps, or AmeriCorps or have done missionary work, you may be attracted to the populations and communities that the IHS serves.

Say you are a college student interested in pre-med or in one of the health professions.  How would you get information about eligibility for the scholarship programs?

There is a national IHS office in Rockville, Maryland that helps anyone interested in scholarships. However, the criteria for scholarships are quite rigorous. Most of these opportunities would be for enrolled members of tribes. If you are in this category, ones’ tribal administration or the Rockville office can guide you through the application processes.

The Native Health Initiative funds summer health and justice internships. The IHS does provide some opportunities nationally in the Commissioned Officer Student Training and Extern Program (COSTEP) that lead to early commissioning in the United States Public Health Service (USPHS) Officer Corps and provide exposure to health professionals in federal agencies, including the Indian Health Service Commissioned Officer Corps.

Are there experiences for baccalaureate students on Indian reservations and other places?

Several reservations and tribal clinics have developed programs, such as the “health and justice” initiatives mentioned above. An interested person should contact a local site. There may be a volunteer program that would suit your interests and background. I am aware that anthropology majors, linguistics majors – even persons interested in law enforcement – have found things to do on some reservations. Undoubtedly, an experience of this kind early in one’s education might reinforce an early interest in this kind of service.

I would expect that there are more opportunities for students who are already enrolled in health professions schools?

Yes, such students have several options. The summer COSTEP program mentioned above requires that one signs up for the commissioned corps. We get a lot of students. Most of the interest is from pharmacy and engineering programs, but other health professionals are eligible.

Many of the schools in the 35 states with federally recognized Tribes have relationships with IHS and Tribal sites. Some programs in Alaska will pay room and board and airfare to get students to remote Alaskan communities.

Other programs will cover transportation and room and board for fourth year medical school elective rotations. You should check with your school and see if there are options for you to work in Indian Health facilities.

In Albuquerque, the IHS has a formal affiliation with the University of New Mexico. One of its Tribal sites takes students from all over the country. The Navajo, Tucson and Phoenix IHS Areas in the Southwestern United States also take students from throughout the nation.

Oklahoma has many local affiliations, so there are many opportunities there. The Northern Plains, Montana, Minnesota, North Carolina and Washington State regions all have some active and dynamic relationships. Check with your school.

How did you personally decide on a career in the Indian Health Service?

I was interested in service to needy populations even when before I was a medical student at the University of Pittsburgh. After taking a senior year elective in preventive medicine on the Navajo reservation, I entered a residency at the University of Minnesota and took an “outstate” (rural) rotation in Cass Lake, Minnesota, home of the Leech Lake Ojibway.

At that time, having a residency rotation at a remote Indian Health Service site was considered so different an experience that my University of Minnesota department chair and several professors flew up to Cass Lake to see it.

If you are a student or resident and want to do something like this, check with your school. Most likely you have faculty that are IHS veterans. The school may work something out with you.

Are there particular lifestyle interests that you find make a good match?

Generally, people who like to live in rural areas may find this is a good fit. Those people who love riding horses, rodeos, backpacking into “frontier” areas, mountain biking, long distance running, skiing, fishing, hunting, and so on often find the rural and frontier IHS settings attractive.

But for those who are oriented to urban life, you could live in a city and work at an Indian Health urban or rural site.  It is a fact that over 50% of the Indian population lives in urban areas. Urban Indian programs exist in some of the largest cities in the US. For some specialties, the only positions that exist are at the urban sites.

Beside the scholarship program for Indian students, do you have “loan repayment for service” programs?

The IHS has a loan repayment program, similar to the federal Health Resources and Services Administration (HRSA) National Health Service Corps program for community health centers. It has been funded at a lower level than the need, but it is quite possible that there may well be more money allocated to this program in the future.

It currently is set at $20,000 a year covering all the health professions, not just physicians. Because of the financial resources of some of the tribal sites, such as the Navajo, there are supplemental funds for loan repayment. One should check with local sites.

In the IHS, to date, loan repayment has been used mainly for retention, rather than recruitment. Stay tuned on on loan repayment, as this may be augmented in this era where health care reform is a legislative priority.

There are a number of IHS Indian health Health centers sites that get HRSA “Section 330” funding – a principal program for funding community health centers. They may be eligible for HRSA loan repayment program for either an urban Indian or Tribal site.

Not every person who went through the University of Pittsburgh medical school chose careers in the Indian Health Service. How did you get interested in this field?

I grew up in Seattle and observed that Native people there had both lower health status and lower socioeconomic status. I was interested in civil rights and social justice. I met Native students in in college and found we had many interests in common.

When I went to medical school in Pittsburgh, they had an elective on the Navajo reservation rotation for fourth year medical students. I went to a preceptorship at Fort Defiance, Arizona, where I worked in the hospital, clinic, and community health program and did some epidemiological research.

Personally, I love the Southwest, and liked working with tribal people, feeling that I was responding to a tremendous demand for health services. I found that the IHS healthcare services were extremely well organized into a rational system, unlike most of the rest of the country.

The IHS integrates public health and primary health care in such a way that one could make a difference quickly in meeting healthcare needs. I found this system of community oriented primary care very satisfying compared to private practice. Then I did a third year residency rotation in Minnesota and found that the system there was very similar and comfortable for me.

I loved the IHS system that existed in both Fort Defiance and Cass Lake. The population needs far exceed our ability to meet them, but I felt that I was fighting the right battle, that the organization’s core values were congruent with my core values. So after residency that is all I wanted to do.

I went to the Hopi Reservation in Keams Canyon, Arizona and served as a family physician, director of community health services and eventually became the chief executive officer of the health system there.

The integration of public health and medicine in team programs made great sense . The health care team is much better developed in Indian health.

Dr. Andrew Lee

Of the 654 applicants who applied to ophthalmology in 2009, 196 (approximately 30%) failed to match. Similar results were noted in the 2007 and 2008 matches, making ophthalmology one of the most competitive specialties.

We recently discussed the ophthalmology residency selection process with Dr. Andrew Lee, chairman of the Department of Ophthalmology at The Methodist Hospital in Houston, Texas and Professor of Ophthalmology at the Weill Cornell Medical College. Prior to becoming chairman, Dr. Lee was professor of ophthalmology, neurology, and neurosurgery at the H. Stanley Thompson Neuro-ophthalmology Clinic at the University of Iowa Carver College of Medicine.  Following residency training at the Cullen Eye Institute at the Baylor College of Medicine, Dr. Lee completed a fellowship in neuro-ophthalmology at the Wilmer Eye Institute.

Dr. Lee is an accomplished author, having written two full textbooks on ophthalmology and over 260 peer reviewed articles. Presently, he is a member of the editorial board of 12 medical journals, including the American Journal of Ophthalmology and Eye. He is also the editor in chief of the Journal of Academic Ophthalmology. For his significant contributions to the specialty, he has received several prestigious awards from the American Academy of Ophthalmology including the Honor Award, Senior Honor Award, and the Secretariat Award.

In a survey of junior and senior US medical students who had chosen to pursue ophthalmology as a career, 13% entered medical school with the intent to become an ophthalmologist.¹ How should students who have an early interest in the specialty proceed?

A junior medical student with an early interest in the specialty should concentrate on insuring that ophthalmology is the right career choice for that particular student. Many medical schools (including the University of Iowa) have an Ophthalmology Student Interest Group (OSIG) that can introduce the student to the field, provide networking opportunities with fellow students and access to busy clinical faculty, and can allow participation in an OSIG service project. The student should consider whether his or her personality matches the “ophthalmology personality type” (e.g., do they enjoy seeing the entire spectrum of ages of patients, taking care of mostly ambulatory healthy patients with focused eye problems, and having a patient mix of both surgical and medical problems). Shadowing both a private practice eye MD or an academic faculty member might allow the student an insider glimpse into the practice of ophthalmology, and can create a mentoring opportunity that could lead to an important and convincing letter of recommendation downstream. The bottom line is that the most important task of the junior medical student interested in ophthalmology is making sure that ophthalmology is the right choice for them.

Although some students enter medical school feeling certain of ophthalmology as a career choice, most do not make their specialty choice decision until after completing an ophthalmology rotation. In the aforementioned survey, 52% did not make their specialty choice decision until late in their third year or early in their fourth year. These students only have a few months to strengthen their application for a particularly competitive specialty. What can students do to make the most of the time that they have?

Once the student is convinced that ophthalmology is for them, then the important task for the student becomes convincing others that they are right for ophthalmology. Ophthalmology is a competitive specialty and an honors level performance on the required ophthalmology rotation and any subsequent eye electives is mandatory. Reading in advance of the rotation and on a day to day basis, coming early and staying late, asking relevant and insightful questions, demonstrating enthusiasm and passion for the job, and connecting with an interested faculty mentor are key differentiating features of the best applicants. Working on a short case report or case series can be an easy way for the student to acquire new knowledge and skills in ophthalmic research, and provides evidence and content for genuine interest and effort in the field at the time of future interviews.

In January 2009, the average USMLE step 1 score for applicants who matched into ophthalmology was 235.² The average score for unmatched applicants was 212. Many applicants are concerned that their application might be screened out because of their score. What recommendations do you have for these applicants?

Ophthalmology programs receive far more applications than available positions. While it is true that most programs use the USMLE step 1 score as a “screening device”, the score alone neither guarantees acceptance nor rejection. This test was not designed for this purpose, but in the real world it is used as a screen. Applicants with a great score should not become overconfident, and applicants with a subpar score should do everything possible to demonstrate their value in other ways. Taking the Step 2 as early as possible to demonstrate a higher alternative score is one tactic. Another tactic is to tackle the problem head on in the personal statement and to highlight other alternative evidence of performance and intelligence in their record (e.g., honors grades, AOA, clinical proficiency). Getting the program to ignore a subpar score is challenging but not impossible. For applicants with scores towards the unmatched level, having a back up application plan is always a good idea. The bottom line is that if you have a good score don’t get cocky, because everyone else has a good score too, and if you have a less optimal score you must demonstrate to the interviewer or the screener that you offer something else in your application that can justify looking away from the score alone.

Medical students often wonder if they should do an audition elective in ophthalmology. In a recent survey of 46 program directors, audition electives were ranked 12^th among a group of sixteen residency selection criteria.³ What are your views on the role of audition (away) electives in the ophthalmology residency selection process?

The official party line is to discourage “audition electives”. The real goal of an away elective is to gain new knowledge and to experience ophthalmology in a different setting. Having said that, however, the away elective offers the applicant the opportunity to shine at a prospective institution and introduces the student to the faculty at that specific institution in a real world setting that can create a relationship that leads to an interview or even a higher ranking for the match. Ranking a “known” quantity with a personal track record and a letter of recommendation from an insider is always a great relief, especially for risk averse programs. In addition, if the choice is between two applicants with similar credentials, the known applicant obviously has the edge. My recommendation for a student doing an away elective is to use the time wisely, read in advance, make a great impression, talk with the residents and the faculty, and make yourself memorable in a good way. The goal is to “stand out,” however, not “stick out”.

In your article, “Re-engineering the resident applicant selection process in ophthalmology,” you wrote about “common but overused themes” in personal statements, including “a personal experience with a vision disorder, having a relative with an eye problem or requiring eye surgery… or some type of dramatic epiphany regarding the intricacies of the anatomy or physiology of the eye.”⁴ How would you advise applicants to approach the personal statement?

Your personal statement is your chance to “talk” to the evaluator in a special way and to make your case for acceptance into the ophthalmology “club”. Thus, the ultimate purpose of the personal statement from an applicant’s perspective is to get an interview. The message should be clear but concise, and should emphasize that information which is not apparent from the credentials and scores in the application. The personal statement would ideally highlight what is unique or novel about a particular applicant and the “storyline” should emphasize a quality or anecdote or credential that is based upon a credible, genuine and personal experience. As a reader, I am looking for evidence of leadership potential, altruism, sincerity, or scholarship potential. The best personal statement to me is one that is memorable, unique, exciting and demonstrates an applicant’s intangible qualities (e.g., passion, humanity, charisma, enthusiasm, motivation, or future academic potential). At the end of reading a great personal statement the reader should want to meet the writer in person (i.e. for an interview).

In a 2006 survey of ophthalmology residency program directors done to determine the prevalence of residents who experience difficulty mastering surgical skills, nearly 10% of residents were found to be surgically challenged.⁵ Types of problems encountered included poor hand-eye coordination and poor intraoperative judgment. In the survey, 20% of participating programs (11 total) were found to use vision testing during applicant screening and 4% used some form of dexterity testing. In the future, do you feel that testing of vision, stereopsis, and hand stability will be a routine part of the selection process?

I believe that validated metrics for determining baseline hand-eye coordination skills in ophthalmic surgery are needed before routine testing can be advocated for resident selection. Testing of vision, stereopsis, and color vision are already required in some professions (e.g, pilots, military) and some jobs require pre-employment testing for dexterity with basic hand-eye coordination instruments. The difficulty lies in correlating performance on such examinations with the actual job description and surgical performance.  I believe that these types of performance evaluations probably should be taking place at the medical school level and not as part of applicant screening, where presumably it would be too late for the applicant to do anything about a failing performance. Many applicants already self direct themselves towards or away from surgical specialties based upon their own self assessment of ability. Unfortunately, one unintended consequence of such screening might be to deter applicants who envision a career as a non-surgical or medical ophthalmic specialist (e.g., neuro-ophthalmology) from pursuing ophthalmology residency.

In your article, you wrote that extracurricular activities “might provide evidence for non-cognitive attributes that may predict resident success.” Which attributes do you feel are important to ophthalmology residency program directors?

The first priority of a residency selection committee is insuring that the applicant does not wash out or cause trouble during their time in the program. This is sometimes referred to generically as “fit”. Everyone wants a team player who is unselfish and working towards a common goal. Leadership skills demonstrated by being an officer in extracurricular activities or being an Eagle scout, or a leader or founder of a new organization or club are all looked upon favorably. The second goal is to look for evidence of noncognitive attributes that might make a superior ophthalmologist (conflict resolution, team work, leadership ability, communication skills, performance under stress, maturity, seriousness of purpose, prior scholarly activity). Finally, programs are looking to graduate (and thus select) residents who will make the program proud.

Many programs encourage applicants to attend a social event (e.g., pre-interview dinner) to learn more about the program. Through these events, programs also learn more about applicants. How do programs use these events to evaluate candidates?

Every part of the application process is important. The applicant needs to present their best face and be on their best behavior throughout the process. Treating every person in the application process with respect, dignity, and courtesy is important. Likewise, the social event is a chance for one to shine, make new friends, network with the other applicants, and most importantly make a good impression. The residents and fellows are looking for someone with whom they can work for three years, and not necessarily the smartest or the most academic applicant. Their vote counts, and while I encourage people to be “themselves” I would caution applicants that being on your best behavior is a good idea. Although these events are a great opportunity to learn more about the program, it is also a chance for the program to get to know you. You should treat the social events as seriously as the rest of the interview process.

What impresses you most about an applicant during an interview?

I am looking for three things in a resident interview. First, eliminate the people who may have looked “great on paper” but are terrible in person (e.g., psychopathic or sociopathic types, hermits or hotdogs, socially inappropriate duds, or selfish, arrogant jerks). Second, elevate the people who look mediocre on paper but are superstars in person (e.g., charismatic, engaging, enthusiastic, well spoken, and passionate). Third, and perhaps less tangible, I am looking for philosophical and personality “fit”. Applicants should understand their own, as well as the prospective program’s, learning environment, institutional culture, and teaching philosophy. Hard work, intelligence, teamwork, leadership, communication and interpersonal skills and professionalism are welcome attributes in most programs, and demonstrating these qualities can be a challenge in a short conversation. I am most impressed by applicants who are comfortable with themselves and with emphasizing their achievements in a credible manner, who can communicate clearly and concisely their career goals, and who can make the interview time “fly by” and who make me want to keep talking with the person beyond the assigned time.

Applicants who fail to match often wonder how they should spend the year before they reapply. What recommendations can you offer to these applicants?

The best chance for a match in ophthalmology is as a first time US senior medical student. The match rate drops off precipitously after this first application. The second application needs to be better than the first application if the second time applicant is to be successful. This means demonstrating perseverance, passion, and persistence through a research year in ophthalmology (e.g., a clinical or bench project), a pre-residency fellowship (e.g., ocular pathology), or an observational fellowship combined with the above. The “brick walls” in the process are meant to keep the other people out (i.e., those who don’t want it as badly or who fail to make a significant improvement in their application).

References

¹Nissman SA, Kudrick NT, Piccone MR. Motivations and perceptions of US medical students pursuing a career in ophthalmology. Ann Ophthalmol 2002; 34(3): 223-229.

²Data from the San Francisco Ophthalmology Matching Program. Available at www.sfmatch.org.

³Green M, Jones P, Thomas JX. Selection criteria for residency: results of a national program directors survey. Acad Med 2009; 84(3): 362-7.

⁴Lee AG, Golnik KC, Oetting TA, Beaver HA, Boldt HC, Olson R, Greenlee E, Abramoff MD, Johnson AT, Carter K. Re-engineering the resident applicant selection process in ophthalmology: a literature review and recommendations for improvement. Surv Ophthalmol 2008; 53(2): 164-76.

⁵Binenbaum G, Volpe NJ. Ophthalmology resident surgical competency: a national survey. Ophthalmology 2006; 113(7): 1237-44.

Dr. Gary Flashner, MS, MD, ABFP is an emergency physician and Vice President of Medical Content for ExitCare, LLC.    He completed his undergraduate work at Muhlenberg College (Allentown, PA), Masters work at Penn State, medical school at Thomas Jefferson University, and residency in Family Medicine at Sacred Heart Hospital (Allentown, PA).    His 20 years of clinical practice and teaching endeavors (including 13 years of full-time work in hospital-based emergency medicine) were split between the eastern U.S. (Pennsylvania and Ohio) and California, including working at Yosemite National Park.

Dr. Flashner has been involved in medical informatics for 15 years with previous work that focused on the research and development of emergency department physician documentation systems and end-user screen design.    As an IBM Business Partner, he pursued a special interest in the use of computerized speech recognition as a data input method for physician charting, and he continues to provide guidance in the use of this technology.   After retiring from clinical practice, he worked for Eclipsys Corporation for four years.  That work included a focus on the development of their first software offering for hospital-based emergency departments.   At the beginning of 2009, Dr. Flashner accepted the position of VP of Medical Content at ExitCare with a focus on the research, development, and updating of patient education materials.

Dr. Flashner lives in Orange County, California.  He recently took the time to speak to the Student Doctor Network about his experiences.

Why did you choose to become a physician?

I recall declaring this as my “designated profession” from the time I was age 8.   During all of my pre-medical school years, the driving idea was “helping people”.

If you had it to do all over again, would you still become a physician? (Why or why not? What would you have done instead?)

With some hesitation, I would say “Yes”, if I had it to do all over again, I still would have pursued medicine as a career.   I experienced too many positives in the process of working with patients, families, etc.  Those positives included the challenges of the “detective work” of medicine, the joys of seeing improvement and/or control of numerous medical and surgical problems, helping to relieve pain (both physical and psychological), and the opportunity to truly “fix” problems that were fixable either by my own hands or through the referral to a subspecialist.

Tell us what it was like serving as the physician in Yosemite National Park.  What was unique about that environment?  What was it like to practice medicine there?

This was a very unique environment from a medical, social, and environmental point of view.    My family and I felt very lucky to be able to live and work in the one of the most beautiful places on the face of the earth.   We also felt very lucky to have our children spend their earliest years in that environment, and now that they are adults, the personal “connection” to Yosemite remains.   The local community was small, compact, tight knit, and retained many of the positive parts of “small town life”.

As a staff physician at the Yosemite Medical Clinic, I was joined by two other physicians (three during the summer months) and a staff focused on primary care services for the local community.   In doing so, we “knew everyone” in the local community – something that I found to be very enjoyable (although it also had its challenges!).   The community was also remote and isolated – the closest hospital and “urban” medical community was 85 miles west in a town of 50,000 people.   This presented challenges associated with medical “isolation” and the inability to conveniently discuss various aspects of patient care with colleagues.

The greatest challenges came mostly in the summer when the Park was jammed full of visitors.   The volume of patients coming to the Clinic for care predictably increased dramatically, and the Clinic functioned more as an emergency department than a primary care practice.   A significant volume of seriously injured multiple trauma patients were brought to the Clinic for initial stabilization, and there were numerous challenges associated with the logistics of transporting these patients to area trauma receiving facilities in Fresno or Modesto.   On site, we had to do everything ourselves with no backup from subspecialists – because there were no subspecialists.   There was no opportunity to call upon anesthesia, surgery, orthopedics, cardiology, ophthalmology, etc. to assist with problems that clearly required subspecialist/surgical intervention and critical care services.   The staff had to be very independent, creative, and resourceful.

What did you like most and least about being a physician and interacting with patients?

What I liked most:

• Collaboration on an intended goal of managing a problem, health maintenance, etc.
• Fixing a problem that can be fixed (broken bone, laceration, etc.).
• Providing reassurance.
• “Being there” during very difficult times.
• The adrenaline rush of a successful resuscitation.

What I liked least:

• Overly burdensome regulatory, malpractice, and insurance hassles.
• Unreasonable patient demands.
• Refusal to change destructive behaviors despite reasonable patient education.
• Anger in relation to undesirable outcomes out of the control of the medical staff.
• “Entitlement” mentality.

What made you decide to move from patient care into patient information systems?

In 1995, I was found to have a disc herniation in my neck.   That problem has progressed and worsened over the past 14 years, and I now have some problems with my hands that made me decide to work on a career change.   Being a computer nerd and having a passion for technology and information systems, this transition made sense.

Describe a typical day at work.

Currently, here’s what it looks like:

1. Email
2. Conference calls and frequent impromptu calls with our Document Manager
3. Organize the work/tasks for the day
4. Medical literature research, document revision, document review
5. Various other project work which may involve spreadsheets, databases, or both
6. Continued email throughout the day

What do you like most and least about what you are doing now?

What I like most:

• Excellent team of people in my work group.
• Work from home.
• Generally regular hours.
• Minimal work travel.
• Reasonable compensation for what I do.
• My work is valued, and I receive a lot of feedback supporting that.

What I like least:

• Occasional intense stretches of work 7 days a week as our company is undergoing rapid growth.
• Too much time sitting at a computer screen.

Are you satisfied with your income?

Yes.

If you took out educational loans, is/was paying them back a financial strain?

I did take out loans; but the total was relatively low ($25,000), and I was able to pay them off over seven years.  That was not a strain; however, that was also many years ago.

On average: How many hours a week do you work? How many hours do you sleep each night? How many weeks of vacation do you take?

Currently, I work 40-50 hours/week.   I sleep 8 hours a night.   I have 3 weeks vacation allotted per year.

Do you have a family and do you have enough time to spend with them?

“Yes” and “Yes”.

In your position now, knowing what you do – what would you say to yourself ten years ago?

“Keep doing what you are doing”.    Ten years ago, I had a pretty good idea that I would not be able to practice emergency medicine for too many more years because of the progressive orthopedic problems in my neck.   I was already pursuing endeavors in medical informatics, and I would have continued on the same path that I was already on.   Interestingly, 11 years ago, I originally met the founders of the company that I work for now, and that certainly reinforces the notion that I would keep doing what I was doing.

What information/advice do you wish you had known when you were an undergraduate? (What mistakes or experiences have you encountered that you wished you had known about ahead of time so you could have avoided?)

I wish I had had some education as regards interview skills as well as help with organizational skills, time management, and being able to prioritize.

From your perspective, what is the biggest problem in health care today?

The biggest problem today is the way health care is prioritized within society and how it is paid for.

What other types of providers and/or technicians do you work with day-to-day?

Currently, I work with a Document Manager, two Medical Literacy Editors, a Cardiac Nurse, and our Foreign Language Coordinator.

What types of outreach/volunteer work do you do, if any? Any international work?

Nothing formal.   I make it a point to donate blood about four times a year.   I give financial support to a variety of medical organizations that include international relief funds (such as Doctors Without Borders and the International Medical Corps).

What do you like to do for relaxation or stress relief? Can you share any advice on finding a balance between work and life?

For relaxation, nothing beats exercise, including walking on the beach and hiking in the mountains (Sierras and the Sawtooth Mountains in Idaho).    To achieve balance between work and life?    Try to monitor it as closely as you would monitor an unstable cardiac patient in the ER or ICU.   Re-assess, re-assess, re-assess.     Figure out a way to intervene when intervention is appropriate.    Work hard at learning how to say “No” – particularly as regards a variety of material gains and financial burdens.

What would you say to medical or other health professional students that want to mix a business career with health care?  What advice would you give them?

I would ask the student a lot of questions:  “Why do want to do this?    What are your goals in mixing business and medicine?”   I would need to know a whole lot more about what the student wants to do before I could provide any advice.

In 1987, NOVA’s cameras began rolling to chronicle the lives of seven medical students embarking on their years-long journey to become doctors. From their first days at Harvard Medical School to the present day, none of them could have predicted what it would take, personally and professionally, to become a member of the medical community.

The final installment of NOVA’s Doctors’ Diaries is a two-part special premiering Tuesday, April 7 and 14 at 8pm ET/PT on PBS (check local listings).  The longest-running U.S. documentary of its kind, Doctors’ Diaries begins by reuniting the physicians on the steps of Harvard Medical School 17 years after graduation.

The seven physicians profiled in NOVA's "Doctors' Diaries" (photo credit: NOVA - Betsey Cullen)

Footage from the previous four installments in the series offers a rare and candid look at the rewards and personal sacrifices each has made over the last two decades – from the stress of medical school exams, to the first cut into a cadaver, through first wedding ceremonies (and sometimes second or third), internship, residency, and life as a certified M.D.

The seven physicians featured in Doctors’ Diaries have taken divergent paths:

• Tom Tarter, Bloomington, IN – The Bronx-born, long-haired, tattooed ER doctor has constantly grappled with how he is perceived as a physician. After his contract was terminated at the local hospital he became an itinerant M.D., forcing him to look for work in distant locations. Once a bouncer, an Olympic-hopeful weight lifter, and a mechanic, Tom is now on his fourth marriage and struggles to make ends meet.
• Jane Liebschutz, Boston, MA – Currently an internist specializing in underserved populations, domestic violence, and addictions. NOVA was there for the gut-wrenching moment when Jane experiences a patient dying in the operating room for the first time.
• Jay Bonnar, Belmont, MA – This private practice psychiatrist is also involved in outpatient group therapy and teaches at the hospital.
• Elliott Bennett-Guerrero, Durham, NC – A successful anesthesiologist who picked his specialty partly based on the less demanding hours-this now affords him more time to be at home with his second wife and two young sons and pursue his new passion: golf.
• Luanda Grazette, Thousand Oaks, CA – Originally trained as a clinical cardiologist, Luanda now works for a pharmaceutical company to develop drugs that will help heart patients.
• David Friedman, Baltimore, MD – As an ophthalmologist and professor at Johns Hopkins University, David aims to one day establish a hospital to provide eye care to the millions of people worldwide who currently have no way to improve their poor vision.
• Cheryl Dorsey, New York, NY – Although she eventually completed her pediatrics training, she never practiced. Cheryl put her residency on hold to found a program that provides free curbside health services for minority communities; today she is the president of the same nonprofit that funded her Family Van mobile clinic.

Producer and director Michael Barnes recently spoke with The Student Doctor Network about Doctors’ Diaries.

Michael Barnes (photo credit: Jim Murphy)

How have you seen the profession of physician change over the course of the series?

Managed care was well entrenched in 1987 when we started filming at Harvard. A couple of the doctors we followed are the sons of physicians. They describe that it was their fathers who saw the biggest changes in the profession. Under Ronald Reagan’s presidency, Congress encouraged the transition of the insurance industry from a not-for-profit ethos into a for-profit approach as enabled by Health Maintenance Organization Act of 1973. Without exception all seven doctors in the series believe the for-profit approach is flawed and that the healthcare system is broken. But this is the model under which they became doctors. Perhaps the biggest change for them is yet to come if the healthcare system can be reformed.

What do you think you would find if you started this series over in 2009 with a new set of first-year medical students?  Do you think the experiences would be similar?

Over the past two decades most medical schools have improved the curricula for the first two years of training (as Harvard did back in 1987 with the New Pathway). I understand 3rd and 4th year students at Harvard now do their rotations at one hospital rather than switching every month. Since we filmed, legislation has resulted in Interns working less hours with fewer nights on call. Despite these changes I am certain the medical school experience would be almost identical to those we recorded in Doctors’ Diaries. There are no short cuts to the process of becoming a fully initiated member of the medical tribe.

Over half the doctors that were featured in the program were married and divorced during the 21-year span of the program.  Do you feel that medical students, residents and physicians are more likely to have negative incidents in their personal lives due to the stresses of their profession?

In the UK, and I suspect in the United States too, physicians do have a higher risk of divorce (as well as drug abuse and suicide) than other professions. Based on our seven physicians it seems that the most difficult time to sustain intimate personal relations is during medical school and residency. Relationships that began later seem to be faring better, perhaps because a reasonable work life balance has been achieved. A couple of the doctors described how their tendency to treat their spouses “like interns” led to conflict.

One of the students (Cheryl Dorsey) is not currently a practicing physician.  Was her journey the most unexpected, or did another student surprise you more with his or her choices?

Luanda’s choice to stop seeing patients and work fulltime in research at Amgen was a surprise. But I am sure her love for patient care will pull her back in to clinical practice at some point soon. Although she kept to herself any misgivings about going to medical school I did sense that Cheryl was ambivalent. Although Cheryl took a circuitous route to get there it is wonderful to see how completely fulfilled she is in her job leading the Echoing Green foundation (that provides seed money for social entrepreneurs).

At the time that the original series was produced, 1987, the whole “reality TV” concept did not exist.  Today, documentary and “reality” television is common.  Do you think that the numerous medical reality shows give a realistic or unrealistic vision of the life of physicians, based on your experience with Doctors Diaries?

I don’t watch a lot of reality TV about doctors. But shows that trade on reality should respect it. Doctors’ Diaries will influence how these seven doctors are perceived and judged by viewers. Even though we shot around 500 hours over two decades for the NOVA series making a film that is completely true to their lives is impossible. Real life is a muddle and as storytellers we must impose structure by deciding which scenes to keep in and which to leave out. As we edit ever more finely it comes down to choices about individual words and frames. The NOVA series only documents a tiny fragment of their lives. But our guiding principle is always to portray the spirit of their careers. In striving to achieve authenticity I have found a good test is to imagine the doctor watching the scene in question in the same room as myself. If that would be an embarrassing experience I have probably made a bad decision. At a recent preview screening which a couple of the doctors attended Jay remarked, “I recognized myself”. I hope the others can say the same.

The Student Doctor Network targets pre-health professional and health professional students.  What key message or messages should they take away from this series?

As Luanda once said becoming a doctor is only for people who cannot imagine doing anything else. Tom agreed and said that if you have any doubts about giving up a decade of your life there are several careers such physician’s assistant and CRNA, which do not require quite so many years of training.

For more information on Doctors’ Diaries, please see the NOVA website at http://www.pbs.org/wgbh/nova/doctors/.

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SDN Member discounts on Kaplan Courses and Materials.

By Janani Krishnaswami, M.D.
Kaplan Admissions Consultant

The school interview inspires anxiety and anticipation in many applicants. A test of poise and communication skills, the interview is a key component of the school application package.

The process inherently benefits those who are:

• Relaxed
• Sincere
• Articulate
• Aware – of both their own motivations for seeking medicine (i.e., self-awareness) and “externally” aware (i.e., current events, salient healthcare issues)
• Able to comfortably carry on a conversation covering a wide range of topics (which stems from all of the above).

Just as the applicant has tirelessly worked to tackle challenging courses, study for the admissions test, and polish a personal statement, work needs to be done to prepare for the interview.  While school interviews are largely casual and friendly affairs (a far cry from, say, “stress” interviews held in some areas of finance and consulting) it is entirely possible to “tank” the interview by adopting a laissez-faire approach.

The following myths should be dispelled by the informed applicant at once:

• Interviews are mostly a formality; once you are offered an interview you’re at least guaranteed a spot on the wait list.
• Interviews are biased toward extroverts and native English speakers. It’s much harder to get a good score if you’ve got a thick accent, speak softly, or are quiet.
• There is no real way to prepare for medical school interviews, since you won’t know in advance what questions will be asked.

Schools vary regarding how much importance they place on the interview versus the paper application. In general, top-tier schools will lend more importance to the interview – especially as a deciding factor between two exceptional candidates.  Sifting through an abundance of stellar-on-paper applicants, they often turn to the interview to assess honesty, enthusiasm, sincerity and the intangible qualities of personal rapport that come across in the interview.

Getting an Interview

What does receiving the offer of an interview mean?  This, of course, is a complex question varying from school to school. In brief, receiving an interview means one of two things:

1. Based on your grades, test scores and secondary applications, you have passed the initial hurdles of score screening and essay review, making either a numbers-based cutoff process or passing an individual committee member’s screen.
2. Your application was perhaps sub-par or borderline in terms of scores, academic performance, etc., but the committee is intrigued by other aspects of your application and wants to evaluate further via an in-person interview.

The linking factor between scenarios 1 and 2, as the astute applicant might have gathered, is that the interview-invited candidate has an advantage in both cases.   In either case, the applicant has impressed the committee to the point where they would like to know more, where they see a potential fit, a potential acceptance.  In that sense, receiving an interview acceptance represents a very positive development in the applications process – more so than, for example, receiving a secondary.  Drawing from this reality, the conclusion that follows is very important:

Once you have received an interview, the goal of getting an acceptance is within striking distance.

The corollary is that under preparing, underperforming or otherwise botching an interview can essentially lower a stellar “on-paper” candidate to the point where he/she is wait-listed or rejected.   I have reviewed the files of high-scoring MCAT/GPA candidates with a very impressive paper application who were out right rejected by the committee – after painful interviews showed them to be uncertain, haughty or passionless.  Thus, the final conclusion, and the one that applicants should take home:

Acing an interview – and earning an acceptance – is almost entirely within the applicant’s control.

Preparing for the Interview

With that said, here are the top strategies for preparing for a medical school interview:

1. Know thyself. You must have a very clear, convincing, and sincere knowledge of a) why you want to attend school more than anything else and b) what you have done – activities, volunteering, research, etc. – that supports your reasons as evidence.  You get a discrete block of time – 2-3 minutes – to answer the question, “So why do you want to go to (medical, dental, pharmacy…) school?” This is one of the most important questions of the interview. Within that time, you should be able to articulate your true reasons and come across as honest, logical, convincing and real.  Having interviewed hundreds of insincere candidates, admissions committees are quickly able to spot a half-hearted, passionless, or – worst of all – dishonest answer, rendering the applicant to the bottom of the admissions pile.
2. Know why School X is the best place for you. Not surprisingly, admissions committees want to accept candidates who would be likely to accept the acceptance. It looks better for the school and the school’s rankings if, say, 90% of candidates offered acceptances decide to matriculate. Thus, if you come across as someone likely to take that spot if offered, your chances of admissions will increase.  Caution: As in #1, schools will quickly identify candidates who are more hot air than genuine substance.  “Substance”-qualifying reasons include: working with researcher X who is a specialist at the school, curriculum-specific initiatives that are only seen at school X, wanting to pursue a career in an area where school X is renowned or offers unusual opportunities.  Coming up with reasons for attending a school leads to #3:
3. Research the school thoroughly, backwards and forwards. This is more than just a quick glance through the website.  Understand latest developments in the curriculum. What areas were recently changed? How has the school revamped or made innovations in its program recently? What are some of the accomplishments of graduates and current students? What are some areas of ongoing research? The questions are numerous and will be tailored to each applicant’s interest (i.e. service outreach, basic science lab opportunities, international relief efforts, clinical training and simulation, to name a few) . But the key is to spend several hours (yes, hours) analyzing and understanding information to answer them in full.
4. Above all, be humble and sincere. This does not mean downplay your significant accomplishments.  But always remember where they’ve come from: it is rare that a stellar applicant has reached his or her heights without help. Often, there is a mentor, a teacher, a volunteering experience, a parent or patient that has paved the way. It is perfectly fine to describe your outstanding achievements, awards, discoveries, cutting-edge research, critical acclaim, etc. But add that “I-remember-where-I’ve-come-from” angle: how you are thankful to Mentor X or Professor Y for their tireless help, how you are inspired to give back to the community (only if you are, of course!), how you hope to be like Doctor Z, etc.
5. Do. Not. Lie. Under ANY circumstances. Often, the truth has a funny way of revealing itself. And if it is ever found that the applicant lied under any circumstances: it is automatic rejection and a firmly closed door on the application process.

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He completed his residency at West Los Angeles Veterans Administration in 2004, and he currently works as a hospitalist at West Hills Hospital and Medical Center in Southern California. Most recently, Dr. Rosen has written “The Consult Manual of Internal Medicine.”

Editor’s Note: For more book information and sample content from “The Consult Manual of Internal Medicine”, please visit http://www.medconsultpublishing.com.

Q: Describe a typical day at work

A: A usual day at work starts off at about 9am when I arrive at the hospital and start on my first can of Pepsi or Coke — or, if I feel daring, a Mountain Dew. The caffeine and sugar help start the day off with a sweet pick-me-up.

I then log into the computer system and review each patient’s labs, imaging, medications, and new consultations. As I do this, I phone orders to the floor as needed. This routine helps me get an idea of how each patient is doing, allowing me to see them in order of severity.

I start in the intensive care units, working my way through the floors. I see an average of 12 patients a day. The patients come to me via ER admissions as well as consultations throughout the hospital. I usually leave the hospital at about 5pm, being on call for my patients and new admissions throughout the night, averaging about 1-2 new admissions after hours.

I take every other weekend off. Although some days may be rough, I really love being a hospitalist, especially caring for ICU patients.

Q: What mix of clinical/research/teaching work do you do? How much power do you have to change that mix?

A: For the first 2 years after residency I worked at a county hospital, covering about 20 to 30 patients per day, with the help of residents, interns, and medical students rotating through as a team. I had a great time with them, and learned a ton doing the work. However, the commute was long and I was not spending the time I wanted with my new daughter, Eden.

I decided to go non-academic and become a solo hospitalist about 10 minutes from home at West Hills Hospital in the San Fernando Valley of California. At times, I give guest lectures at various medical schools, but remain academic mainly through my work on the book. Being that I work on my own, I can manipulate my hours, patient load, lecture responsibilities, etc. as I feel — and as long as I consider my family first.

Q: Did you plan to enter your current specialty prior to med school?

A: I spent the first several years of my university studies changing majors and completing both my general education requirements as well as most of the undergraduate classes for a business major. However, I had not found my passion.

One day, a close friend asked me if I would be interested in taking some biology major classes with the thought of perhaps eventually applying to physical therapy school. After some hesitation, I jumped in — and found my passion. I simply loved to read and learn all about the human body, changing my major to pre-med. At that time I simply wanted to get into a medical school, without much thought to the actual specialty.

Q: Why/how did you choose your specialty?

A: I enjoyed my years as a resident very much, and found myself drawn to inpatient care. Hospitalist medicine was quite new at the time, but just in time for me.

Q: Now that you’re practicing in your specialty, do you find that it met your expectations?

A: Yes and no. Although I gain a great deal of satisfaction and knowledge on the wards, I simply feel that there is too much politics and egos in medicine in general.

Q: On average: How many hours a week do you work? How many hours do you sleep each night? How many weeks of vacation do you take?

A: I work about 9 hours a day. However, I am on call for my patients and new admissions throughout the evening. Even so, I sleep pretty well most nights — perhaps 8 hours or so depending on how late I want to stay up. I take every other weekend off, and set aside vacation time whenever I want — as long as I have someone to cover for me at the hospital.

Q: If you had it to do all over again, would you still become a physician? (Why or why not? What would you have done instead?)

A: Absolutely! The art and science of medicine is simply super-interesting to me. The field also allows for a great deal of flexibility in terms of specialty, subspecialty, hospital type, patient population, as well as academic and research opportunities.

Q: Are you satisfied with your income?

A: Yes. I earn over 200K per year doing what interests me most.

Q: If you took out educational loans, is/was paying them back a financial strain?

A: Not at all. The money I borrowed allowed me to fulfill my dream. Payback will always be cheap and easy in relative terms.

Q: Do you have a family and do you have enough time to spend with them?

A: My wife Maya and I just celebrated our 13th anniversary. We have three beautiful girls: Eden, Sophie, and Lillie. There are certain days when I may get back home just in time to help put the girls to sleep at 8:30. However, I usually get home by 5 to 6pm, allowing me to enjoy my family.

Q: In your position now, knowing what you do – what would you say to yourself 10 years ago?

A: To enjoy medical school and residency as much as possible. You’ll miss it when it’s over.

Q: What information/advice do you wish you had known when you were a premed? (What mistakes or experiences have you encountered that you wished you had known about ahead of time so you could have avoided them?)

A: That all it takes to become a physician is the will.

Q: What do you feel is the biggest problem in health care today?

A: Globally, overpopulation. In America… healthcare for all children.

Q: From your perspective, what is the biggest problem within your own specialty?

A: To my surprise, there is a great deal of misunderstanding in terms of what a hospitalist is — even among physicians.

Q: Where do you see your specialty in 10 years?

A: In 10 years, I would expect adult hospitalist medicine to be incorporated into almost all medical centers. I hope to see pediatric hospitalist medicine thrive as well.

Q: Why/how did you decide to write “The Consult Manual of Internal Medicine?”

A: During my internship year, I went through a great deal of pocketbooks, looking for something akin to a concise pocket attending. I found all the handbooks to be either very verbose (like a miniature textbook) or simply a cursory listing for quick recall. In all cases, pharmacology was severely downplayed. As an internist your tools are, to a great extent, medications. I found it odd that all the handbooks focused on diagnosis, leaving treatment protocols to simple lists of appropriate medication classes.

I decided to begin work on a handbook which would serve as a concise resource for learning the disease syndromes with a focus on pathophysiology and pharmacology. A source taking you from the very basics of the disease, to the intricacies of diagnosis and treatment. One which could serve as both a quick reference, and an in-depth resource. The result is “The Consult Manual of Internal Medicine.”

Q: How did your experiences in medical school and residency influence how you wrote the guide?

A: The book is written in what I call an expanded outline format, serving as a medium between outline and paragraph form. My experiences in both medical school and residency gave me the ability to judge not only what information needs to be conveyed but how to best convey it. I wanted a book in which every chapter could stand alone, one in which the importance of mechanistic understanding takes precedence over memorization.

Q: What obstacles did you encounter when writing? How did you work past/around/through them?

A: The biggest obstacle was in finding conflicting information. When this occurred, I simply further expanded my search with majority rules, but minority explained.

Q: In addition to “The Consult Manual,” what other resources would you recommend for students rotating in internal medicine?

A: For the pocket:

• “The Tarascon Pharmacopoeia“
• “The Sanford Guide to Antimicrobial Therapy“

For home:

• “The ICU book“

Q: What words of advice do you have for current and future physician-authors?

A: Always take the time to thank your loved ones for their understanding through the process.

Otha Myles, M.D. is the Deputy Chief of Epidemiology and Threat Assessment at Walter Reed Army Institute of Research’s United States Military HIV Research Program in Rockville, Maryland.

Dr. Myles graduated from the University of Maryland School of Medicine. He went on to complete his residency in internal medicine at Walter Reed Army Medical Center in Washington, D.C. followed by a fellowship in infectious disease. He was also a recipient of the U.S. Military’s Health Professions Scholarship Program (HPSP).

Dr. Myles has become one of the leading researchers in the field of HIV. His involvement includes projects in the United States, Europe, Asia, and Africa. Dr. Myles recently sat down with SDN to give us a glimpse into the lifestyle of an Infectious Disease specialist.

Describe a typical day at work.
Being a principal investigator as well as a physician, my days consist of performing both research and clinical infectious disease specialty consultation. As a principal investigator, my days are kept busy working with other investigators to develop a globally effective vaccine to protect soldiers around the world against all sub-types of HIV. I develop research protocols aimed at gathering information regarding the prevalence, incidence, and sub-type of HIV at locations around the world and then bring it back to our headquarters in Rockville, Maryland for further analysis and potential publication. I also develop and attend lectures on continuing medical education topics in Infectious Diseases in order to keep up to date on the progress being made in my field. As the deputy chief, I communicate with others in our department and chief of the department, providing expert infectious disease consultation as needed. Working within a military research institute, my day usually begins at 7:30 and ends at 4:30 on most weekdays with little to no weekend or on-call duty.

If you had to do it all over again, would you still become a doctor?
I definitely would still become a doctor. For me it was a true calling. From a young age, I would follow my mother as she would provide healthcare for the community. This gave me a great value for helping others.

Why did you choose your specialty?
One of the things that influenced me to go into infectious diseases was my experience working as a Research Physician’s Assistant in the NIH’s AIDS Minority Infrastructure Program (now called AIDS Clinical Trials Group or ACTG). Also I saw the benefit of working in infectious disease as a military physician very early in my internal medicine training. The opportunity for travel medicine, tropical medicine, and biological weapon consultation is very different than those offered to others in non-military training programs and work places.

Now that you’re in your specialty, do you find that it met your expectations?
My expectations have definitely been met, even though now I do more clinical work than before. One of the greatest things about my field is that I am able to help populations of patients as opposed to just one individual at a time. Working in public health (clinical epidemiology) is basically protecting populations of individuals at once. Also, I feel like I am able to be more personal with my patients based on the nature of their illnesses and the type of personalized management each individual may require.

Are you satisfied with your income?
I have to say that I am fortunate to make the salary that I do now. However, military physicians’ direct incomes are somewhat lower compared to civilian physicians. The military tries to give bonuses in order to bring physicians’ income up compared with their qualifications and training.

What do you like most about your specialty?
You get to see exotic cases. More often than not these are very complex cases and it depends on you to figure out the diagnosis. It is absolutely a great challenge. On top of that you get to know a little about places all over the world. You tend to become a more international/global individual. One of the positives is that contrary to what most people think about this field of medicine, patients get better. There is a very small mortality rate. It feels as if you are actually “curing” people.

If you took out educational loans, is paying them back a financial strain?
Since I went to medical school through the HPSP, I did not have to pay for medical school because the military paid for it in return for service after graduation. I was considered to be a non-traditional student due to the fact that I was married, had a young child, and a mortgage to pay. So even though the military paid for school, I still had to take out loans to support my family. There is very little strain now because the military pays for most things, such as housing and medical care.

On average: How many hours a week do you work? How many hours do you sleep per night? How many weeks of vacation do you take?
The Army gives you thirty days of leave per year and unlimited sick days. At least once a year, I take two weeks off which I usually coordinate with my children’s school schedule. For the summer, I take one week off. Being a military physician, my schedule goes by the military work hours which is normally from 7:30 to 4:30pm or 5pm, Mondays through Fridays. During the week I do not take calls unless I am on the ward. I do not usually work on the weekends.

What types of outreach or volunteer work do you do, if any?
In my job, everything is considered to be outreach work. However, one of my personal community outreach concerns is related to providing the opportunity for underrepresented students to be able to go to medical school and receive a stellar medical education. I have created a scholarship with one of my own mentors (Dean Emeritus Donald E. Wilson, M.D.) called the Donald E. Wilson Legacy Scholarship Fund. Just by grassroots efforts alone we have been able to raise nearly $50,000. My goal is to raise at least $2 million over the next five years.

From your perspective, what is the biggest problem in healthcare today?
One of the biggest problems I see with our field is the limited number of admissions of underrepresented minorities into medical school and graduate school. The shortage of these students being admitted greatly impacts the medical care that can be provided to disadvantaged patients in the future. Unfortunately, it is often individuals from minority communities that are infected with diseases such as tuberculosis (TB) and HIV and without the insurance of resources to obtain the appropriate medical treatment. Consequently, due to the extremely high cost of attending medical school, many minority students are discouraged to even apply let alone attend. I believe that we should work on making medical school less of a financial burden for all students and that finances should not keep any qualified students from attending.

What is the best way to prepare for this specialty?
The best preparation is to begin with a residency in internal medicine, then a fellowship in either adult or pediatric infectious disease. Students who are interested should [aim] for primary care and global medicine-based programs. Also, doing a rotation outside of the country and working with disadvantaged patients is definitely beneficial and gives students greater exposure into the field of infectious disease.

Where do you see your specialty in 10 years?
In many places, the majority of ID is HIV and it is now expanding to doctors actually chronically managing it. Through medications and therapeutic research it is becoming much more of a manageable disease. People are now living greater than 19+ years post-diagnosis. With adherent patients, it becomes the same as treating any other chronic disease such as hypertension and/or diabetes. Hopefully with HAART (Highly Active Anti-Retroviral Therapy) we will be able to keep patients living for a very long time.

After starting out as a failed journalism major, Dr. Lawrence Terra wound up graduating Phi Beta Kappa from a prestigious midwestern university with a B.A. in Psychology. He graduated with High Honors from an University of California medical school and now pursues his original dream of journalism through a popular blog.

He completed a four-year OB/GYN Residency and then went on to a Fellowship in Reproductive Endocrinology and Infertility (REI). He has worked with many of the pioneers in the field of In-Vitro Fertilization (IVF). Dr. Terra is currently in full-time private practice as the Medical Director of an IVF program in Southern California. He is a sought-after lecturer, giving educational talks to hundreds of physicians and medical students annually. Dr. Terra is a Board-Certified Fellow of the American College of Obstetrics and Gynecology and an active faculty member at two medical schools.

He recently sat down with SDN to give us a glimpse of life as a Reproductive Endocrinologist.

What mix of clinical/research/teaching work do your position include? How much power do you have to change that mix?

90% clinical / 10% teaching It’s current at the balance I want. I believe it’s easily changeable if I should so choose.

If you had it to do all over again, would you still become a doctor? (Why or why not? What would you have done instead?)

Absolutely. I don’t think I arrived where I am currently by my carefully crafted plan. I am grateful that things fell into place. I attribute a lot of it to befriending the right mentors, being a nice person and having a lot of luck.

Why did you choose your specialty?

I originally wanted to be the greatest Gyn-Onc surgeon in the world, but when I discovered REI, I was excited to discover that it is the field whose features uniquely suit the majority of my goals in life.

Did you plan to enter your current specialty prior to med school?

I went into med school with no clue and no biases on what field to pursue.

Now that you’re in your specialty, do you find that it met your expectations?

Absolutely.

Are you satisfied with your income?

I have other business ventures that supplement my income, but even without them, I would be fairly satisfied with my medical income. Bear in mind, I personally don’t require a high-consumption lifestyle to be very fulfilled.

What do you like most and least about your specialty?

What I like least: I am so specialized as to not be a “general doctor” any more. Hypertension? Arthritis? What’s that?

What I like best:

1. FAIRNESS. The harder I work, the better job I do for my patients, the more I reap rewards. The more I slack off, the more I am punished financially (therefore I don’t). It is a fair system (something not necessarily true of other areas of medicine)
2. GREAT EMOTIONAL REWARD. Everyone loves the ideas of bringing babies into the world (except the global warming fanatics)
3. VARIETY and SUSPENSE: An IVF cycle will be successful 30-60%. But there is no way to know for sure which ones will succeed and which won’t. When those pregnancy tests roll off the analyzer, we rush to see the results and either cheer or grieve.
4. Relative AUTONOMY and INSULATION from a broken medical system.

If you took out educational loans, is/was paying them back a financial strain?

I went to a California state school with a reasonable tuition. I worked various jobs during medical school.

On average: How many hours a week do you work? How many hours do you sleep each night? How many weeks of vacation do you take?

I work 7 days/week. But Saturday and Sunday consist of 1-2 hours without a lot of stress. I take off all of December each year. If I can find some good help, I might take off June each year as well. I sleep comfortably at home every night, maybe getting a call once or twice a year.

Do you have a family and do you have enough time to spend with them?

I’m pretty happy with my social life and I enjoy many non-medical activities. I am single and live with my two dogs. If I’m not married in the next five years or so, I can always get an egg donor and a surrogate and have a child. (Not entirely kidding!)

In your position now, knowing what you do – what would you say to yourself 10 years ago?

Read a wide variety of non-medical books. Make quality friendships. Actively learn about yourself. Actively learn “life-hacks” to better use your time, hone your body, manage your energy, efficiently use your mental capacity. Explore a variety of non-medical activities. Make every week of your life at least a little different from the previous one.

What information/advice do you wish you had known when you were an undergraduate? (What mistakes or experiences have you encountered that you wished you had known about ahead of time so you could have avoided them?)

Be open-minded and gather your information from a variety of sources. Don’t believe everything that one person says. Don’t believe most of what the mainstream media says. Don’t believe everything that every professor says. On the other hand, don’t reflexively discount everything either. Bottom line: think critically, try and gather information from both sides of an argument and make up your own mind.

From your perspective, what is the biggest problem in health care today?

This would take me two hours to just scratch the surface even with all my Power Point slides. Since you are asking, I can’t really answer without injecting my political viewpoints. We need more freedom to unleash human work ethic, ingenuity and fair competition (just as our country’s forefathers wanted it) and less bulky bloated restrictive inefficient government. In other words, we need the proper rules in place so doctors can do their best without doing inefficient things (spend hours filling out insurance paperwork) ordering unnecessary tests to defend against frivolous lawsuits, the freedom to put out a better level of medical care and be recognized accordingly. In our present system, a doctor who spends more time talking to his patients is punished indirectly through effectively getting intolerably low per-hour compensation, therefore giving incentive to go the high-volume route and rush through more patients in less time.

From your perspective, what is the biggest problem within your own specialty?

While we don’t have to deal with the insurance bureaucracy and medical-legal nonsense as much as other specialties, we still have SOME.

What is the best way to prepare for this specialty?

I don’t know. It depends on your situation.

Where do you see your specialty in 10 years?

Technologically, at the rate we’re advancing it’s hard to imagine the limits! Who would have thought 20 years ago, that 1 out of every 75 babies born in the US would be products of IVF? Success rates which originally were under 5% are now getting close to exceeding 60% in many patients.

What impact do mid-level providers have on your day-to-day practice?

I would love to have a good NP / PA to help me, but in three years, have yet to find one that would be good fit for my practice. I’m still looking.

What types of outreach/volunteer work do you do, if any? Any international work?

Currently, I do many philanthropic activities, made possible in part by the financial resources and social connections afforded by my job. But I participate in a non-medical capacity. Back in med school, I worked in clinics in Mexico; I’d be less useful today, because I know essentially zero primary care medicine.

What do you like to do for relaxation or stress relief? Can you share any advice on finding a balance between work and life?

This question requires another two hour power point presentation. I do motivational speaking about life strategies. I guess if I could just give ONE universal piece of advice, it would be this. If your life is in any way not 100% exactly the way you want it, then EXPERIMENT. Learn a new language. Wake up one hour earlier. Drive a different route to school. Strike up a friendly conversation with someone you would unlikely talk to. Go to the book store and explore something totally new to you. 90% of the time, you’ll find that you don’t like the new thing and you’ll abandon it. However, that 10% now adds to your repertoire of fun new things in life.

Is there anything else you’d like to share that we haven’t covered? Any other advice for student interested in pursuing a career in medicine?

Think of this not as a blatant plug, but as a polite invitation: If you want to know more about what I think, read my blog at http://fertilityfile.com You can also contact me with questions through the site.

John T. Sinnott, MD, FACP is the Director of the Division of Infectious Disease and International Medicine at the University of South Florida College of Medicine.

Recently, he sat down with SDN to give us a glimpse into his career as an Infectious Disease specialist.

Describe a typical day at work.

I don’t think there is a typical day at work for me. It seems that each day is full of something new and exciting and different. One day I may be teaching concepts of diagnosing illnesses to medical students, the next day working on a grant and the day after that analyzing an epidemiologic study. To me the best part of my job is that there are no typical days. 

Why did you select academics over private practice?

Selecting academics was a relatively easy choice over private practice. While private practice allows autonomy, it also entails the responsibility of business. I prefer the academic pursuits of seeking new knowledge, teaching and academic patient care. Academics affords me the freedom to work at my own pace, study areas important to me and practice in areas that I am truly knowledgeable about.

What mix of clinical/research/teaching work do you do? How much power do you have to change that mix?

As a professor, I have a wide range of freedom in choosing my mix of activities during the day. There are some administrative responsibilities where organizational talents are required. But I can mix my ratio of clinical, research and teaching work in a manner that gives me the most professional satisfaction. It seems that some years I am more oriented towards clinical work, others to teaching, and yet others to research. There are advantages and disadvantages to academic medicine. To me the advantages far outweigh the disadvantages.

What are the advantages/disadvantages to academic medicine?

Advantages of academic medicine:
1. Atmosphere of lifelong learning.
2. Excitement and energy of the students.
3. Giving back to medicine through mentoring.
4. Having time to thoroughly understand a disease.
5. Being surrounded by smart people. Never being the smartest person in the room.
6. Dealing routinely with thought leaders.
7. Balancing a career and research and writing.
8. The thrill of “making a difference”.

Disadvantages:
None that I know of.

If you had it to do all over again, would you still become a doctor? (Why or why not? What would you have done instead)?

Being a physician is a dream come true. I simply can’t imagine pursuing a profession that did not care for and was not about people.

Why did you choose your specialty?

Infectious disease has a broad horizon and I like to take a long-term wide angle view on my profession. Furthermore, I had polio as a child and was always curious: “why me?” and “what happened?”

Did you plan to enter your current specialty prior to med school?

Yes. As a college student, microbiology fascinated me. I was lucky to do research with Dr. Charles Craig before starting medical school which helped solidify my goals.

Now that you’re in your specialty, do you find that it met your expectations?

Infectious disease and international medicine have far exceeded my expectations. Science, medical practice, exotic illness, diverse patients and uniquely curable patients make it quite fulfilling.

Are you satisfied with your income?

Of course I am satisfied with my income. Actually, I would probably do this job for free…but don’t tell my boss.

What do you like most and least about your specialty?

Infectious disease is constantly evolving as a specialty. New knowledge is discovered every day and it’s wonderful to have the skills to apply these spectacular advances. The paperwork is the least tasteful part of my profession, but it is hardly unique to medicine.

If you took out educational loans, is paying them back a financial strain?

I was fortunate enough to have financial support to attend medical school. This was supplemented with loans. Today, however, the financial climate is different. Unfortunately, perhaps tragically, education is increasingly expensive. It is not fair that our future students will face a burden of debt. It is also not in the best interests of our society.

On average: How many hours a week do you work? How many hours do you sleep per night? How many weeks of vacation do you take?

I work about 60 or more hours per week, if you want to call it work. Much of what I do is fascinating and gives a deep sense of fulfillment and professional satisfaction. I sleep about six hours a night but usually awake eager to go to the hospital or school. I spend two to three weeks fishing a year. Additional time is spent in healthcare in an international setting. I look at it as fun. I could take more time, but I don’t desire to.

Do you have a family and do you have enough time to spend with them?

I enjoy family life but it is, by my choice, secondary to work.

In your position now, knowing what you do – what would you say to yourself 10 years ago?

10 years ago I would have told a younger John Sinnott to be less judgmental, more accepting and to pursue an agenda for personal growth with a good mentor.

What information/advice do you wish you had known when you were a premed? (What mistakes of experiences have you encountered that you wished you had known about ahead of time so you could have avoided them?)

My “pre-med” years were fortunately spent playing tennis, working in a boat yard and exploring life. My grades would not be acceptable to medical schools in this day and age. Fortunately, people tell me that standardized exams are my strong point so the MCAT helped. So did some admission committees less focused on grades. A mistake that current pre-med students seem to make is a bad blend of too many “difficult” courses at the same time and a lack of liberal arts experience.

From your perspective, what is the biggest problem in healthcare today?

The main problem with medicine today is the paradigm of the iron triangle and the confusion of success with money. The iron triangle balances success, cost and quality. Essentially, you get only two of the three. It would not be incorrect to say we need a healthcare revolution. Secondly, some physicians confuse financial and professional success. Hopefully, our new generation of doctors will define success as being a great doctor in the framework of being a great human being. That the better “angels” of their nature will prevail over natural desires.

From your perspective, what is the biggest problem within your own specialty?

Perhaps the greatest problem facing infectious disease is the consequence of emerging pathogens with a medical community that sometimes suffers from a failure of imagination.

What impact do mid-level providers have on your day-to-day practice?

Mid-level providers are an invaluable resource. They allow more time for complex issues and often bring a different perspective to our view through a sometimes mirrored prism.

Where do you see your specialty in 10 years?

There will be tremendous growth in the study of infectious disease and international medicine over the next decade. Overpopulation, globalization, new disease, antibiotic resistance and advances in medical science will change our calling completely.

What types of outreach/volunteer work do you do, if any? Any international work?

Volunteerism is a key to professional satisfaction as well as to projecting a positive image of the profession. Volunteering can range from free clinic work to community board service to international efforts.

What’s your favorite TV show?

TV has, for me, some appeal in the history and learning channels.