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.

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.

His areas of interest are glaucoma and neuro-ophthalmic disease and binocular vision disorders. He also enjoys complex, specialty contact lens fittings.

He recently took time from his schedule to answer a few questions for SDN.

Describe a typical day at work.
On Mondays I see a variety of cases as I work with Rosa Tang, MD (a well respected neuro-ophthalmologist) out of the University of Houston. It keeps my interest in learning and gives me good detective skills to use. The rest of the week I deal with primary eye care issues at my own practice. I enjoy the the hectic pace and the management of a business. It has been both rewarding and frustrating, and it constantly pushes me to learn and adapt and grow.

What mix of clinical/research/teaching work does your position include? How much power do you have to change that mix?
I do not have experience in research but I enjoy the prospect of showing students interesting cases at the university. At some point I would be interested in teaching more in a clinical setting.

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?)
Yes, I would. I don’t really know what else I could have done that would have given me the autonomy to help people, have a position of respect, run my own business and challenge me constantly. It’s a good fit for me.

Why did you choose your specialty?
I fell into it due to a friendship with my optometrist.

Did you plan to enter your current specialty prior to professional school?
Yes.

Now that you’re in your specialty, do you find that it met your expectations?
Most of the time.

Are you satisfied with your income?
No, but who is?

What do you like most and least about your specialty?
Most: the reward of grateful patients and a big smile.
Least: the fact that we are a “legislated” profession.

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

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?
Too many. I sleep 4-5 hours a night, I rarely take vacations, but I don’t know if this is representative of the profession. i just have insomnia and I work too hard.

Do you have a family and do you have enough time to spend with them?
I always make time for family. Wednesday is “family day” and we plan special dates with me, my wife and our 4-year-old son.

In your position now, knowing what you do – what would you say to yourself 10 years ago?
Stop being so stubborn!

What information/advice do you wish you had known when you were an undergraduate?
Learn all you can about practice management, coding and billing and learn to watch your money and business like a hawk!

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

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

What is the best way to prepare for this specialty?
Study and shadow an OD.

Where do you see your specialty in 10 years?
Hopefully as an integral part of the health care profession.

What impact do mid-level providers have on your day-to-day practice?
Not sure.

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

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

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 health care?
Don’t do it for money – do it for passion. Love what you do or don’t do it. Life is too short.

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.

Lee C. Rogers, DPM is the director of the Amputation Prevention Center at Broadlawns Medical Center in Des Moines, IA. Dr. Rogers graduated from podiatric medical school at Des Moines University and completed a residency in foot surgery at Saint Vincent Catholic Medical Centers of Brooklyn/Queens in New York City.

He completed a fellowship in diabetic limb salvage and research at Scholl’s Center for Lower Extremity Ambulatory Research (CLEAR) in Chicago, IL. Dr. Rogers has approximately 50 publications, in press or in print, including scientific articles, book chapters, and editorials concentrating on the treatment and prevention of foot complications in diabetes.

Describe a typical day at work.
I am a hospital-based podiatrist and work in a group of 4 DPMs. We typically round on inpatients at 7, then perform surgery or see patients in our Amputation Prevention Center until 5 or 6 PM and usually finish the day by attending to any inpatient consultations that were requested. In addition to wound debridements, off-loading surgeries, and skin replacements, we perform seemingly complex surgeries like Charcot reconstruction or plastic procedures to close soft tissue defects. We also have a lot of emergent/unplanned cases involving diabetic foot abscesses or amputations. These types of emergent surgeries are usually “walk-ins” or come from the emergency department.

If you had it to do all over again, would you still become a doctor?
Absolutely. I’m sure you’ll hear the same pessimistic outlook on medicine that I did by some disgruntled doctors, but doctors make a big impact in the lives of our patients. Of course, no field is perfect, but you can expect to make a nice living as a doctor. Of Forbes magazine’s highest-earning professions, physicians and physician specialists occupy 13 of the top 15 spots.

Why did you choose your specialty?
I was interested in medicine and surgery. Podiatry allows you this mix. The limb salvage patient is complicated. They often have diabetes with 10+ comorbidities and we have to work closely with other medical specialists like endocrinologists, nephrologists, and cardiologists. Almost all limb salvage patients are surgical patients requiring debridement of wounds or stabilizing surgeries to maximize limb function.

Now that you’re in your specialty, do you find that it met your expectations?
I’ve been very happy with my subspecialty. Much of this was due to good direction by mentors earlier in my education. It’s important to find a successful, ethical doctor that you can strive to emulate.

Are you satisfied with your income?
I am salaried and receive raises dependent on professional fee generation for the hospital (production-based model). Having completed a fellowship and declared a subspecialty helped tremendously to increase my base salary. As a researcher and a medical author, my salary is also supplemented by lecturing and consulting for pharmaceutical and medical device companies.

What do you like most about your specialty?
Often when I see a patient, they’ve been “offered” an amputation by another doctor. Patients are often depressed and desperate. Many times we are successful at salvaging the limb, which gives me great personal satisfaction and results in the most grateful patients!

If you took out educational loans, is paying them back a financial strain?
Podiatry schools are private and expensive. I borrowed the maximum federal loans to pay for school. I am lucky that I consolidated the loans when the interest rates were at an all-time low. I opted to take a graduated repayment plan and can afford my loan payments without difficulty.

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 generally work 50-60 hours a week. I am on call one night per week and one weekend per month. Sleep is a luxury, not because of an overly hectic hospital work schedule, but due to research and authoring articles. I am contracted to receive 7 weeks of vacation plus CME time but it will be difficult to actually take that much time off.

What types of outreach or volunteer work do you do, if any?
I volunteer as a member of the Des Moines Citywide Institutional Review Board (IRB), which oversees research for the city hospitals. We are a board of physician-scientists and community laypersons and we’re responsible for the protection of human research subjects.

From your perspective, what is the biggest problem in healthcare today?
I have heard some say our system would be more appropriately named a “sick”-care system (not a healthcare system). Payors fail their patients by inadequately covering preventative medicine. Not only does preventing diseases improve quality of life, but in most cases prevention reduces costs, especially in diabetes and diabetic complications. An example from my subspecialty is that 85% of diabetic amputations are preventable. The 5-year mortality rate after a major lower extremity amputation is 68%. Physicians, payors, and policy-makers need to come together and act to prevent illnesses, not just treat them.

What is the best way to prepare for this specialty?
In my first week of podiatry school, one of my mentors (Dr. Vincent J. Mandracchia) said, “Read, read, read.” This is a simple concept, but undoubtedly true. Weekly I receive PubMed alerts on all the new publications with the key words “diabetic foot ulcer, diabetic neuropathy, and Charcot foot”. There are approximately 50 articles weekly; I must at least read the abstracts to stay current in my own subspecialty. We owe it to our patients to offer them the most current treatments, ones based on evidence. Plus, the best way to win a scientific argument with your peers is to quote literature!

Where do you see your specialty in 10 years?
Diabetes is a pandemic. The CDC estimates that there are 20 million people with diabetes in the United States and that this number will double by 2030. I see podiatrists becoming “America’s diabetic foot doctors.”

Born and raised in Niagara Falls, Dr. Elder graduated from the State University of New York College of Optometry after serving an internship with the Indian Health Service on the Navajo reservation in Arizona.

Upon graduating, Dr. Elder completed his residency in Primary Care at SUNY. After his residency Dr. Elder served as clinic director for TLC Laser Eye Centers in Las Vegas, Nevada before moving back east to Connecticut.

Today, he is a partner in a two-doctor private practice in central Connecticut. Dr. Elder enjoys golf, photographing historical sites, and cheering on his beloved Buffalo Sabres during the NHL hockey season. Describe a typical day at work.
I see patients 5 days a week, averaging about 20-25 per day for various eye and vision-related problems. One morning a week I see patients in area convalescent homes. I normally do administrative duties early in the morning or at the end of the day.

What mix of clinical/research/teaching work do you do? How much power do you have to change that mix?
Most of my work is clinical. I have a few small research projects on the go that center around eye movement disorders in children with reading difficulties. I occasionally lecture at local universities, usually in the education department. I also conduct a yearly cow eye dissection at a local high school. One of my patients is a science teacher and she asked me to volunteer, and it got such a positive response that I’ve been asked to do it every semester.

If you had it to do all over again, would you still become an optometrist? (Why or why not? What would you have done instead?)
In a nutshell, I would do it again but I would do it a bit differently. It took me longer to find a professional situation I was comfortable with than I anticipated it would. Also, some of the obstacles that I encountered when I graduated were things I never anticipated would be a problem. It took longer to overcome those obstacles than I expected.

Why did you choose optometry?
Ironically enough, I wanted to be an airline pilot and I found out my eyesight wasn’t good enough to join the Air Force. I was about 15 when I found this out, so I made an appointment with my local optometrist. While waiting in his chair for him to come in and perform the exam, I looked around and noticed he had a bunch of cool-looking gadgets. When he came in, I asked him what he did all day. He was young and enthusiastic and showed me around his office. I thought “Great! This is what I’m going to do with myself!”

Tell us a bit about the education of an optometrist. What specific classroom, laboratory and clinical educational experiences helped prepare you to enter the profession?
Optometrists study a wide range of anatomy, physiology, pharmacology, physics and optics both in didactic and clinical settings. The number of patient encounters was particularly strong as a student so I felt more than comfortable seeing the vast majority of patients I encountered when I graduated.

Now that you’re in your specialty, do you find that it met your expectations?
For the most part, yes. Optometry has met my expectations.

Are you satisfied with your income?
Yes, more than satisfied, but it took becoming a practice owner to achieve that. Working for someone else almost invariably left me less than satisfied with my income.

What do you like most and least about optometry?
The day to day interaction with different and unique people is a big plus. Helping people improve their most precious sense is very rewarding. Most people don’t have unusual phobias about going to the eye doctor so the patient interactions tend to be casual and low stress. The worst part is the daily battles with insurance companies, and the fact that I need a virtual armada of staff to process and chase down insurance claims.

If you took out educational loans, is/was paying them back a financial strain?
I took out more than the average loan and it was a very minor strain to repay.

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 about 45 hours a week seeing patients, and about 15 administering my practice. I sleep about 6 or 7 hours a night, but we are expecting our second child very soon so I’m sure it will be much less than that soon! I take about 2-3 weeks of vacation a year. I also prefer to go away for continuing education conferences rather than do them close to home. It’s just another excuse to get out of the cold Connecticut winters.

Do you have a family and do you have enough time to spend with them?
I have a wife, who is also an optometrist, a son and another on the way. I feel that on the whole I get to spend enough time them.

In your position now, knowing what you do – what would you say to yourself 10 years ago?
I would say that the things you are worrying about are not the things that are the highest priority. Optometry students (like most doctoral students) generally tend to worry about repaying student loans, finding a “job” and finding an area to settle down in which the competition from other providers is low. I would submit that none of those things are things that need to be worried about.

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 known the extent to which managed care participation would impact my ability to see and help my patients. Unfortunately, this is somewhat of a regional phenomenon so people considering optometry should have some rough idea of where they want to practice when they are finished so that they might scout those issues out ahead of time. Another mistake I made was spending far too much time dealing with and negotiating with small-time thinkers with respect to buy-ins and partnership offers. In retrospect, I spent too much time trying to work out unworkable situations. I wish I would have recognized that sooner.

From your perspective, what is the biggest problem in health care today?
Probably the amount of money that gets wasted on administrative tasks and people. I recall reading an article in a public health journal that said that from 1977 to 1997, the number of doctors and nurses went up 11%. The number of health care administrators at the same time went up 2600%. I don’t know how anyone can argue that THAT is an efficient use of resources.

From your perspective, what is the biggest problem within your own specialty?
Optometry is somewhat of a fractured field in the sense that most optometrists can’t seem to come to a consensus on what the most important issues facing the profession and the future of health care are. For whatever reason, optometrists tend to have somewhat of a “lone wolf” mentality and I think that that sometimes exacerbates that problem.

What is the best way to prepare for this specialty?
Obviously a good background in science and scientific method is important. Many people get into health disciplines because the pay is generally good, and people have a strong desire to “help people” but I would submit that that’s not enough. You need to have good critical thinking skills and a genuine sense of scientific curiosity to be a good clinician.

Where do you see your specialty in 10 years?
The advances in progressive spectacle and contact lens technologies have been astounding in the past 10 years, and I think the next 10 years will usher in a whole new generation of highly biocompatible contact lenses. I fully expect that the time will come where people will put on a pair of contact lenses and sleep in the them for months or even a year at a time. The advances in diagnostic and treatment modalities for ocular disease are also incredible. New instrumentation has allowed ocular pathologies, particularly glaucoma and macular degeneration to be diagnosed and treated at much earlier stages in the past.

What other types of providers and/or technicians do you work with in your day-to-day practice?
In my office, we only have optometrists so in that sense it gets a bit lonely. We do consult with primary care, internal medicine, neurology on a daily basis. Of course, we have a good network of ophthalmologists that we can refer to for surgical cases so we are in frequent contact with ophthalmologic counterparts as well.

What types of outreach/volunteer work do you do, if any? Any international work?
I am in the Lions club, and I sometimes volunteer to tutor high school math and science students. I have not done any international work.

What do you like to do for relaxation or stress relief? Can you share any advice on finding a balance between work and life?
I play the guitar, and I enjoy photography. As far as finding a balance between work and home life, it really varies from person to person because it’s such a personal issue. I would say though that the traditional 40 hour week is generally for people who are never going to succeed at a high level. If you want to punch the clock, you’re likely to realize only a limited amount of your potential. Yet at the same time, I have never heard of anyone who lies on his or her deathbed and declares that they wished they spent more time in the office all those years ago. So it really boils down to your own individual personality.

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.

Michael Rack, MD grew up in Southern California. He graduated from the University of Iowa College of Medicine in 1997. He completed combined residencies in Internal Medicine and Psychiatry at West Virginia University-Morgantown in 2002. He completed a Sleep Disorders Medicine fellowship at the University of Mississippi in 2003.

He stayed on at the University of Mississippi as an Assistant Professor of Psychiatry and Internal Medicine until 2005, when he left to start Somnus Sleep Clinic in Flowood, MS.

He is a diplomate of the American Board of Internal Medicine, the American Board of Psychiatry and Neurology (Psychiatry), and the American Board of Sleep Medicine. He is a member of the American College of Physicians and the American Academy of Sleep Medicine. 

He is on the Behavioral Sleep Medicine Committee and serves as an Accreditation Site Visitor for the American Academy of Sleep Medicine. He is also a Clinical Assistant Professor of Psychiatry at the University of Mississippi. Recently, he was kind enough to sit down with SDN and share his perspective on his specialty with our users.

Describe a typical week at work.

I spend approximately three days a week seeing outpatients at Somnus Sleep Clinic, a 6-bed sleep disorders center near Jackson, Mississippi. I own the clinic with 2 non-physician business partners. I spend one to two half days a week reading sleep studies at Somnus Sleep Clinic, and also read some sleep studies on the weekends. Approximately two days per month I perform sleep lab accreditation inspections for the American Academy of Sleep Medicine. This frequently involves travel to another state. Once a month I provide psychiatric care for mentally retarded and autistic adults at several group homes. Several times per month I travel to a rural hospital approximately 45 miles from Jackson and perform sleep consults. I am also helping to set up a sleep lab at that hospital.

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

Most of my work is clinical. I do some research, but this is purely voluntary on my part. Several times a year, I write a sleep disorders review article for Medlink Neurology. I am also analyzing some data from the Jackson Heart Study with a colleague who is a nephrologist at the University of Mississippi Medical Center. In addition I am working on a case report with my wife, who is a psychiatrist at the University of Mississippi Medical Center.

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?)

I probably still would become a doctor, but if I had to do it over again I would have taken some advanced mathematics classes in college and explored the possibility of becoming a quantitative analyst for a hedge fund.

Why did you choose your specialty?

I became interested in sleep medicine while completing an internal medicine/psychiatry residency at West Virginia University, Morgantown. I find the multidisciplinary nature of sleep medicine, which involves psychiatry, neurology, ENT, pediatrics, pulmonology, and general medicine, fascinating. Sleep medicine also has a profitable cognitive procedure (polysomnography) which requires no manual dexterity on the part of the physician.

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

No, prior to medical school I planned on becoming a primary care physician.

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

Sleep medicine is a rather narrow field to limit one’s practice to, and it is rather repetitive. I do some general psychiatry also. I wish that I could do a primary care clinic once a week, but I lack the infrastructure at my clinic to do this.

Are you satisfied with your income?

I am not satisfied with my income for 2007, but it should improve in 2008. My sleep lab has been gradually increasing the number of sleep studies performed, and it should soon be up to 100 per month. When that number is reached, it should result in an acceptable income.

What do you like most and least about your specialty?

I like reading sleep studies the most. The repetitive nature of a sleep clinic- primarily evaluating for and treating obstructive sleep apnea- is what I like the least.

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

My educational loans were not excessive due to the help of my family. Paying them back was not a financial strain.

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 about 60 hours per week. I sleep 7-8 hours each night. I don’t like to take long vacations. I attend frequent CME conferences during the year (4-5 per year) and take anywhere from 1 to 4 workdays off at a time to attend these. I do try to travel back to Southern California at least once per year; I will sometimes take off 4 workdays for this.

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

I am married to a psychiatrist and have a 7 year-old son and a 4 year-old daughter. I have enough time to spend with them.

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

Pay more attention to your retirement accounts while you are residency. Don’t keep your money in stock index funds during a bear market. Don’t make rapid changes in your allocation, but do react to market changes. Beware of falling knives.

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?)

I would advise premed students to begin doing hospital volunteer work or obtain some type of medical position as soon as they begin college. This will help in the medical school application process.
I would advise residents to retain the services of a good accountant and lawyer immediately upon finishing training (or sooner if they plan to practice in the same area they trained).

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

The old social contract between physicians and society has broken down. In the past, doctors would provide call coverage for local ER’s and would provide some charity care. In return, doctors were provided generous reimbursement by Medicare and private insurers. Increasingly over the last decade, society has become unwillingly to subsidize doctors’ charity care and ER coverage; Medicare and private reimbursement has been cut to the bone. As a result doctors have limited the insurance plans they take and fled local hospitals/ER’s. Cherry-picking specialty hospitals are proliferating.

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

Becoming an independent sleep specialist requires a large capital investment. It takes approximately $250,000 to start a 4-bed sleep lab. Changing Federal regulations threaten the financial viability of sleep labs. For example, CMS (Medicare) is in the process of approving portable sleep monitoring for the diagnosis of obstructive sleep apnea. This would have a negative financial impact on many sleep labs.

What is the best way to prepare for this specialty?

Sleep medicine is a one year fellowship after a psychiatry, neurology, ENT, family practice, pediatrics, or internal medicine residency. The best way to prepare is to do one or two sleep medicine elective months during residency. Sleep medicine is becoming a more competitive fellowship, and it is hard for someone who has only completed an internal medicine residency to get- general internists are competing with pulmonary specialists for slots. If a resident is trying to go straight from internal medicine residency to sleep fellowship (rather than doing a pulmonary fellowship first), some sleep research during residency would be helpful.

Where do you see your specialty in 10 years?

There will be more hospital associated sleep labs but fewer freestanding sleep labs. There will be more physicians with sleep board certification. However, the number of doctors who practice sleep medicine full time will decrease; most will practice sleep medicine part time in conjunction with the specialty they trained in during residency.

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

I do not work with mid-level providers. Some sleep physicians utilize mid-level providers for patient follow-up visits, which allows the physician more time to read sleep studies.

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

I don’t do any international work. I am an active member of the American Academy of Sleep Medicine and serve on its Behavioral Sleep Medicine Committee.

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 and stress relief, I am currently taking online classes for an MBA at Mississippi State University. I also have two blogs, sleepdoctor (http://sleepdoctor.blogspot.com/) and rebel doctor (http://rebeldoctor.blogspot.com/). I also find playing no-limit Texas Hold’em relaxing. As far as finding a balance, my advice is that if a physician is feeling overworked, he should examine his work activities and drop the lowest paying or least enjoyable one.

Dr. Dennis C. Stokes is a Professor of Pediatrics and Chief of the Program in Pediatric Pulmonary Medicine at Children’s Medical Center-St. Jude Children’s Research Hospital-UT Health Science Center. He is also the Director of the University of Tennessee Cystic Fibrosis Care and Research Center.

Dr. Stokes graduated from the University of Kentucky College of Medicine and obtained a Master of Public Health degree from Indiana University-Purdue University. He completed his medical internship and pediatric residency at Johns Hopkins Hospital, with fellowship training at Children’s Hospital Medical Center and Harvard University Medical School.

Dr. Stokes has consistently been named among America’s Best Doctors®, and is known for his expertise in asthma and cystic fibrosis.

Dr. Stokes has graciously agreed to be interviewed by The Student Doctor Network in order to impart some of his wisdom and perspective to prospective doctors.

Describe a typical day at work.
I work in a group of four pediatric pulmonologists. Since we cover two children’s hospitals, my work day is quite variable. When we’re on the inpatient service, we see patients with a variety of pulmonary conditions, including cystic fibrosis, asthma, chronic lung disease of infancy (BPD), and consult on a even wider variety of pulmonary problems. At St. Jude Children’s Research Hospital, we see patients with pulmonary complications of cancer therapy, including bone marrow transplantation. These complications include drug and radiation-induced lung injury, as well as infections. We teach residents and medical students, as well as lecture to area pediatricians and St. Jude staff. We also have outside clinics in surrounding communities to serve families who would prefer not to drive into downtown Memphis.

What mix of clinical, research and teaching work do you do? How much power do you have to change that mix?
Our division is primarily dependent upon clinical revenue and teaching, so that has been our primary emphasis. However, after the addition of new faculty, we are now beginning to expand our research work in cystic fibrosis, and hope to add more faculty who will focus instead on research as their primary role. The old days of an individual physician being a “triple threat” are long gone, but it is still possible for a division with adequate staff to be outstanding in clinical care, research and teaching by working as a group, and building on each individual member’s strengths.

If you had it to do all over again, would you still become a doctor? If not, what would you have done instead?
I love medicine and would definitely make the same choice again.

Why did you choose your specialty?
My father worked in a TB sanatorium in Kentucky, so I am sure working several summers with him had a big influence on my interest in pulmonary infections. Later, as a pediatric resident, I became interested in pulmonary infections in the immunocompromised host, a relatively new phenomenon in the 1970’s. This led me to pursue a fellowship in pediatric pulmonary medicine, along with a desire to better understand pulmonary physiology.

Did you plan to enter your current specialty prior to entering medical school?
I had no specific plans when I entered the University of Kentucky College of Medicine. I loved surgery, and did consider pediatric surgery, but I thought that I was too nearsighted to be an effective surgeon in 20 years. While doing an incidental appendectomy with Dr. Ward Griffin, chief of surgery, I cut on the wrong side of a suture. That probably helped seal my decision, as did my admiration for Dr. Jackie Noonan and the other pediatric faculty with whom I worked.

Do you feel that your choice of specialty has met your expectations?
I was the first of a new group of pediatric pulmonologist trainees, so at the time I entered my fellowship I’m not sure that I had very clear expectations. Clinical care and research are now very different than they were in the 1970’s, when the people who trained me were starting the field. The interesting and challenging aspects of my specialty have kept me from never being bored.

Are you satisfied with your income?
I have reached the point in my career where I have an income that is adequate. However, when I was younger, my income definitely was not what it should have been given the hours that I worked. I had worked at several outstanding academic centers, where simply being there was considered an adequate substitution for the gap in salary!

What do you like most and least about your specialty?
I love working with kids, who never cease to keep me focused on what is truly important. What I like least is the red tape that complicates so much of medical care these days.

If you took out educational loans, was paying them back a financial strain?
I was very fortunate to have a scholarship to the University of Kentucky, and that meant that I left medical school with very little debt. We made very little money as interns, and I can remember the strain we felt repaying the few thousand dollars we owed. I can’t imagine the strain on current medical school graduates who are saddled with hundreds of thousands of dollars in debt. I am sure it influences their career decisions, and consequently gives them less choice than I was fortunate enough to have.

What is your general schedule like? For instance, what are the number of hours a week you work, the number of hours you sleep each night, and the number of weeks of vacation you take a year?
I live 2.5 miles from the hospitals, so I’m available all the time. Fortunately, with four physicians in our group, it means that I am on call much less now than when I was in practice by myself. I am usually in bed by 11 p.m., and try to be up by 6 a.m. My vacation time has varied, but mostly it has been about 4 weeks a year.

If you have a family, do you find that you have enough time to spend with them?
My children are grown and living in Los Angeles and New York now, so currently it is just my wife and myself. I do wish that I had spent more time with my kids when they were younger, although I did try hard to make the important events in their lives when they were growing up. You would have to ask them whether I was around too much or not enough!

What advice do you wish you had been given prior to medical school?
I think the most important advice I wish I had been given was to ask more questions and advice from mentors. Find successful people you admire and talk to them, listen to their advice, and stay focused on what is important.

From your perspective, what is the biggest problem in health care today?
The biggest problem is the lack of health care coverage for large segments of our population, and the lack of quality care for so many people despite the money spent on health care. “The Quality Chasm” is more than just a book title, it is a reality for millions of Americans, including children, who should be our highest priority

From your perspective, what is the biggest problem within your own specialty?
There is going to be a significant shortage of pediatric subspecialists in the future. My generation will begin to retire, and fewer and fewer medical students are choosing pediatrics and are willing to spend an additional three years in training. With the aging of the population, overall the number of pediatricians will probably be adequate, but the role of the subspecialist may have to change.

What is the best way to prepare for your specialty?
Study hard and pick a related area of expertise that you can bring to the specialty. For example, pharmacology, epidemiology, quality improvement, etc.

Where do you see your specialty in 10 years?
My hope is that within the next 10 years we will have important new therapies completing clinical trials in cystic fibrosis, and that they will make a major impact on outcome for CF patients and families. I would also like to see a new generation of pediatric pulmonologists in place, providing leadership and innovations in our field.

What impact do mid-level providers have on your day-to-day practice?
Our division is currently replacing a nurse practitioner, but nurse practitioners can provide an important role in chronic illnesses like CF, asthma, BPD and complex technology-dependent patients. They can provide most of the day-to-day support and care that families need.

What types of outreach or volunteer work do you do? Also, do you do any international work?
None currently, although that is something I hope to do in the future as I move toward more of a part-time role in my specialty.

What do you like to do for relaxation or stress relief? Can you share any advice on finding a balance between work and life?
Fishing, kayaking, running, biking. The best advice regarding balance that I can give comes from an old mentor, Dr. Joseph Simone, the former director of St. Jude Children’s Research Hospital. In his well-known essay, “Understanding Academic Medical Centers: Simone’s Maxims,” he points out that “Institutions Don’t Love You Back.”