"You've matched to a Preliminary position."

by Brittany Bankhead-Kendall, M.D, M.Sc.

Every medical student looks forward to "Match Day." Even non-medical people know what this "match day" is . . . . they hear about it from us, read it on our Facebook posts, and see our blogs about it. We're obsessed with it. What happens, though, when "match day" isn't all you hoped and dreamed it would be?

As I've written before, my husband and I tried to couple's match our fourth year in medical school and were unsuccessful. He obtained a residency position outside the match, and I matched to a preliminary position.

To any hopeful medical student, matching a preliminary position is bittersweet. It's devastating that no one "wanted" you long term. It's frustrating because you will, quite literally, be starting the match all over again in a few months time. And mostly, for me, you will go for another year of your life in a large amount of debt, after thousands of hours of very hard work, with an insane amount of knowledge... and no career to show for it. None. Nothing. Just a degree that says "M.D." but that you could never actually DO anything with. I, too, was devastated.

But instead of drowning in my devastation, I chose joy: Joy that I matched at all. Thousands of hopeful medical students don't match each year and are forced into non-clinical jobs that they did not really aspire to. I also found joy in matching to a preliminary position in my field of choice; I was very happy to be a surgical preliminary resident.

I chose to use my preliminary year as a gift to see if surgery was really what I wanted to do for the rest of my life. What an amazing thing! How many of our colleagues actually get to "try out" their chosen profession for a year, with no strings attached, to see if it is something that they really like? As a medical student, you have 6-12 weeks of watching residents do what you THINK you want to do, and deciding to make a career of it. I was able to walk the walk and talk the talk (and work the work :) ) to decide if this was really what I wanted to do.

When I matched to a preliminary position I communicated to my new chief residents that I wanted to be thrown into the very most difficult rotations (busiest, hardest, longest hours, however they wanted to take that request) at the beginning of my year- in July and August. This would give me an up front, real time, on the front lines view of General Surgery, as well as expose me to the most intense months that I would be encountering. For me, these months were very busy and very overwhelming at first, but I was absolutely positive at the end of it that I was supposed to be here, and I was supposed to be doing surgery.

Letters of recommendation are very important in your preliminary year, they are basically the only thing that will have changed between last year and this year's application. You should have the maturity and the responsibility to seek these early and form relationships with faculty that allow them to easily communicate how dedicated and just how good you actually are at what you do. I love my job, and that was evident to my attendings. Also important: having an answer to "So what happened last year?" I was asked this on almost every interview I went on. Be prepared for being offered about half the number of interviews you were intially offered your fourth year of medical school. Save up money on your small resident's salary for interviews. Talk to your program director early about expectations for vacation time to be able to travel for interviews. Be nice to your co-interns because they will have to cover your call now while you travel. You are no longer enjoying a lax 4th year as you travel, you are in the thick of intern year and you will be tired. I can almost guarantee that at one point during interview season, you will walk off a night call and walk straight on to a plane. The next day you will need to look as fresh and excited as those chilled out fourth years who are interviewing around you.

The absolute best part about interviewing for a categorical position as a preliminary intern: I knew my stuff.  I know what to do, and am not frazzled, when a trauma comes in to the Emergency Department and starts decompensating right in front of me... because I've done it. I walked into every interview with complete confidence that this was going to be my career, 100%, and I was going to be VERY good at it... because it's been my job for a year now. I discussed the parts of being a surgical resident that I love that medical students don't have a clue about yet... because I'm here when everyone else goes home.

Match Day 2014 was a success for me. I matched to a categorical position. I've got a career. I'm so, so happy.

If you matched to a preliminary position this year, keep your head up. Keep your eyes on the prize. View it as an opportunity to try out a field in medicine or surgery for a year. Take the high road. Work your butt off.

You'll have a career soon, too. And it will be everything you'd hoped it would be.

~~~

Brittany Bankhead-Kendall, M.D, M.Sc. is a PGY1 preliminary general surgery resident at Methodist Dallas Medical Center in Dallas, Texas and will be a categorical resident at St. Joseph Mercy Oakland in Pontiac, Michigan this summer. She obtained her M.D. from Ross University School of Medicine, M.Sc. from Barry University in Biomedical Science, and studied Biomedical Science and Spanish at Texas A&M University. She enjoys being a surgical intern and mentoring medical students. In her personal time she enjoys spending time with her husband and son, interior design, international travel, and Texas Aggie football.

Interview with Dr. Diana L. Farmer

by Lauren B. Nosanov

Dr. Diana L. Farmer, an internationally renowned fetal and neonatal surgeon, is Chair of the Department of Surgery at UC Davis Health System, where she oversees more than 250 faculty, volunteer clinical faculty, post-doctoral fellows, residents, students, and staff who provide highly skilled, specialty services in bariatric, burn, cardiothoracic, gastrointestinal, plastic and reconstructive, oncology, transplant, trauma and vascular surgery. A recognized leader in pediatric surgery, Dr. Farmer is known for her skilled surgical treatment of congenital anomalies and for her expertise in cancer, airway, and intestinal surgeries in newborns and for her investigations on the safety and effectiveness of providing spina bifida treatments before birth.

At a recent American College of Surgeons Chapter meeting, I was fortunate enough to attend a Women in Surgery luncheon featuring Dr. Farmer. Among the topics she discussed was the journey she took from the beginning of her career to her current position as Chair of Surgery at UC Davis. She had a great deal of wisdom and advice to offer for surgeons at all points in their professional life. Below she shares some of these insights.

Q: You have taken what some would consider an unusual path through your career. What do you consider to be the most crucial turning points that have brought you to where you currently are?

A: Following my husband to match our careers allowed (forced) me to spend three years in the Lab. My resident surgical oncology lab time (two decades ago) working on adoptive cellular immune therapy for cancer, has proven to be unexpectedly valuable in my career as a pediatric surgeon now working on stem cell therapies for children’s surgical diseases.

Q: What roles have mentorship and networking played throughout your career development? 

A: In the early days, mentorship and networking were less formal, and I would define it as functioning more by observing people who served more as role models than mentors.

Q: Does being a woman affect the way in which you approach your position as Chair of Surgery? If so, how?

A: I don’t think that being a woman affects my approach to the Chair job. It’s a very maternal/paternal kind of job in a very big family!

Q: What advice can you provide to our younger members looking to have a successful career in academic surgery?

A: Follow your passion, “lean in,” don’t be afraid to try things and fail.

~~~

Lauren Nosanov is a fourth year medical student at the University of Southern California Keck School of Medicine. She spent a year before her last year of medical school as a Dean’s Research Scholar, dedicating her time to clinical research in the field of Trauma and Critical Care. Having loved surgery from the very beginning, she is excited to start her General Surgery residency in a couple of months. She is passionate about issues surrounding surgical education, mentorship, and finding a balance between motherhood and medicine. Outside of medicine she enjoys practicing Taekwondo and spending time with her husband and children.

I sought professional help.

By Stephanie Bonne, MD

When I finished my training, my husband and I were overwhelmed by decisions - student loans, college planning, life insurance, oh my! So, we decided to seek the help of a financial advisor. It's definitely been one of the better decisions we have made.  To address financial planning this month, I decided to interview my financial advisor, Robert Balice of Bridgewater Asset Management, and the answers to my questions are below.

Q: Many people say, “I'm finishing training, so I’ll just quickly pay down my student loans and max out my 401k.  What do I need a financial advisor for?”

A:  Some people don't need one, but I cannot think of a case when an advisor would not provide significant benefit to someone, particularly someone just starting out. When you are starting out, you need to have some perspective of where you are going.  Set goals, then focus on what you do well (surgery), while having an advisor guide you through the rest can help you take advantage of the opportunities available to you, and help you miss some of the pitfalls on the way.  Even simply establishing an investment strategy for your 401(k) is fraught with pitfalls. 

Q: Okay, so I think I need an advisor. How do financial advisors get paid?

A: Good advice is not free, but it is important to understand how an advisor is compensated to make a choice that fits your situation.  There are 2 predominant ways:

1. Commissions – The advisor makes a commission on the products they sell you (insurance policies or investments).  This can work if you don’t need long term advice, like managing a one-time inheritance.  However, beware of implication that you don't pay anything for the investments they place you in simply because you don’t “see” the charge.  There may be up front, ongoing or back end sales charges. It may appear that you are not paying anything, but the advisor is definitely making something by recommending a certain investment or insurance product.

2. Advisory fees - for the vast majority of people, you want your advisor to be compensated in a way that he/she is motivated to keep your interests first, and stay engaged over the long term.  A fee-based advisor is not getting transactional compensation up front by selling products, they make money on your business over time, so it is in the interest of the advisor to keep you as a long term client and make sure you continue to get advice on your investments. 

Either one can be right for any individual.  A fee-based advisor is a true consultant and not a salesperson.

Q: What’s the best way to address my student loans?

A:  There are a few strategies that apply to everyone.  Consolidate your loans to get lower interest rates, and try to get fixed rate loans in case interest rates rise.  Next, consider what you can make in your investments versus the interest on your loans to decide what to pay off. If you are paying 2.5% on your loans, don't rush to pay those off and forego savings where you can earn 5% and build an investment account.  Remember you can always liquidate your savings to pay the loan off in the future for some other reason. To contrast, if your student loan rates are 8% annually, you should pay those down, because it's hard to expect that your investments will make 8% annually after tax.

Q: I have little kids at home.  How much is college going to cost for them?

A: Most children of educated parents, certainly doctors, would expect that their children are going to attend college. You can pay for college by either saving for it with discounted dollars, or pay for it afterwards with loans that have additional interest costs.  I suggest that you not plan for financial aid.  The best way to plan is to start early, and save for a good 4 year university, either private or public.  A child born today will need about $200,000 for a 4-year degree at a public school, or up to 3 times that for private school.  To achieve this, you need to save $400-$1000 per child per month from your child's birth. It's hard to imagine that private schools will cost over half a million dollars, but that's just the reality.  However, college inflation was previously 6-7% annually, but has recently slowed.  Still, I'd plan for the worst and hope for the best.  

Q: Taxes are always a concern for those in higher income brackets.  How do I avoid taxes?

A: Start by taking full advantage of employer matching contributions through your qualified plan (401k, 403b). Today, many companies offer traditional pre-tax savings or after-tax investment savings as in a Roth 401(k).  If you are still in residency, you tend to be in a lower tax bracket, and at that point, you are better off using Roth 401k or Roth IRAs, because the taxes today are not as large as the taxes you will pay when you take that money out.  If you are out of residency and in a higher tax bracket, then you definitely want to use the pre-tax options so you get the tax benefit today.  You can control your taxes better in retirement by choosing how much income you are going to take, whereas you have less control now, as your income is decided by your employer. If you have outside income due to speaking engagements or consulting, you should consider opening a personal qualified plan for that income.  The tax code allows you to have multiple qualified plans as long as there is no common ownership with your employer.

After your retirement accounts, your tax deductions dwindle quickly.  If you are saving for your child's education, some 529 plans offer state income tax deductibility.  

After that, try minimizing taxes on the savings that you are making on an after-tax basis. These generate taxable income and capital gains.  Variable annuities or variable universal life policies can accomplish this, but consider all the pros and cons of these vehicles and the tax implications of such products.  Bottom line is: you can lose up to 1/3 of your investment earnings if you don’t pay attention to the tax treatment of your investments. .  Not all investments make sense for everyone - this is why you need a qualified advisor.

Q: I am concerned about an injury that causes a loss of my ability to do surgery.  How do I plan for this?

A: You’re right; statistically, you have a 40% chance of being disabled for 90 days or more before age 65. Your first line of protection is your employer’s group long term disability plan. However, be aware that it typically does not cover all your compensation; specifically, it may not cover your bonuses and will not cover any outside income. You may want a personal disability policy that overlaps the group coverage.  If you purchase options for future coverage, that guarantees your insurability as your income continues to go up.  If you plan on having your own practice, and therefore not working for an employer, then a personal disability policy is essential to do at a young age when you are healthy and costs are lower.  

Q:  Long term care insurance (LTCI) is getting more expensive and is of greater necessity for women than men.  How should we be prepared?

A: Because women statistically live longer than men, insurance companies have struggled to fully assess LTCI.  As a result, some states have recently taken away unisex rates for LTCI, resulting in up to 300% increases in rates for women, who use LTCI more and live longer.  Not all states have moved away from unisex rates, but they probably will at some time.  If you have any genetic conditions that would result in long term care needs (Parkinson’s, Alzheimer’s); then early coverage is essential.  

Q: What if I still live in a state with unisex rates?

A: If you are in a state that still has unisex rates, you should take advantage of some sort of coverage.  The premiums are not guaranteed, and all rates will go up as the demand for long term care increases. But, if you are in a unisex state, you would probably get a much better premium if you get a policy before your state changes. If your state changes later, your rate will probably be more than the unisex rate, but less than the female rate.

Q: Does long term care insurance follow you if you move?

A: Some employers have group long term care which are portable if you leave employment.  But, these tend to have limitations in coverage for things like in-home care. In that case, a personal long term care usually will provide more comprehensive coverage, and is portable if you change jobs. The timing of when you should acquire LTCI is based on many individual factors such as age and health.

Q:  Women typically have longer life spans.  What does this mean for financial planning?

A: We already addressed long term care.  The other challenge is to accumulate retirement assets.  If you live into your 90s, you may need to draw 30 years of income from your investments.  Longevity translates to a more aggressive savings strategy now. This does not necessary mean taking on more risk, but would require higher accumulation to meet their retirement needs. The advantage women have due to longevity is cheaper life insurance rates because insurance companies are less likely to have to pay your death benefit early.  What that means in terms of financial planning is that we can consider insurance-oriented products to provide sources of retirement income with relatively low insurance costs.

Q: I hear a lot about the debt accrual by the US Government, what does this mean to me?

A: This isn't meant to be political, but the fact is, the government has a lot of debt.   In the intermediate and long term, having so much debt is likely to translate to higher inflation and higher taxes.  This requires your retirement savings to outpace inflation, in particular.  In the short term, interest rates will likely need to increase. This means you should be aware of the impact of rising interest rates, in particular to fixed income investments.

~~~

Robert Balice is a full-service financial advisor at Bridgewater Asset Management in Chesterfield, MO.   He completed his undergraduate education at Lawrence Technological Institute in Michigan, and has an MBA from Washington University in St. Louis.  He has over 20 year experience in financial planning. www.bwam.net

 Stephanie Bonne is an assistant professor in trauma, acute and critical care surgery at Washington University in St. Louis. 

Respect

by Erin W. Gilbert, MD 

“Your job gives you authority. Your behavior gives you respect.”
—Irwin Federman, general partner at U.S. Venture Partners

Throughout my surgical training I blindly accepted that having grey hair (and experience) equaled garnering respect as a surgeon. Now that I am junior faculty at an academic institution (and beginning to grey myself), I’m wondering if there is more to the story. There is a noticeable difference in how residents treat me as compared to how they treat the Department Chair- which is of course OK by me, but I have begun wondering how can I ensure that I will achieve and more importantly maintain the same level of respect?

As a medical student at LSU in New Orleans, we followed a very hierarchical system where the intern was the boss of the students, the junior was the boss of the intern and so on. It seemed to me in this system that the doctor’s role dictated the level of respect they earned from the team, but just because you follow someone’s orders does not mean you respect them. Other misconceptions I have had include believing respect comes from being a good dresser, having large muscles or simply being intimidating in some way. Now that I have matured a bit I am learning that people may admire good looks, muscles, or a power suit, but this does not translate into respect.

Federman’s quote alludes to the real heart of the story. Think about people in your life you respect; who you would follow into battle without question, who you try to emulate… they are kind, generous, caring, and fair. They treat all of those around them with respect - from the hospital CEO to housekeeping staff - without question and without needing a reason to show respect. They value others’ efforts and acknowledge them; they listen, and they are always sincere. I may just be figuring this out for myself now, but thanks to my upbringing, I know that treating all people with respect is the expectation not the exception- I just didn’t realize how much it could influence how others treat me.

Readers, think back to the role models in your life. What behaviors of theirs did you respect? Share with us in the comments below. 
 

~~~

Erin Gilbert is an Assistant Professor at Oregon Health & Sciences University in Portland where she is a member of the Knight Cancer Institute. She received her medical degree from LSU in New Orleans and completed her general surgery residency at the University of Washington in Seattle. She was fellowship trained in Minimally Invasive Surgery at OHSU and specializes in the surgical management of pancreatic disease.

Creating your own academic timeline

by Christina Cellini, MD, FACS, FASCRS

This topic came to me during a grand rounds given by a well-known surgeon in his mid-career - henceforth will be referred to as “WKS”. I had just returned from my second three-month maternity leave in two years and was looking forward to hearing about what advice he had to give.

That morning WKS gave a talk about how he advanced academically starting from residency to his early attending years that eventually led to his promotion to associate professor. His talk was very informative, and he made a really big deal about being present for your family while trying to achieve your goals. All in all it was a thoughtful presentation. However a few things caught my attention and highlighted how everyone’s situation is unique.

One piece of advice given was that one should constantly “be writing papers” and even to “get up at 4 am before work” to write in order to fulfill that goal.

4am??? I thought back to what I was doing at four A.M. that morning. Oh right… I was nursing an infant. I’m certain that’s not something that ever stood in his way of writing papers. Oh well, no time for paper writing this morning. Maybe tomorrow.

His next piece of advice was to take advantage of all the wonderful scholarships and traveling opportunities that are catered towards young attendings under the age of 45 . He showed lovely pictures of him and his family frolicking around a foreign country that was many time zones away.

I thought- wow! I didn’t know about these awards. I should think of putting something together. Then I thought of the logistics- I don’t think I’ll be able to leave my tiny children away for that amount of time. And since these days I need to plan about an hour in advance to take both kids out to a trip to Target…. maybe in about 5-7 more years. But then I’ll be too old for these scholarships!

Finally he mentioned being involved in society meetings and to bring family along so that you can take advantages of the opportunities there while your spouse and kids go and do fun things in the area. See- you can work and spend time with your family as well! I thought- that might be doable. I did have to skip the last 2 of my society meetings because I was either too pregnant to fly safely or did not have the resources to travel with an infant. Let me ask my husband how he’d feel about watching the girls in a strange place for a week while I do my surgery thing. I texted him- I got back “absolutely not”. Apparently dealing with two cranky, nap-less, off schedule children by himself while I do my own thing most of the day was not my husband’s idea of “family fun”. He encouraged me to go alone. Now don’t get me wrong- my husband is awesome and takes care of the lion’s share of child rearing and is supportive of my career- but I couldn’t blame him for not wanting to sign up for that.

WKS had a number of great ideas that worked for him to achieve academic success so quickly in his career. I am certain there are many young surgeons - both men and women- who can achieve that as well. However, WKS had a personal situation that allowed him to flourish early on. He was able to follow the typical academic timeline that usually consists of publishing 2-3 papers/year, obtaining some sort of early career development grant or funding in the first 5 years as a means for future funding, active involvement in the ACS and specialty societies - all in addition to growing one’s clinical practice at the expected pace. With this timeline one can usually expect promotion to associate professor within five years or so. I know that I will not be able to keep up with that timeline. My path to promotion will likely take a few (or more) years longer than others. Occasionally I get antsy about it when I perceive that my peers are advancing faster than me or that I am in some way “behind”. However, I have been lucky to have colleagues and mentors that understand my need to slow down for my family and are supportive of an “extended” academic timeline to academic advancement.

Now, if you can breastfeed and write scientific papers at the same time go for it! If not, I suggest the following:

1) Take some time to really think about what your future academic goals are. Make them very discrete, not ambiguous. Also, take the time to write them down.

2) Prioritize the goals and create a timeline to go with them. Give some real thought as to how you might go about achieving these goals. Again, the more specific you are, the more likely you are to realize them.

3) Share your academic timeline with a more senior colleague or mentor. Doing so may help you identify potential opportunities or pitfalls in your strategy that you may not have considered. As always AWS members are available to help- and have likely been in your shoes at one time or another!

4) Periodically look back on what you have written and adjust as necessary. Do not feel bad or guilty if it takes longer than you thought. Try not to fall into the “keeping up with the Jones’s” trap that can be prevalent in surgery (I know I have on more than one occasion). Take the time to write down and reflect on everything that you have accomplished up to that point. Remember no accomplishment is too small! As long as you remember what’s important to you and keep your eye on the prize you will no doubt be able to balance your personal and professional life and accomplish what you have set out to do.

Readers, how have you adjusted your own professional timeline to achieve both personal and professional goals in a reasonable manner? Share your thoughts below.
 

~~~

 

Dr. Christina Cellini is an Assistant Professor of Surgery and Oncology at the University of Rochester Medical Center in the Division of Colorectal Surgery. After obtaining her undergraduate and medical school degrees at Cornell University she trained in general surgery at the NewYork Presbyterian Hospital-Weill Cornell Medical Center. Following residency, she completed a fellowship in Colorectal Surgery at Washington University in St. Louis. She recently completed a Masters in Medical Management at the Simon School of Business at the University of Rochester. She lives in Webster, NY with her husband and 2 children and enjoys running and snowshoeing in her free time. Dr. Cellini serves on the AWS communication committee.

How I Make It Work

by Danielle Walsh, MD

December is the time of year when the constant struggle between the needs of work and the commitment to family become most strained. Holiday performances at school, parties for kids sports and other organizations pop up, work-related celebrations occur, and both of my children celebrate birthdays within a week of Christmas Day. After a long day of operating you try and shop online or in crowded stores before heading home to make dinner, ensure homework is done, and then proceed to whatever holiday event is scheduled for that night. It’s exhausting. But I can’t imagine it any other way.

People always ask how to make it all work. Lately, my response is more refined than in the past and it utilizes the tried and true analogy of the full bucket. You have to start with the biggest rocks. My kids’ birthdays, gymnastics meets, the annual AWS conference and a few other events are rocks. They are unmovable, non-negotiable events on my calendar. These are my biggest rocks. My OR days are Monday and Friday. My clinic days are Tuesday afternoon and Thursday morning. They are not movable and are the next size down rocks. I schedule a date night with my husband at least twice a month. Still a rock, but can fit around the other stuff. Then everything else gets filled in order of priority like the AWS, work on a grant, student and resident teaching – gravel, then sand, then water. Most of the time I try to leave pockets in “reserve” – an hour in my schedule for the gym, prayer, or just walking through a store undisturbed (my husband calls this retail therapy, even if I don’t buy anything). Often this is when I can review what the priorities are for that day or week to determine what goes in the bucket.

Sometimes the bucket overflows. I try to do too much at the same time or something unexpected causes the balance to tip. Then I call in the backup buckets – my husband, my parents, my partners, or some hired hand to take on what I can’t handle. Occasionally it means a paper is late (not unlike this blog, which I had hoped to write last week), emails get left in the inbox, and phone messages are not promptly returned. These times never feel good. I hate not being able to do it all on time. Some of the dislike is frustration of leaving others hanging, waiting for me to take action. Some of the issue is realizing that I made an error in taking on so much. But it serves a purpose – a reminder to be patient with others, accept imperfection, and continue trying to do better.

I always schedule at least some vacation time in December when the kids are off. The first day is set aside to clear out all the late assignments from work (like this blog) that will keep me giving my family my full focus. And then I sign out to my partners, turn off the beeper, set up the auto-reply for work email, and be just a mom, wife, and daughter to family for a while. It always feels good.

So as 2013 draws to a close, take a look at your bucket. What are the rocks, the stones, the pebbles, sand, and water? What can fit where and when? Find your time for work, time for family or friends, and time for yourself. May your bucket be full and satisfying.

Peace to all.

Danielle Walsh

P.S. – Didn’t get around to Christmas cards yet. Might still try to do them, but don’t hold it against me if they arrive a little late.

~~~

Dr. Danielle Walsh is an Associate Professor of Surgery at East Carolina University in the Division of Pediatric Surgery. After obtaining her undergraduate degree at Columbia College and her medical degree from the University of South Florida College of Medicine, she trained in general surgery at Massachusetts General Hospital in Boston. She also completed a fellowship in fetal surgery and research at Children’s Hospital of Philadelphia and a fellowship in pediatric surgery at Children’s National Medical Center in Washington, D.C. She practiced in Jacksonville, FL holding faculty appointments at the Mayo Medical Center and University of Florida before moving to her current position in North Carolina. She is the 2013-14 President of the Association of Women Surgeons and mother of 2 children.