MSHQ 092 : What an Attending Would Tell Her Premed & Medical Student Self

The Premed Years

Session 92

In this episode, Ryan is joined by Allison as they talk about Allison's first work anniversary in private practice. This episode is framed for premed students and medical students or even residents as to what certain things need to be considered when thinking about work in private practice.

Learn about the good, the bad, and the ugly as Allison shares her highlights, her struggles, and her insights from her first year of private practice which you can learn from as early as now.

Here are the highlights of the conversation with Ryan and Allison:

Allison graduated from the Harvard Neurology Residency Program in June 2013. She is now an attending physician working at a private practice in Boston and affiliated with a nearby academic teaching hospital. 85% of her time is spent on outpatient practice while 15% is on inpatient and ER consults.

An overview of cases Allison are seeing and call schedules

The best things about Allison's practice:

  • The fulfillment of establishing relationships with patients
  • Seeing the evolution of things and people
  • Learning through your patient population in real-time
  • Establishing working relationships with other primary care physicians in the community who refer patients to her – a critical part in building your patient base

The power of collaboration and teamwork:

  • You need to build these skills as premeds, medical students, and residents
  • Having a positive mindset on the concept of second opinion
  • It all boils down to patient care

Allison's struggles during her first year in private practice:

  • Lack of experience
  • An uncomfortable feeling of knowing that you don't know everything
  • Balancing inpatient and outpatient responsibilities while dealing with her pregnancy
  • Taking late night calls from home

On getting access to resources that you used to easily get right at your fingertips as an in-house physician:

  • When you are a medical student or resident, start asking those questions of the case managers you're interacting with everyday.
  • If you are shadowing with a physician, look and see what they have available and take notes.

Skills Allison wished she had learned earlier:

  • Billing
  • Knowing how to create an efficient team in an outpatient setting

On dictation:

  • The importance of learning how to dictate when you're training
  • Streamlining things by utilizing tools such as Breevy, a text expander tool that allows you to be more efficient in writing your notes

3 Things Allison would tell her younger self to help her on where she is now:

  1. Stay focused.

You will go through all the hurdles, hard work, and sleepless nights so stay focused as best you can.

  1. Stay flexible.

Allow yourself some flexibility to change your mind along the way.

  1. Stay passionate.

There are people who will try to drag you down so stick with it and keep fueling that passion to keep you going.

Links and Other Resources:

Are you a nontraditional student? Go check out oldpremeds.org.

For more great content, check out www.mededmedia.com for more of the shows produced by the Medical School Headquarters including the OldPremeds Podcast and watch out for more shows in the future!

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Hang out with us over at medicalschoolhq.net/group. Click join and we'll add you up to our private Facebook group. Share your successes and miseries with the rest of us.

Check out our partner magazine, www.premedlife.com to learn more about awesome premed information. Read one of articles gleaned from this podcast, 8 Pieces of Information Every Premed Should Know

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Transcript

Dr. Ryan Gray: The Premed Years, session number 92.

Hey, this is Z-Dog MD; rapper, physician, legendary turntable health revolutionary, and part-time gardener. And you're listening to the Medical School HQ Podcast, hosted by the irredeemably awesome, Ryan Gray.

Hello and welcome back. I am your host, Dr. Ryan Gray, and I believe that competition amongst your premed and medical student peers is detrimental to becoming a great physician. In this podcast we show you how collaboration, hard work and honesty are critical to becoming a superior physician in today's healthcare environment.

Hi Allison.

Dr. Allison Gray: Hello Ryan Gray.

Dr. Ryan Gray: If you haven't heard Allison yet on this podcast, if you're a new listener, welcome, thank you for joining us. If you're an old listener you know Allison and some of you have even written to us saying that I should let Allison on the podcast more.

Dr. Allison Gray: I love that terminology, ‘let' me on.

Dr. Ryan Gray: I know, but that's-

Dr. Allison Gray: Like I'm like, you know a little puppy out in the doghouse, you have to let-

Dr. Ryan Gray: But that's what they wrote. And it's not like I prevent you from coming on, it's just-

Dr. Allison Gray: It's true. Well I have a lot going on, and you know.

Dr. Ryan Gray: We're busy.

Dr. Allison Gray: Yeah.

Dr. Ryan Gray: That's okay.

Dr. Allison Gray: I would love to be on every week but I personally also think that it's nice for our audience to hear from all of these great guests that we have.

Dr. Ryan Gray: Yeah I think you listening benefit more from guests getting a wide variety of experiences and expertise than just hearing Allison and me talk all the time. So that's what we do. It's nice to have you here, though.

Dr. Allison Gray: Well thanks, and I always enjoy being on.

Dr. Ryan Gray: What are we talking about today?

Dr. Allison Gray: We're talking about my first year in private practice.

Dr. Ryan Gray: Yeah, you just passed your kind of one year anniversary- workiversary.

Dr. Allison Gray: Workiversary, I did.

Dr. Ryan Gray: Good.

Dr. Allison Gray: I did, yeah. So we're talking about what did I- what were the best things, the worst things, the things I wish I had known, and really with a focus on you the premed student and you the medical student, because we could focus this toward- or gear this rather toward residents who are graduating but we think that there are a lot of things that you might actually benefit from earlier on in your path. So we'll dig into it.

Dr. Ryan Gray: Yeah. Before we get into that, let's talk about our new Facebook group. So if you go to www.MedicalSchoolHQ.net/group, that will take you to a new somewhat private, it's closed at this point, I don't know if I'll open it up. But it's a closed Facebook group, it's just called the Medical School Headquarters Hangout. And it's different than our Academy, we have our Academy Facebook group that's specifically for our Academy members who are part of our Academy getting premed advising from us. This new hangout is for listeners of the podcast to get together, to share their thoughts on the podcast, to collaborate like we talk about at the beginning of the show about collaboration and hard work. This is just a different forum for you guys to get together and to hang out and talk. And it lets us distribute information to you the listener a little bit easier as well.

Dr. Allison Gray: Yeah and maybe you'll build relationships, friendships, colleagues.
Dr. Ryan Gray: Yeah. So www.MedicalSchoolHQ.net/group, click on ‘Join this Group,' and we'll accept you as soon as we see all of them. So hopefully we'll see you in there.

Dr. Allison Gray: Looking forward to it.

Dr. Ryan Gray: Also, this is session 92.

Dr. Allison Gray: Wow!

Dr. Ryan Gray: We are eight weeks away from session 100.

Dr. Allison Gray: Wow!

Dr. Ryan Gray: You never thought we'd make it this far, did you?

Dr. Allison Gray: Wow! No, that's not true. I know you Ryan Gray, and I know that you're very determined and very passionate and yeah, who said? I never said that you wouldn't make it this far.

Session 100

Dr. Ryan Gray: Okay, now be honest. Did you think we would make it to 100?

Dr. Allison Gray: Okay, I'll tell you what I did not think. I did not think that you would be able to go every single week until episode 100 almost without skipping a week. That is impressive.

Dr. Ryan Gray: Especially with a baby.

Dr. Allison Gray: Yeah, and a full-time job, and everything. Yeah.

Dr. Ryan Gray: Anyway. So for session 100, a couple episodes ago we'd asked for some ideas. And Jessica, one of our Academy members, emailed me recently and said, “This is my idea.” And she recommended, and I loved it, and so did Allison, that we get you the listener to email us your stories, your hardships, your struggles, and give us your story about how you overcame those struggles and where you are on your path. And mention to us maybe possibly what podcast episode that we did out of the 100, maybe helped you on that path, and helped you overcome those struggles. And with those we'll take the top five or ten depending on how long they might turn out to be, and turn those into some audio clips and we'll gather all those and make a podcast episode out of it.

Dr. Allison Gray: Yeah, and I think it will be really beneficial for a lot of people out there. On of Jessica's points which I completely agree with, is that people really benefit from hearing what other people have struggled with and have overcome. And I think clearly on the road to becoming a physician there are many hurdles, many obstacles, and there are so many different paths that people take to get to becoming physicians. And so hearing about similar struggles that others may have had or what things might lie in front of you that you're not even aware of, and how people surmounted those obstacles, I think that will be-

Dr. Ryan Gray: Just knowing that other people are struggling with you.

Dr. Allison Gray: Yeah, absolutely. I think it'll be great, we're really excited about it. So yay, Jessica.

Dr. Ryan Gray: You know what Jessica's struggling with right now?

Dr. Allison Gray: Secondaries or interviews?

Dr. Ryan Gray: No the 405. The freeway. Hi Jessica.

Dr. Allison Gray: What are you talking about? The 405- I'm trying to think like is this some kind of FAFSA, like financial aid document that-

Dr. Ryan Gray: No, it's a California inside joke.

Dr. Allison Gray: Well see I'm from Ohio technically, but really Boston, so.

Dr. Ryan Gray: Anyway, alright. So thank you Jessica for that idea.

Dr. Allison Gray: If you'd said the Pike I would have totally understood.

Dr. Ryan Gray: Anyway. Contact us through our contact page, www.MedicalSchoolHQ.net/contact. Let's get into this.

Dr. Allison Gray: Alright.

Dr. Ryan Gray: So as you passed your workiversary, you graduated your residency in June of 2013.

Dr. Allison Gray: Yep.

Dr. Ryan Gray: And it's not August of 2014. You've been in private practice now for a year and almost two months.

Dr. Allison Gray: Correct, and I was out on maternity leave for thirteen weeks, but yes.

Dr. Ryan Gray: So about a year you've been working.

Dr. Allison Gray: Mm hmm.

Dr. Ryan Gray: That has given you enough time now to reflect upon where you've been, where you're at now, and kind of where you're going. And I want to have the conversation, I'll kind of lead you through this interview, and talk about the good, the bad, the ugly and again as you said we want to frame this for a premed student, a medical student, and maybe even a resident to what they should start thinking about now even before they're thinking about work and private practice, or work as an attending.

Dr. Allison Gray: Mm hmm.

Dr. Ryan Gray: So let's talk about- let's talk about the good stuff first.

Dr. Allison Gray: Alright.

Dr. Ryan Gray: So what are some of the highlights from this first year working in private practice?

Private Practice – The Good

Dr. Allison Gray: So to give everyone a little bit of background, to give you all just a bit on what I am doing. So I graduated from the- if you don't know me or haven't heard from me before, I graduated from the Harvard Neurology Residency Program in June of 2013 as Ryan said, and it was a combined program through Mass General and Brigham and Women's Hospital in Boston. And I- after graduating we took a trip to Hawaii, yay, but then after we got back we- I started my job. And I am an attending physician, I work at a private practice out in west of Boston. And I'm affiliated with a nearby hospital, so which is an academic teaching hospital. Most of my time, probably 90% of my time- I haven't done the math on this, but 80% to 90% of my time is spent in outpatient practice. The other 10% to 15% of my time is spent doing inpatient and emergency room consults at the nearby academic teaching hospital.

Dr. Ryan Gray: It's 15% in the hospital.

Dr. Allison Gray: Is it?

Dr. Ryan Gray: Yeah. Eight weeks out of 52.

Dr. Allison Gray: Oh, good job. Okay so someone did the math.

Dr. Ryan Gray: I just did.

Dr. Allison Gray: Alright, so 85%, 15%. When I'm in the hospital I am seeing patients acutely, I have to be in the hospital within fifteen minutes when the stroke pager goes off. If I'm in the shower with soap in my hair, I still have to be there in fifteen minutes, it's a good thing we live so close to the hospital. But anyway, I see patients for acute stroke calls and I see patients for all sorts of other reasons in the emergency department whether it's seizures or horrible migraines, or whatever it may be, and I also see inpatient consults. So I will see patients who've already been admitted to the hospital or who are going to be admitted to the hospital with a series of different neurological issues, and I will go in and see them every day for- we take call for about a week at a time. Different practices do different things, and that's one thing definitely to look into before you join any sort of practice as an attending. Find out what the call schedule and call coverage is like. But for me, I share call with several different physicians and when I'm there I'm the neurologist. So for anything neurological at this hospital, it comes to me which is a big job.

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: My outpatient time though, which is what I do the majority of the time, is spent seeing patients with a range of different neurological issues. I see folks for- with general neurological issues, and again that could mean stroke, seizure, migraine, not really brain tumors because if someone is diagnosed with a brain tumor then they- I send them on to a neuro oncologist for management. I see patients with all sorts of things; peripheral neuropathy, spinal cord issues, multiple sclerosis. So I'll see them and then I'll see them ongoingly- Ryan always tells me that's not a word, but the point is that I'll see someone and then I'll continue to follow them often which has been great. So that leads me to my- one of the best things about this year which has been establishing relationships with patients. So one of the things that was really exciting to me when I was trying to decide what specialty to pursue, I really wanted to become the type of physician who would develop relationships with her patients. I really- the thrill of the emergency room is great on the one hand, but for me what was missing about that is you see them once and then you never see them again, or maybe you see them again-

Dr. Ryan Gray: And some people love that.

Dr. Allison Gray: Oh absolutely. Some people thrive on that, or being an intensivist you see someone acutely when they're sick in the hospital and then hopefully never again.

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: For me I really, really loved- like when I was a kid it was so nice to see my primary care physician every year, I really liked the idea that you could form a relationship with your patient and really become someone that they trusted and someone who took care of them. So that for me has been one of the most rewarding parts of this year, that I've really- I really have now my patient group and I'm always seeing new patients, but I love seeing my follow-up patients, following people. We talk about other things besides medicine and neurology, we talk about how is your family and people know I was out on maternity leave and they ask about how my baby is doing, and we look at pictures; it's you know, life stuff. So I've loved that, it's been one of my favorite things.

Dr. Ryan Gray: Yeah and I'll jump in and just piggyback- I know this is your talk here. But that's probably one of the biggest things for me as well, is those relationships.

Dr. Allison Gray: Yeah and I know you've talked about that too. I know we see very different patient populations, but I think for a lot of physicians they really enjoy that.

Dr. Ryan Gray: Yeah, and again that comes down to knowing you. Knowing what you want and as I said, I've talked to many who are in- or are emergency department physicians now, emergency medicine physicians, and they love the lack of continuity. They love seeing a person once and then never seeing them again, although in today's day in age the emergency room has kind of turned into-

Dr. Allison Gray: Yeah, it's kind of a revolving door in some ways. But I would- I mean there are good and bad sides to everything, so if you do have a patient who is particularly challenging, and we all have patients who can be more challenging for different reasons. That- you don't-

Dr. Ryan Gray: It's hard to shake them.

Dr. Allison Gray: Right, to be- yeah. I mean you can't- you can discharge a patient from a hospital or from an emergency room. To discharge a patient from your practice is a very different animal.

Dr. Ryan Gray: Yeah. Alright. So that's the thing you've liked the most, is there anything else that you've liked about-?

Dr. Allison Gray: Well just sort of very closely related to that I would say seeing how things evolve. So one of the things that you don't really get to do as a premedical student, a medical student, even a resident, is really see how things evolve. And I mean by that, how a person who has a certain neurological or medical illness, how that disease evolves, how the person who has that disease changes over time. It's been very interesting and eye-opening to me to see what happens with people and to really follow them. And I always look forward to that when I was- earlier on in my training, and it's always something that you sort of- like you really wish you got to do, like, oh you just diagnosed this new condition in this person and you want to see what happens to them but you don't ever get that opportunity. A lot of- maybe you'll see them a few months later when they come to you for follow-up in the clinic, but it's so hard as a medical student and a resident to really follow people. So seeing how things evolve is really-

Dr. Ryan Gray: And that depends on what type of residency you're doing as well. If you're doing a family practice residency where most of your work is going to be in an outpatient clinic, you might see the same people over and over again. So-

Dr. Allison Gray: That is very true, it really does depend.

Dr. Ryan Gray: But a lot of residencies are going to be inpatient-based, and it's going to be a lot of revolving patients because hopefully the inpatients are being discharged home.

Dr. Allison Gray: Yeah, correct.

Dr. Ryan Gray: And that- what you're talking about, so you can see a patient on day one, give them a medication, and then see them a couple weeks later and they can say, “You know what? The medication makes me feel great, or it makes me feel worse.” You can see responses. You don't typically get to see that as an inpatient physician or resident, or whatever you're doing, because you're prescribing and then sending home.

Dr. Allison Gray: Absolutely.

Dr. Ryan Gray: Or follow-up in the community.

Dr. Allison Gray: Without a doubt. So as a resident or a medical student, I think that you're relying on what you've been taught by your- by those who are ahead of you, meaning your senior residents, your attendings, your fellows. When you're out in practice, you're- well and also I should say when you're in your training you're learning through books obviously and through the literature. When you're out in practice you're-

Dr. Ryan Gray: Books? Isn't it Wikipedia?

Dr. Allison Gray: Oh geez.

Dr. Ryan Gray: Oh wait, no.

Dr. Allison Gray: When you're out in practice, not only are you learning through what's in the literature and what's evidence-based, but you actually what's so cool is you get to build your own anecdotal sort of evidence. You learn through your patient population just as you said Ryan, what works, what doesn't, and it's real time and that's what's really neat about that. So that's been great, and I just want to add one more, I know you told me the best thing but there really have been a lot of great things. The last thing I would say is one of the things that's been so rewarding for me is establishing relationships, working relationships with the primary care physicians in the community who refer patients to me. What you don't recognize, what I didn't recognize as a medical student and certainly not as a resident, is the importance of those relationships. That you just- you think, “Okay well when I go to become a doctor I'm just going to start and then patients will show up at my door.” It doesn't work like that, right?

Dr. Ryan Gray: You're not an island.

Dr. Allison Gray: No. And you don't really have the time or the- and it's not really appropriate to go stand out on the street with a big sign that says, ‘Please come see me for the following conditions.'

Dr. Ryan Gray: Will work for-

Dr. Allison Gray: Right.

Dr. Ryan Gray: Proper ICD 9 codes.

Dr. Allison Gray: Yeah, exactly, it's not really appropriate. And I'm not kidding, I mean physicians do struggle with building up their patient base. But it's been so nice for me to form these relationships with primary care physicians, to have that dialogue going back when someone says, “I'd love you to see this person,” or if someone shows up and I know the physician by name, the primary care physician because I've worked with them and we share a lot of mutual patients, and we've talked over the phone, and worked out things together. I just have really loved that and find that really, really rewarding. And I've learned somuch from those primary care physicians, and I hope that I've done a good job in helping them with their patients, too.

Dr. Ryan Gray: So that all goes back to collaboration, teamwork.

Dr. Allison Gray: Oh absolutely.

Dr. Ryan Gray: Everything that we harp upon that you should be building these skills as premeds, and medical students, and residents, that the relationships that you're going to need to be able to form as attending physicians is what's going to drive your business.

Dr. Allison Gray: Absolutely.

Dr. Ryan Gray: If you piss off another attending who's an internist that maybe referring to specialists, in your case you're a neurologist. So these internists are going to need to refer patients to neurologists; if you're not a good team player, if you don't collaborate well-

Dr. Allison Gray: If you don't communicate well.

Dr. Ryan Gray: If you don't communicate well, you are not going to get those referrals.

Dr. Allison Gray: Right and I think- and certainly you're not going to be helping anyone out.

Dr. Ryan Gray: Yeah, ultimately it comes down to patient care.

Dr. Allison Gray: Absolutely, yeah.

Dr. Ryan Gray: Good.

Dr. Allison Gray: One thing, too on that note Ryan, is the whole concept of second opinions. So some people get really scared about that, that “Oh, my patient has an attending, oh my patient is going elsewhere to get another opinion.” I encourage that quite frankly, because I think for two reasons. Like you said, collaboration. So it's another brain thinking about the problem, and I think for a lot of patients it can be reassuring. Let's say you've given someone a really- what's the word I'm looking for? An unfortunate diagnosis; let's say you've diagnosed someone with Alzheimer's dementia. And maybe they don't feel- or their family feels very conflicted about that, and is not sure that that's really the case, and sending someone out for a second opinion can provide reassurance for that person that you are doing the right things by them, and that you have thought about it properly. And so I encourage people to do that, and I think- like certainly that I could learn from that individual, so I've had people go for second opinions and then they come back and they say, “Okay well I feel better knowing now that both of you are on the same page,” and maybe I'll learn something from that other provider.

Dr. Ryan Gray: Yeah. Good. Alright, so lots of good stuff-

Dr. Allison Gray: Lots of great stuff.

Dr. Ryan Gray: And I'm sure there's plenty more.

Dr. Allison Gray: Oh yeah.

Dr. Ryan Gray: Let's talk about what you've struggled with during this first year.

Private Practice – The Bad

Dr. Allison Gray: Alright. So probably- and this may be sort of straightforward, but because it was my first year out in practice, the lack of experience is probably the most obvious and certainly rings true. Any time you start the first time, if you think back when you're a premed student, your first premed course, if you think as a medical student your first- like your anatomy course, your anatomy lab, your first time on the wards, as a resident that first day of intern year; I mean those are all scary times.

Dr. Ryan Gray: Your first love.

Dr. Allison Gray: That's totally different.

Dr. Ryan Gray: Oh right, sorry. You were talking about firsts.

Dr. Allison Gray: Well hopefully you're not like terrified the first time you meet the love of your life. Anyway, we digress. No so the lack of experience- I will say the first day that I showed up at my practice, I was not terrified. I did not have that sort of feeling in the pit of my stomach.

Dr. Ryan Gray: But I'm going to interrupt you, but that's because you knew this person that had hired you.

Dr. Allison Gray: That's very true.

Dr. Ryan Gray: And he was your mentor, you kind of knew some of the other people at the office.

Dr. Allison Gray: Oh, 100%. So I was just about to say that, that I had a slightly different situation and that I did know a lot of the people whom I was going to be working with. And so yeah, in other circumstances I might have been scared silly. One of my mentors, one of the attendings whom I had worked with at Brigham and Women's told me that when he- years and years ago when he first became an attending, the same consult that took him fifteen minutes as a senior resident the day before, come July 1st it took him like an hour and a half because he was just so nervous because he didn't want to miss anything. I mean here he is, he's an attending now. So I think that that's what I'm saying, that when you first start out, you're an attending; now I had a lot of mentorship along the way which was wonderful and I think that's so great if you're able to join a practice where you know some folks because that mentorship is so helpful in so many ways. But still, I mean there have been plenty of days when along the way when I was at the practice seeing patients and maybe I didn't know exactly what I needed to know at the time, and I had to figure it out. And that's part of- I think as a premed and a medical student, as a resident, we need to always be determined and sort of, to just launch yourself forward and jump in and figure out what you need to figure out, use your resources, there's a lot- you know it's that whole teamwork thing you talk about Ryan. You know don't go out there and decide, “Okay well I'm an attending now and I'm going to just do it on my own.” It doesn't- that's not going to- I mean maybe you can make that work, but I don't think that that really is a good recipe for success. But the lack of experience can be hard. You know you have people coming to see you, and you're an attending now, it's your name and-

Dr. Ryan Gray: It's your license.

Dr. Allison Gray: Yeah, it's your license, it's your butt on the line, it's all those things. So there's a little bit of uncomfortableness if you will in knowing that you don't know everything. But for God's sake if you thought that after you graduated residency you knew everything, there's something very well.

Dr. Ryan Gray: Or you had an awesome residency.

Dr. Allison Gray: Well fine, but the whole point is that we're supposed to be lifelong learners.

Dr. Ryan Gray: Yes, that's true. Alright, so lack of experience.

Dr. Allison Gray: And that will only get better, right?

Dr. Ryan Gray: Yeah, hopefully. What else?

Dr. Allison Gray: I think for me just in the nature of where I am- and this will probably ring true for many people who become attendings, who work in both in inpatient and outpatient practice. I found balancing my inpatient and outpatient responsibilities somewhat challenging. Also because I was pregnant, I mean I'm not going to lie when you're three months- not three months, when you're in your third trimester and you're waddling around trying to run to a stroke code, that's somewhat difficult.

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: You know and I think having home call, that's something else to certainly look into when you're a medical student looking into your residency programs, and also when you're a resident looking into private practice- or not private practice, but becoming an attending. Find out, like I said about the call structure and coverage, but also where are you taking call? So one thing you might not know as a premed is that when you take call, it's not always like on Grey's Anatomy, you may be in the hospital in the call but you also may be taking call from home where you get woken up and you may or may not have to go into the hospital, and I had some very late night calls at 4:00 AM and had to throw clothes on and run into the hospital and Ryan would hear me groan and give me a positive encouragement.

Dr. Ryan Gray: And roll over and go back to sleep.

Dr. Allison Gray: And roll over, yes! Exactly. But I found that somewhat challenging, and that's I think partly because the hospital where I am, it's some places have sort of a team structure and for me it was- I was the neurologist on call and that was it. So it was just a lot of responsibility on my shoulders. I felt prepared from residency, but it was just a lot.

Dr. Ryan Gray: So something else that as we were preparing for this session, something else that you talked about was the lack of understanding how to get all of the resources that were right across the hall as an inpatient physician, the social workers and everything else. Now all of a sudden you're separated from them. You don't have as easy access to those as an outpatient; talk about that for a second.

Dr. Allison Gray: Absolutely. So I would say- well yeah first let me explain. When I was a resident and a medical student I found it- I won't lie, I found it somewhat frustrating sometimes how many pages you'll get. I would be paged nonstop, and we all do as residents, and med students get paged too, but as residents you get paged all the time. Now who was I getting paged by? Well nurses, case managers, physical therapists, social workers. What you don't realize as a resident is those resources are so- they're gold. They're absolute gold.

Dr. Ryan Gray: It goes back to teamwork.

Dr. Allison Gray: It does. And you learn so much- and Ryan and I have talked about this on many different episodes. But you learn so much about the importance of a team, and so that stuck with me very much so but what I didn't realize- I really, I would say I took for granted the fact that those resources were really at your fingertips. So for example, if I had a patient when I was in residency who was- had a stroke and was going to be discharged to a nursing facility, if I needed help from the case manager or let's say the patient was going home and I needed to obtain resources for that patient, it's just a phone call away. It's right there, I can walk over to their desk and get their help.

Dr. Ryan Gray: You're typically rounding with them in the morning.

Dr. Allison Gray: Oh yeah. I mean it's sort of you're forced to work with them which is great because I mean you can't do anything these days in inpatient work without the help of these folks. Now fast forward to when I'm in practice, I've had a series of patients come along who have needed resources big time as outpatients; whether that's visiting nurse care, whether that's- I mean physical therapy is a little bit easier to obtain because we have a lot of physical therapists in the area. But home health care, and basically just case management. I mean people to help coordinate everything.

Dr. Ryan Gray: So the one thing that kind of popped into my mind as we kind of tie this to what medical students, what residents, and even premed students can start thinking about here, is when you are a resident or when you are a medical student, start asking those questions of the case managers that you're interacting with every day. And say, “Hey you know what,” pull them aside when you're done with all of your other duties and say, “Next year I'm going to be in a private practice. Who should I be thinking about calling for a patient like this as an outpatient?” And have them kind of walk you down that path, they might have all the numbers. Be like, “Oh you call this person, and that person,” and then you're golden.

Dr. Allison Gray: Right, because when you're trying to do that legwork real time in the office, it's very difficult, it can be very challenging. And the other thing is that some physicians may- you may start practicing in the middle of a very rural area without a lot of resources, you may be practicing in a very saturated area, but still not know where those resources are. And I found that challenging, and thank goodness for primary care physicians as a specialist or as a consultant, I can go back to the primary care physician and say, “Look I really need your help with this,” and they're often very happy and willing to help. But it would be so nice if I had known some of those things beforehand to just sort of have that resource at my fingertips. I really- so one other thing for premedical students out there. If you are shadowing with a physician at a practice, or in an academic center, look and see what they have available. And so take notes on that, and keep that in your mind because as you then go through medical school and then you go through your residency, and maybe you are someone who does want to do family practice or outpatient practice, but it would be great if you still had that in your mind knowing what are these resources that I want to see, and what is available at this practice that I'm interviewing at that I might want to join?

Dr. Ryan Gray: Yeah. Perfect. So we talked about some good, we talked about some bad, let's talk about if we could rewind back as a premed, back as a medical student, what sort of skills that you wish you had learned earlier that you're trying to play catchup with now?

If I Knew Then…

Dr. Allison Gray: Billing.

Dr. Ryan Gray: Billing. Yeah, we wish they would teach us billing in medical school.

Dr. Allison Gray: They don't teach you a lot of things in medical school. So they don't- well another one just came to mind which is interesting. But they don't teach about how to bill, and as a resident I remember being in clinic and sort of you circle a code and then you just move on. But it's much different as an attending when you're actually- you're actually charging the insurance company, or you're charging the patient, the patient's insurance is getting billed, and you have to select what are the different things I'm seeing this patient for? And what are the- what is the appropriate sort of level of care that you're providing? So there are all these different levels of care, and you can't just sort of pick one. I mean in residency it was almost sort of like, “Well just pick one because somebody is looking out for you.” You cannot do that if you just sort of pick and-

Dr. Ryan Gray: There's lots of criteria that each level has to meet.

Dr. Allison Gray: Yeah, and you can be accused of fraud if you're not careful, I mean you know, I mean you just- So anyway I mean not to be tongue in cheek about it really seriously. If you can find out- I mean a friend of mine during his fellowship really learned how to bill, and that was so helpful to him and now he's about to start working as an attending for the first time, and he's going to be so far ahead of the pack and just- and it's not even about that. It's not about being ahead of your peers, it's about just having your day be easier because billing is a major thing that you need to understand.

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: So billing, what else did I wish I had known? I think you know we talked about being able to really know who your team is once you're in the outpatient setting. I have a wonderful team who I work with every day at the practice with- I have a wonderful NP I work with, and other physicians, and medical assistants, and receptionists, and an office manager, I mean we have a great team. But I think again, being able to really have your team in place and know how to create your team is the key point when you're in outpatient would be great. And efficiency. I mean one of the things that we're always working on at every level of our training is efficiency, but that gets ramped up a little bit I think when you're an attending because you go from having three patients in clinic to maybe twenty patients in clinic.

Dr. Ryan Gray: Yeah. And I remember specifically when you first started working, that I kept mentioning, “Don't worry, you'll get better. Don't worry, you'll get better.” And you got mad at me.

Dr. Allison Gray: I did.

Dr. Ryan Gray: Do you remember what you said to me?

Dr. Allison Gray: I said, “I've been doing this for four years already, and I should know,” yeah I was full of it. No, I mean I think I was frustrated.

Dr. Ryan Gray: I was talking about how you would become more efficient in seeing the patients, and writing your notes, and you came back to me with, “I've been doing this for four years, I obviously know what I'm doing.”

Dr. Allison Gray: Oh man, I sound terrible.

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: Well no one is perfect.

Dr. Ryan Gray: I'm the older, wiser one here.

Dr. Allison Gray: Okay.

Dr. Ryan Gray: I was trying to give you some motivation that you will get more-

Dr. Allison Gray: Practiced.

Dr. Ryan Gray: More practice and more efficient.

Dr. Allison Gray: Yeah, there's a reason we call it practicing medicine. I mean no joke, I was absolutely wrong, I had been a physician for four years but I was knee deep- I mean very heavily involved in seeing inpatients and acute care and I had had certainly some outpatient care throughout my residency, but I was not seeing twenty outpatients a day, or ten to twenty outpatients a day. And so it was a different kind of work, and Ryan is absolutely right. It just took a matter of time and getting those algorithms down and getting comfortable and getting more efficient, and he's absolutely right. Not only did I become more efficient in seeing patients, but also getting my work done in terms of the administrative part and the notes. So he's right.

Dr. Ryan Gray: So there's a new tool that you downloaded for your computer at work.

Dr. Allison Gray: I did, I'm so excited I used it today again.

Dr. Ryan Gray: I hope you're using it every day.

Dr. Allison Gray: I do.

Dr. Ryan Gray: So what's it called?

Dr. Allison Gray: It's called Breevy.

Dr. Ryan Gray: Yeah, so Breevy is a text expander type tool. I'm a Mac guy, I use the program that's called Text Expander. And it's something that I have tried to get Allison to use for awhile now. It's to allow her to be more efficient in writing her notes.

Dr. Allison Gray: Right and I was dictating for awhile which is something that a lot of you may do when you're medical students to help your residents, and then when you're residents, and certainly when you're out in practice a lot of physicians I know just dictate. And I did dictate, but I was using Dragon Software and when I came back from maternity leave my- well someone borrowed my headphone, in quotes, ‘borrowed.' I got them back but in addition my software broke.

Dr. Ryan Gray: Yeah, but it goes back to looking at what you're doing on a day-to-day basis and trying to figure out how you can streamline it. And so for you it was understanding that, “Hey, I type the same thing every time pretty much when I diagnose somebody with Alzheimer's. So let me make this a little snippet and when I have a new diagnosis of Alzheimer's I'll open up Breevy and type whatever, and then my whole paragraph will spit out.”

Dr. Allison Gray: Absolutely. And one other thing, because dictating in some ways if you're not going to be typing, I mean a lot of people heavily rely on dictation and medical transcriptionists. And I remember as an intern, my dictations were terrible, I mean I'm not going to lie to you, they were horrible. Because I just didn't know, I wasn't practiced at it. And so I think- I don't know, hopefully when people read them later they weren't like- I mean I'm sure they were fine but I felt like they were just so all over the place. So one thing I would say is if you're shadowing, when you're shadowing, pay attention and see if the physician in the office or post-op, in the OR, dictates the note right then and there. Listen and watch how they do it to just get an idea of how efficient can you be? How can you get this done in a really efficient but also helpful way? And then when you're a medical student, you can work on it that much more, and certainly by the time you're a resident so that by the time you're out in practice, you might be just the dictating king or queen. I'm not kidding, I mean it really is valuable to spend time learning how to do this when you're in your training.

Dr. Ryan Gray: Definitely. Alright, so talked about the good, the bad, some skills we wish we had. Now that you're out in practice, you're an attending physician, you're a doctor; back nine years ago, is it nine years already? Or- yeah four years of med school.

Dr. Allison Gray: Well when we graduated, yeah.

Dr. Ryan Gray: When you started med school nine years ago, what can you tell your former self to kind of help on that path to where you are now?

Dr. Allison Gray: What can I tell my younger self?

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: Well and I might even go as far back as like AP Bio in high school, and what could I tell that self?

Dr. Ryan Gray: Yeah.

Dr. Allison Gray: I think I would say- I would tell myself three things. Number one I would say stay focused as best you can because it's a very long journey. Nine years doesn't sound like that long, but just because of how much has happened in the last nine years. But it might sound kind of long in some ways. And either way, I mean know for sure as a premedical student that's a long journey. And then as a med student, then as a resident, it's a lot- it's a lot of years, it's a lot of blood, sweat and tears. And I think it's so important to stay focused because when I dreamed of being a doctor years and years ago, I can't- I mean I really do feel very strongly that when I go to work every day, this is what I wanted to do. I feel fulfilled in that way and I feel very blessed and very lucky that- I mean yes there are lots of challenges to being a physician in this day in age but I feel that this is what I really always dreamed of doing and it's very exciting to go to work every day and be enjoying what you're doing, in your practice of medicine. So stay focused through all of the hurdles, and all of the craziness and all of the hard work and sleepless nights. What else would I say? I would say stay flexible because there- life will throw you lots of curveballs, but so will medical school and residency. And I think your interests can change drastically from one year to another, from one rotation to another. And you want to just keep your eye on the ball but also be willing- allow yourself to be flexible because you may start medical school, or you may finish high school and go to college knowing deep down in your soul that you want to be a cardiac surgeon. And then you might get to third or fourth year of medical school and be really freaked out because you've realized that now you want to be an OB-GYN. And that's okay. Maybe you wanted to be in a rural place, the only physician within miles, and now you want to be right in a big academic center in the middle of New York or something. The point is allow yourself the flexibility to change your mind along the way because that's part of the beauty of having an MD or a DO; you can do a lot with your degree. And finally I would say, stay passionate. I think that because there are a lot of challenges to becoming and maintaining your practice of medicine, being a physician these days, it's so important to just keep that passion. To not let yourself get bogged down by people who are cynical, people- and at every stage of the journey, people who are trying to kind of drag you down into the muck if you will. And to just know that this is what you want to do, and just stick with it, and just try as best you can to keep fueling that passion because that is what will keep you going really. I mean we've- Ryan and I have been through a lot in the last nine years, and as we've talked about I was diagnosed with Crohn's disease and [Inaudible 00:40:10] and some lovely auto-immune conditions and that's made life harder. But you know what? It's certainly not going to stop me and I've just tried to continue being as passionate as I can be about being the best doctor I be, and about providing good care to the patients I see, and helping my community. And I think that it's really important to just keep fueling that passion, that desire to care for others, to be the best physician that you can be, because it will get you through those more difficult times.

Dr. Ryan Gray: Well said.

Final Thoughts

Dr. Allison Gray: So hopefully I didn't bore you all.

Dr. Ryan Gray: I don't think so.

Dr. Allison Gray: Or put you to sleep. But no, I mean I think that's what I would say to my younger self and hopefully that makes- or is helpful to you.

Dr. Ryan Gray: Yeah, thank you. Thank you for sharing your experiences through your first year of being an attending.

Dr. Allison Gray: You're very welcome, thank you for having me on tonight, letting me out.

Dr. Ryan Gray: For letting you on.

Dr. Allison Gray: Letting me on.

Dr. Ryan Gray: I'm letting you on the show. Awesome. Well as we wrap up this session of the Medical School HQ Podcast, please remember that you can continue this conversation at the dedicated show notes page for this episode at www.MedicalSchoolHQ.net/92 as in session 92.

We also want to remind you that we are the partner podcast for Premed Life Magazine. Their newest issue is now live, their digital issue is now live at www.PremedLife.com. The big headline for this issue is ‘The Best Medical Schools for the Entrepreneurial Student,' which is kind of interesting. They actually have one of our articles, part of our partnership is they're turning some of our podcasts into articles and that first one went live last week I think. The ‘Eight Pieces of Information that Every Premed Should Know.' That was a good episode.

Dr. Allison Gray: I think so.

Dr. Ryan Gray: I remember that one. So www.PremedLife.com, go check them out. Say hello for us.

Something else that we want to remind you about is that we're on Twitter; I'm on Twitter really. Allison's kind of on Twitter, but I like Twitter.

Dr. Allison Gray: Actually the last time I tweeted was about a television show.

Dr. Ryan Gray: Yeah, we'll ignore Allison for this time. So I am @MedicalSchoolHQ. Twitter was one of the top ten for my premed resources, resources that every premed student should be using. I think it's a great learning tool; yes it's social media, yes you can waste hours of your day on it, but if you use it properly it's a great tool to learn and to connect with people.

Dr. Allison Gray: I don't think they had Twitter when we were in med school.

Dr. Ryan Gray: Twitter came out around 2005-2006.

Dr. Allison Gray: So I guess they did, but not as premeds.

Dr. Ryan Gray: Not as premeds, no.

Dr. Allison Gray: Interesting.

Dr. Ryan Gray: And I think that's it. So back to our 100th episode, if you have any- if you want to share your story email us. I am Ryan@medicalschoolhq.net. Allison@medicalschoolhq.net, or you can contact us through our contact page, www.MedicalSchoolHQ.net/contact.

Dr. Allison Gray: I absolutely do respond to emails, I've very good with email.

Dr. Ryan Gray: Yes you are.

Dr. Allison Gray: I just don't tweet.

Dr. Ryan Gray: She's not a tweeter, that's alright. Alright, I hope you enjoyed today's episode and I hope you learned a lot that hopefully you can take with you as you progress on your journey, so that when you are an attending like Allison is now, that your life will be easier. Everything we do here is to make your path, make your life, make your job, make everything a little bit easier and so you're happier-

Dr. Allison Gray: More fulfilled.

Dr. Ryan Gray: And in the end your patients are better treated.

Dr. Allison Gray: Absolutely.

Dr. Ryan Gray: So with that said, I hope you join us next time here at the Medical School Headquarters.

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