What Makes a Neonatologist? A Program Director Weighs In

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Session 101

Dr. Patrick Myers joins us to talk about what he looks for as a fellowship program director, what makes a good neonatologist, and his own unique journey to this specialty. Out of training for about eight years now, Patrick also shares what they’re looking for in candidates if this is something you’re interested in.

Meanwhile, be sure to check out all our other episodes on Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:30] Interest in Neonatology and Real-Life Experience

Patrick realized he wanted to be in Neonatology until after his entire residency class matched into Neonatology. He spent a year being a peds hospitalist as he experienced a ton of deliveries.

He thinks the fellowship match is helpful in terms of streamlining and getting everybody a chance to get their application out to several people. 

'One of the things that program directors look at is if you've picked something else already or wavered a little bit, it makes people skittish.'Click To Tweet

A big downside is if you decide you want to do something else when you’re already two years in.

For residents taking an extra year to figure things out to become a better applicant, Patrick thinks doing a chief or hospitalist year is great. Being to able to work with other people in an actual, real setting allows you to understand your work skills. In fact, Patrick considers having this kind of real-life experience as a gold mine.

This shows programs that these people really love the field and they’re going to have so many more skills than people who just went straight through.

Patrick started medical school when he was 29 years old. He was a Theater major. He just got married at that time and had to work. Desire is another thing he looks for in applicants.

'It doesn't mean you've got to take time off to show the desire. But wanting to do it is really key in terms of finding people.'Click To Tweet

[05:55] Traits that Lead to Becoming a Great Neonatologist

The ability to solve problems is very important so you really have to love problem-solving. Especially in Neonatology, there is a variety of illnesses so you always have to be solving problems.

Other essential traits include exceptional communication skills and empathy. Moreover, you’d be working with a lot of other specialties. You should know how to negotiate and pull divergent views together and still come up with a really good plan.

[07:45] Common Cases in Neonatology

Except for rheumatology, all of medicine is in neonatology. In NICU, the kids are sick and a lot of them are ventilated and unstable.

What differentiates it from PICU or Neuro ICU or medical or surgical ICU is that a lot of their really sick kids stay for a long time. It’s not unusual for kids to stay at their unit for 100-200 days. Some of their kids have even stayed with them since birth to a year.

'Its a weird hybrid of ICU but also some amount of chronicity involved.'Click To Tweet

The hardest thing to manage is children with underdeveloped lungs so there’s that balancing act. Either help the lungs and keep the kid alive, but mechanical ventilation for 10 to 100 days is actually bad for you.

[10:10] Letters of Recommendation

To figure out whether an applicant for residency is a good communicator, Patrick explains they try to 2-3 very open-ended questions to let people be comfortable and talk. He personally evaluates how people treat his support staff. These are his section administrators, the people touring you, the fellows.

'A letter from the program director is actually really key, so if you can get the different fellowship program director to say good things about you is really important.'Click To Tweet

Patrick also highly values letters of recommendation from fellowship directors you have a personal relationship. He further shares this tip to ask a director if they could write you a really good or superior letter of recommendation. If you get any hint of body language that it isn’t an equivocal, enthusiastic yes, then do not take that letter.

There’s medical literature on interviews that talk about a lot of the code phrases in letters of recommendation. It tells you of phrases that program directors look for.

Already two years as a program director, Patrick admits it took him a while to write good letters. Because you want these people to go out, be successful, and get a really good fellowship.

But sometimes when you’re selling somebody the way you want them to, you actually aren’t. You could say one thing but others may read it in a different way. So it takes a bit of skill to get this down.

Nevertheless, the letter of recommendation is just a tiny piece of the application so you can make it up in so many different ways.

[14:24] What They’re Looking for in Applicants:

There are about a hundred NICU fellowships and what he does is different than other directors do. But first things first, know your audience. You don’t want to apply to a hundred programs. Around 10-15 that fit you would already be good. It has to fit you and your goal.

'Know your audience.'Click To Tweet

Patrick comes from an academic program and his goal is to generate leaders in the field of neonatology over the next 5, 10, or 20 years. So he’s looking for that capability to be a very good clinician. This is hard to prove but essentially, just do well on all your rotations in residency. Patrick actually looks all the way back to your medical school rotations.

He also looks for that potential in research. Although not mandatory, you should at least be able to spark their interest. He’s looking for someone who is able to demonstrate interest, curiosity, and the desire to solve problems.

Some people could come in with really good publications and that’s an easy one to show them you’re interested. But that’s rare. So you have to be able to show them at least some interest.

[17:10] Writing Personal Statements

The personal statement is also very crucial. Patrick says that out of the 100+ applications and personal statements they’ve read, 95 said they love neonatology because they love babies and this baby and this family changed their life. But he admits his brain just hurts reading them because everybody says the same thing.

Tell them a unique story and what fires you up. Tell a story of something you’ve done and done well.

For instance, you love dancing and been doing it since you were three. Then you’ve got great grades despite dancing 15 hours a week. You kept doing it in college and you’re still going to do it now. But you’ve discovered your passion is being a doctor in neonatology. This shows the admissions committee your commitment, work ethic, and balanced life.

The hardest applications for them to read are those that are trying to build their application. They’ve done a hundred things for one week each. There’s so much stuff on the paper that they can actually tell what’s meaningful and what’s not. They simply want to know about you. But instead of them knowing you, they might just think you have a very busy CV.

'It's confusing when there's millions of things on the application...I need to know something about you. And when you do a million things, I don't know anything about you.'Click To Tweet

Instead of saying so much stuff, tell a story that demonstrates your longevity. Being a subspecialist, you’re going to be doing this even when you’re 65. Investment is what Patrick is looking for.

[20:00] What the Residency Application Looks Like

The application comes in different chunks. The personal statement is a letter that’s 500-1000 words long. You can put anything you want in there. Patrick recommends you do research if you’re interested in an academic place. Otherwise, if you apply and not say anything about research, people could get confused.

You have to give 3-4 letters of reference. You can also get more than that. The important thing here is to get good people that are known in the community. More importantly, these are people who can enthusiastically talk about you.

In one of those references, there’s a summary letter of your pediatric program director with a very specific language that they will use.

They will also look at all your medical school transcripts. Most medical schools make a summary statement about who you are. They will probably have a paragraph that would say what you did and what’s unique about you during medical school.

All in all, it ends up being around 40 pieces of paper on an average person. This would also include your hobbies, posters, presentations, papers you wrote, visa status, permanent address, languages spoken, etc.

If you’re looking for programs, look at their websites and reach out. Work those connections you have with the nurses. They should know stuff about the program directors and the programs. Patrick personally wants applicants to know his worst before they get to the program. Talk to the junior people.

'You should be worried if people are hiding stuff because they've got something big to hide then.'Click To Tweet

[25:00] Procedures in Neonatology: Should You Have a High Level of Dexterity?

Patrick is 100% convinced that they can teach students every skill they need to have. You need to have some manual dexterity but you don’t need to be able to play the classical piano for two hours. The level is relative.

'Anybody can learn it. Some people are natural at it, some people are not natural at it. But we have a whole process of making sure you get enough procedures.'Click To Tweet

Moreover, the biggest thing in neonatology is intubations. In neonates, the airway is very different than even kids or adults. Some of their kids are very tiny, the smallest kid they’ve intubated is 275 grams. The airway changes all the time.

That’s one of the hallmarks of neonatology is you’re constantly developing underneath. All that being said, you’ve got to have the skill level to intubate along that spectrum.

They also put in test tubes. They catheterize the umbilical, arterial, and venous lines. This takes a little bit of time. Nevertheless, Patrick is never worried about people’s ability to do procedures.

[27:40] What Makes Neonatology Fellows Stand Out the Most

Patrick explains there’s a variety of ways for people to be successful. And the people who are successful as a fellow are sometimes different who become ultimately successful down the road.

'Really good people skills just get you a long way in life no matter what you do.'Click To Tweet

The ability to be curious is another great trait. What’s unique about Neonatology is you’re going to be working relatively hard and putting in a fair amount of time, like a ton of weekends. The people who are successful are those that are willing to do the work, communicate well, and are good problem-solvers.

[29:12] Audition Rotation

Patrick explains you’ve got to get the program letter of agreement with regard to insurance, among other things. It’s doable though. And it’s useful. But this is not something Patrick would personally look for because especially for those coming from a small place, it’s hard for them. Hence, an audition rotation doesn’t help them too much.

[30:15] Osteopath Applicants

Patrick’s doctor is always an osteopathic doctor. He applied 50-50 when he applied to medical school. What he really likes to see is the research aspect.

However, he feels that a lot of the osteopathic residents that apply to him don’t have the research chops or don’t demonstrate their interest in research. This is unique to the top 15-20 programs in neonatology. They’re all big centers and people are doing a fair amount of research.

Hence, if you’re an osteopath and interested in neonatology, you’ve got to be able to show to them that you’re interested or have that experience. This can be a summer lab or finding somebody wherein you can do some type of research.

Some interest or experience in bench research is also something that’s desirable as this is rare in pediatrics. This is so hard to pull off, but if you do, this makes you incredibly desirable especially to the big programs.

'The more you can demonstrate, the more desirable you'll be.'Click To Tweet

At the end of the day, Patrick really just looks at your ability to be a leader in the long run and curiosity.

[32:42] Easy No-Go’s

An easy no-go for applicants would be felony conviction. This would be logistically challenging for him in terms of the level of additional work he would have to do in order to get the person approved.

Some programs have a hard cut-off for board scores. They don’t have it though at Patrick’s program. Instead, he looks for long-term potential.

'What I'm looking for is long-term potential and board scores don't totally reflect that.'Click To Tweet

Moreover, when you fail your boards, this can be problematic. This is hard for any program director to swallow. It’s not just about being mean.

If you fail peds boards, they would then have to set a chunk of time out of your second and third year of fellowship so that you can pass your peds board. And if you fail peds board enough, then you’re not boards-eligible for neonatology. 

And if you fail neo boards, even though you’re working somewhere else, they’re still your responsibility so they have to find ways to remediate you with the American Board of Pediatrics or the ACGME.

Whatever you do, figure out what you need to do to pass those exams or it will just hurt. And it will keep hurting forever. Or this will have negative consequences on the people hiring you.

[36:00] Measuring the Metrics of Medicine: Getting Accreditation

Patrick adds that if enough people fail your peds board, the ACGME becomes extremely interested in your program. They’re interested in hard metrics.

'They can't measure the art of medicine so they measure the metrics of medicine. And one of the metrics they measure is board pass rate.'Click To Tweet

If enough people fail, they’re going to lose their accreditation. They could either get on probation or they could get citations. Each of those things has adverse effects on the program. And they can’t recruit as well obviously. It then potentially becomes a bigger problem.

[36:55] Day-to-Day Life of Neonatologists

Patrick recommends that if you’re interviewing, really find out what the day-to-day life is. There is a fair amount of heterogeneity among the programs.

You have to do a minimum of 12 months of clinical service. You typically show up between 6 or 7. Do rounds and sign out and manage the unit and the myriad of problems that show up. You’d be teaching residents and then signing out again. There would be calls and weekend calls but these vary a lot.

'Know what you're getting into. Don't assume that it's all the same because it's not.'Click To Tweet

You’ve got to have a research project in some way, shape, or form. And there are a couple of ways to meet that. You could get a master’s degree. You can do a QI project or administrative stuff.

You also have to do a followup clinic. Every major center that does neonatology has a follow-up clinic. They measure the developmental outcomes of their kids that are really tiny and high-risk.

At the end of the day, what Patrick is worried about is the output. So he really doesn’t care how you do it. That said, he makes sure you have the help you need and he can step in when necessary.

You will be taking care of babies a lot and you’d be in the hospital a lot. But the rest of your life will vary depending on the program and what your research interests are.

[39:50] Final Words of Wisdom

Know what you’re getting into. What Patrick sees a lot is that people get attracted to the field by a dynamic mentor or a dynamic faculty member. And people don’t think about the lifestyle very much.

Think about what you’re going to be doing as a resident, as a fellow, or as an attending for the next thirty years.

What you could be doing as a resident is way different than what you’re going to be doing as an attending. So try to cultivate those relationships with attendings in the middle of the night. Ask them what life is like raising kids or how it feels when you’re taking calls at 65 years old.

If you don’t like doing night calls and being in the hospital for a good chunk of your life, it probably isn’t for you.

If this is something you’re interested in, Patrick drops some resources you could look into. Check out ONTPD and TECAN for more NICU-related resources.


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