Dr. Nii Darko is a community-based Trauma Surgeon. He's also an Osteopathic physician. Listen to his journey and what you should be thinking about. Dr. Darko has also been on The Premed Years podcast back in Session 196 and he is the host of the podcast called Docs Outside the Box.
[01:05] An Early Interest in Trauma Surgery
Practicing for almost five years now, Dr. Darko knew he wanted to be in two points of his life. As a seventeen-year-old, Nii had the opportunity to shadow a trauma surgeon in Newark, New Jersey, with his first exposure to trauma case was a person who got shot where they evaluated the patient and seeing a whole chorus of nurses and different medical staff helping the person. The trauma surgeon he was shadowing was at one corner of the room conducting the stuff, which to him seemed like an orchestra or rather a concerted type of chaos. The patient was taken into the operating room and when the doctor came out, he talked with the family. The doctor comes out of this operating room as a big superhero and saves the day. From then, he got hooked.
Fast-forward to residency around ten to twelve years later, Nii noticed that general surgeons were doing everything including trauma and found himself moving towards operating on the unknown which to him was the fun part about trauma. You don't know exactly what's injured so you have to use all of these different detective-type qualities to figure out exactly what's going on. So Nii felt trauma surgery was the best mix for him in terms of taking care of patients who need things like appendix or the gall bladder and at the same time use his superman qualities in high-adrenaline and highly stressful situations.
[04:40] Traits that Lead to a Good Trauma Surgeon
Nii cites patience as a very big trait considering that oftentimes, with trauma, you don't know what's going on and a lot of things are going on at the same time. Another important quality is leadership. You need to understand that it's a very highly stressful situation. You have the ability to take a step back, be patient and at the same time, have the qualities where you direct people respectfully. Nii stresses the fact that no man is an island, particularly in medicine and although you'll be making decisions on your own, you are leading a team and if you can lead them effectively, it's always going to end up, for the most part, with good results for the patients.
Nii initially wanted to be obstetrician being greatly inspired by Bill Cosby of the Cosby Show who played the part of an obstetrician who was a positive African-American doctor figure. In fact in medical school, Nii was the first year representative for the OB/GYN club and he quickly realized afterwards that it wasn't for him. Orthopedic surgery was also in the running for a very short period of time for him but everything fell by the wayside when he did a rural general surgery rotation in the middle of Kansas and then knew from then on that general surgery was for him.
[06:58] A Typical Day and Types of Patients
Nii gets into the hospital by seven in the morning and a sign out period occurs where they talk about all the patients on the list, anything major that occurred the night before and then they talk about the plan for the next 12-24 hours. From 8 am to 7 pm, Nii handles different duties whether it be patient evaluation at the trauma bay or someone on the general floor. By 7pm, they do the sign out process again and whoever is on at night handles any situation that needs to occur at night and then do it all over again.
Nii typically treats patients from all walks of life, children and elderly patients as well patients in their late teens and 20's. As a trauma surgeon, majority of patients he sees are patients in their teens to mid-late 20's and 30's, which he describes as the “invincible years” where people think they're invincible so they do more of the reckless stuff. Additionally, he sees a huge boom of geriatric patients consisting of the baby boomer generation who as they get older are more prone to falls and different types of mechanisms, making them the second largest patient population he deals with.
70% of his job consists of true trauma cases such as car accident, gunshot wounds, stab wounds, and critical care while 30% goes to general surgery. Only about 10-15% of his patients that come through the trauma bay get taken to the operating room for various operations such as removing a spleen or fixing a liver laceration or a washout of an exposed bone. A very small percentage of patients get taken to the operating room which is a significant shift from trauma surgery that our generation knows from most TV shows in the 70's and 80's. Because of how advanced technology now is, those days are way behind us. Now, you can study someone and take a look in their, say abdomen or chest, and have more information before you take them to the operating room.
[12:08] Calls, Work-Life Balance, and Burnout
In terms of taking calls, Nii works in a two-week-on-two-week-off type model which is basically a shift work where he and another surgeon alternate call for two weeks and he gets another two weeks off. No administrative work, no hospital work, no patients. So Nii works hard in Central Pennsylvania for two weeks and then he's able to get home for a week to see family. This makes it attractive for people who really care about being able to travel or being able to do things with their families that they may not be able to do in a regular type of job. But that said, Nii describes his two weeks on as tough. You can do it but it's not for everybody. However, Nii finds those two weeks off as very valuable.
When his patients come back during the two weeks he's off, they have this agreement among all surgeon where it's no longer his patient but their patient. Hence, other doctors take care of him or treat him during his time off. Nii sees this as the wave of the future. It may not be necessarily two week in a row and two weeks off but more and more specialties are taking on this type of work model with varying number of days on and off and where they're working as a team. Considering the amount of work or the amount of patients one person has to see and to be able to have the lifestyle with the new generations coming up, millennials and GenX, he sees lifestyle as coming into center stage and as a result, this type of schedule is becoming a lot more attractive.
Nevertheless, Nii still feels he has enough time for family since he's working very hard for two weeks and prior to this year, he was in a situation where he spent 24 hours in the hospital and another 24 hours afterward is for backup in case he's needed to come in. he ends up convincing the OR to give you time to operate early in the day which doesn't happen much due to elective cases filling in. So you may be spending an additional five to six hours in the hospital. Again, Nii stresses how tough those two weeks are and oftentimes, you may still not be able to see loved ones during that time, but during the two weeks off, you may still catch up. But it's not for everyone. Nii has still missed a lot of important life events and he honestly says there are times he's questioning if this is all worth it but in order to be human, you have to have that type of thought process at one point. Nii is not complaining but this is real talk. This is bringing to light something people have not talked about before and it may have been manifested in bad behaviors in the operating room. So it's important to have this type of discussions now.
[17:35] Residency, Fellowship, and Competitiveness
Nii did five years of general surgery residency which includes training in a whole bunch of various areas of surgery such as general surgery, surgical oncology, ENT, neurosurgery, a little bit of orthopedic surgery, but less focused on general surgery. Afterwards, he was allowed to practice general surgery and decided to do a one-year fellowship where he did additional training at University of Florida's Ryder Trauma Center. He got as much experience in trauma as he could as well as critical care experience. After his training, he became board-eligible to practice trauma surgery and critical care surgery as well as general surgery.
Nii describes trauma surgery as not a very competitive residency for a host of reasons. For one, a lot of people are little bit nervous about the hours you work with trauma. Second, it's very stressful. Third, a lot of programs offer trauma so it's not as competitive as in the realms of vascular surgery or any other type of subspecialty such as laparoscopic surgery or bariatric surgery. For the most part, people may think of trauma surgery as not being too competitive but it's very hard to get into the top trauma centers like the University of Miami, Grey Memorial Hospital, USC in California, or Shock Trauma in Maryland, these hospitals.
[19:55] How to Be a Competitive Applicant
From a medical student's perspective, Nii cites the the key things for becoming a very competitive applicant to general surgery. First, set the groundwork by being an excellently trained general surgeon. Show your interest in general surgery whether it be going to conferences or shadowing a general surgeon. You're going to be doing a general surgery rotation so you may want to do an additional rotation as a third or fourth year doing a sub-internship in general surgery or trauma surgery. Get excellent letter of recommendation and do well on your board exams.
Once you become a general surgery resident, make sure to have an open mind. Make sure you're giving every rotation that you're doing enough attention and being as open as possible to basically learn as much possible. Be open to the idea that maybe you thought you wanted to do trauma surgery but you're actually really interested in surgical oncology or what have you. At this point, which usually happens during your second or third year, start getting yourself involved in research or doing some additional trauma surgery rotations if you like or get yourself involved in co-authoring a chapter in a textbook if you're at a large institution that does that. As for Nii, University of Miami has opportunities for not only medical students but also for general surgery residents to attach themselves to one or two general surgeons who are making probably a 25-30-chapter textbooks. There are plenty of opportunities to get yourself ready but focus on getting into a general surgery residency and as a resident, start putting your hands in different ways to show your commitment to trauma surgery.
[22:40] Tips for Choosing Your Program
Nii says he wouldn't have done anything differently with how he chose his program. The way he did it as a fourth year surgery resident at Grey Memorial Hospital where there was a lot of trauma done, there were multiple trauma surgeons who train at various places and they've come to work at that hospital. What he did was querying all of those surgeons, going to various people and asking them about their program and why they think it would be good for him to train there. Aside from getting advice from them, he went online and looked up more about those different programs and even calling up the program directors where some of them accommodated him.
Nii wants people to understand that medicine is an extremely small world but as you start to get into more sub-specialties like trauma surgery, it's a very, very small world. For instance, their chairperson knew the trauma director at Miami and they ended up getting introduced in that way so he got to talk to him and told him about the program. So he applied and ended up working for him.
Additionally, when you apply you get the opportunity to interview at these places if given the interview, which is an opportunity for you to showcase how well you speak and think or how you are in person, outside, separate from a piece of paper. Also take it as an opportunity to interview them. Ask them in how well they train their residents or fellows and in doing well on their board exams, how much experience do they get operating in x or y, how much time do they get off.
[25:00] His Hustle to Allopathic Residency as a DO
Nii is a DO but he went to an allopathic residency program for general surgery. Based on the NRMP Match Data for 2017 for Surgery programs, out of 1,276 positions filled, only 64 were filled by osteopathic students.
When asked about how it was for an osteopath to get into an allopathic residency, Nii explains how much he hustled which means grabbing an opportunity and not waiting for someone to give you an opportunity. He knew he wanted to do general surgery and was open to doing a general surgery residency at an osteopathic program. He went through the rounds of interview at all these different DO programs and at the same time he decided to interview at all different places. He got a phone call from three or four general osteopathic surgery programs that they have matched outside of the match, which was part of their culture. They at times will just agree to take in a certain person before the match.
So Nii had no other places available to him to get into a DO general surgery residency. But since he got to interview also at allopathic programs, he still had that chance within that allopathic realm. He ended up doing a last-minute sub-internship at Morehouse School of Medicine in the Medical Intensive Care Unit (MICU). When he got there, he made it very clear that he was doing the MICU rotation because he tried to get into the SICU (Surgical Intensive Care Unit) rotation but it wasn't available. He actually got lucky he had a very good pulmonology critical care physician and he honestly told him that he enjoyed intensive care unit but at the same time he was really interested in being a surgeon but he took the opportunity since it was the only thing available to him. Then every now and then he would request to round with the trauma surgeons and then he eventually maneuvered that into seeing what they do in the trauma. He basically got his foot on the door and hustle his way into making sure they know him.
As a result, he got accepted into their program. It wasn't until his second year that he had the opportunity to talk to the chairperson who accepted him because they saw his ability considering they have never ever taken an osteopathic medical student before. By the time he graduated from the program, he was the best resident that has ever come through that program. Nii's advice is to make sure that if any osteopathic medical students are ever interested in their program, you have to take them more seriously. Think that we're all going through the same trials and tribulations and stress. Nii thought they may think that because he's a DO, he's different but he went above and beyond and he crushed it. Back then, they didn't treat him any differently or did anything to make him feel that way, but it was the thoughts he had at that time. His advice to medical osteopathic students out there is if you want to get it then go get it. And if you have to get into a general surgery in the allopathic world, then go and be as aggressive as possible and take the opportunities that may be presented to you. Kick the door open and don't wait for someone to give you an opportunity otherwise you're going to be on the outside looking in.
[31:40] Subspecialties, Other Specialists, and Special Opportunities
As a trauma surgeon, your subspecialty is called Trauma Critical Care. You can go and get some additional education like other specialties can like take additional courses in ultrasound. This is very useful if you're trying to figure out if someone is bleeding in their abdomen or has blood anywhere else. Using it is cheap, quick, and it doesn't require moving the patient to a CT scan where their pressure can drop or end up dying of a collapsed lung. You can get additional training in mostly anything. It won't get you additional certification but Nii explains it's always good to have that additional training in your back pocket because you never know when you're going to use it. Moreover, if you want to get any type of additional training that would get you certified in something else, you may have to do an additional fellowship aside from trauma surgery such as laparoscopic surgery or plastic surgery.
In trauma, Nii always works with an orthopedic surgeon for broken bones, neurosurgeons for head and spinal cord injuries, plastic surgeons and oral and maxillofacial surgeons for broken bones in the face or missing teeth, broken nose and broken sockets. Other specialties they work a lot with include cardiothoracic surgeons.
Other special opportunities outside of clinical medicine for trauma surgeons can be EMS. For example, if EMS is called to a scene and a patient is found down, if there's enough training, and EMT may bring that patient to the ER and allow the ER to work that patient up. But if the patient has a bunch of bruises on the head or anything on the rest of the body that may suggest they've fallen, if a trauma surgeon did the education and ER comes together, they may be able to educate EMS as to what to do first.
You can also create your own type of experience. You can do a podcast like Nii where he interviews ordinary doctors do extraordinary things. And as with any other specialty, the world is your oyster. Nii further says that as a doctor, whatever you do, you just have so many opportunities to do anything you want. There are so many ways that you can branch off and go into.
[36:38] What He Wished He Knew Going Into Trauma Surgery
Nii trained in Atlanta, Georgia and from his experience, he found trauma surgery as a burden in their hospital since majority of trauma patients at their facility were indigent populations. Other services are expensive so if a patient with polytrauma comes through and they don't have insurance, it could be a huge expense for the hospital since a lot of that care has to oftentimes be written off. This normally occurs in areas where you have patients who don't have a lot of insurance or indigent populations.
When Nii ended up becoming a trauma surgeon and going into areas where people have car insurance or people have other health insurances to pay for this, he didn't know that trauma surgeon could be as lucrative for a hospital as well as for the providers. And at the hospital he's currently at, trauma surgery is not a burden and instead is the biggest money maker for the hospital just because there are so many tenets of care.
He wished he had known this before because he used to often get physicians who tried to turn him away from trauma surgery whereas in his current situation, trauma surgery is not seen as a burden and the administration can't get enough of trauma surgeons and want more of them.
[39:00] Most and Least Liked Things About Trauma Surgery
The thing Nii likes the most about trauma surgery is being the jack of all trades. He enjoys stressful situations and being trained in all different areas knowing you've got to stay calm. You get to orchestrate a lot of people and run a team and you're seeing someone literally from the door as they come in and all the way to when they're discharged and you're in charge of all facets of the care. He finds this very fascinating reason that the went to trauma surgery in the first place.
On the flip side, the thing he liked the least is also the stress that comes with it that there's a lot to handle. In other specialties, you get to triage it to another person but you don't have this option in trauma surgery. There is constant stress which can eventually wear you down considering that Nii is still in his late 30's and he already feels the stress of that so he knows he can't continue like this into his 50's since it's not sustainable. But Nii loves this too so it's like an addiction.
[40:45] Major Changes in Trauma Surgery
Nii explains that trauma in the 80's and 90's was known to be not as operative as other specialties. There were even times when a lot of trauma surgeons lost the operative skills they've acquired during residency so a lot of trauma surgeons were not very good at operating. But a new field has come up called Emergency General Surgery or Acute Care Surgery, which Nii describes as a different thought process. For instance, if a trauma surgeon has to be in-house, he handles all the general surgery emergencies that occur in a hospital. This helps the general surgeons who have very busy elective services in the morning so they won't have to come in during the middle of the night to take out an appendix when at 7am they had a whipple surgery, which is one of the most intricate surgeries you can do in the abdomen that takes roughly about five to seven hours. So the general surgeon is no longer tired because he doesn't have to come in the middle of the night while the trauma surgeon can still get his hands dirty.
Technology-wise, it continues to push things further and further. The obvious things would be technology getting smaller and smaller that you can transport patients with, which Nii considers as a small thing compared to the combination of trauma surgery and general surgery.
[44:00] Would He Be Doing It All Over Again?
If he had to do it all over again, Nii actually doesn't know if he would do it all over again. His thought process has changed a lot from medical school and residency, from a gunner mentality to now more of enjoying what he does and at the same time, he is no longer defined by being a physician. There is more to Nii Darko than just being a doctor. And if he had thought process in medical school, he may not have decided to go into general surgery and he may have decided to do something else where he'd be really be able to take care of patients not only in the way he would want to take care of them but also at the same time have a lifestyle where he can get away and that when he's off, he is off. No work no matter where he goes. Sure he does work two weeks on and two weeks off, but this may not be the same in another facility. As opposed to Emergency Medicine, you work a certain amount of shifts a month and you're guaranteed some time off. So if he had to do it all over again, he may have chosen something different.
[45:40] Final Words of Wisdom
Nii's advice to premed and medical students and residents looking at trauma surgery is to relax and take a big deep breath. If you want to be a trauma surgeon, there are plenty of places and spots available for you to get into trauma surgery. From a premed standpoint, focus on getting into medical school and being the best student you can be. At the same time, take opportunities to shadow a general surgeon and contrast that with shadowing a trauma surgeon so you can see the differences in how they practice. From a medical student's perspective, this is the time for you to really do as well as you can with your boards and with your rotations. At the same time, start laying the foundation for your commitment to general surgery if this is where you're interested in. Finally, as a resident, keep an open mind and give all of your rotations an equal share of your attention. At the same time, if you know for a fact that it's what you really want to do, go and get it. Don't let anybody keep an opportunity from you and know that trauma surgery is extremely rewarding. Although very stressful, Nii enjoys it everyday and at the same time you deal with people at their most vulnerable states and being able to take care of someone every step of the way, not many other specialties say they can do that so he is very grateful and humbled he has the opportunity to do this.
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