An Academic Peds Pulmonologist Talks About Her Specialty

Session 60

Dr. Taylor Inman is an academic Pediatric Pulmonologist who is also a locums physician. She has been one and a half years out of fellowship training. We discussed her path into the specialty, what it’s like, and much more.

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[01:20] Interest in Pediatric Pulmonology

Taylor realized she wanted to be a pediatric pulmonologist when she got to her second year of residency. She always knew she wanted to get into medicine at a young age, having had Type I diabetes and getting diagnosed at five years old.

She has been exposed to medicine at a young age with her mom being a nurse and her dad having a PhD. So always knew she was going to do something in medicine.

Then when she got into pediatrics residency, she knew wanted to specialize. She likes interesting kids and she’s been trying to figure out which interests her and pulmonology just fit the bill.

[03:27] Traits that Lead to Being a Good Pediatric Pulmonologist

Taylor describes that one of the traits that lead to become a good pediatric pulmonologist is being able to pay attention to details. Especially in pulmonology, there are a lot of details that you have to tease about patients to help optimize their treatment.

Another trait that can be a hard thing to learn is the ability to listen to families. Working together is important to figure out a plan. this being said, building long term relationships with patients and their families is very important.

[04:23] Being a Locums Physician in an Academic Setting

Taylor says she actually fell upon her practice as a locums physician by chance. She trained in San Diego and her husband’s family is in Las Vegas, where they moved after her training since at that time, they had a 22-month-old and a 3-month-old. She wanted a break so they needed to live somewhere where the cost of living was lower. Her plan was to take six months off, study for boards, take boards, and then start working locally. Only to discover that it wasn’t as easy as she thought it would be to get a job locally in a pediatric subspecialty.

Then she found the locums position in Fresno, California where they’re desperate for a pediatric subspecialist. They have a huge pediatric hospital with over 300 beds so they needed help with their inpatient service.

So Taylor travels to Fresno one week at a time where she gets on-call and does rounds. They pay for her rental car and her hotel. And she finds having a work-life balance and she’s been doing this for about eight months now. So she works one week, and then have three weeks off to be home with the kids.

The hospital she’s working at started their own pediatric residency only this year. They have residents rotating through. They can do a pulmonology elective and they can have residents covering some of their CF (cystic fibrosis) patients. But for the most part, most of the patients in the hospital are taken care of mainly by attending physicians along with the resident service. So it’s nice to have that balance of residents covering for them at night.

[07:10] Types of Patients and Primary versus Consulting

Majority of their patients have cystic fibrosis. They do see a lot of asthma patients as well as chronic patients. They have a separate service for all the chronically ill patients and they do consult on them. When she trained back in San Diego, they were oftentimes the primary physician for these patients although they’re dealing with multi-system problems. Other cases are patients with pneumonia, embolism-type stuff, and TB, bronch patients.

As a primary physician, you’re in charge of everything – feeding, breathing, medications, discharge, etc. As a consulting physician, as a specialist, you just consult on your special field. She can make suggestion about other organ systems but she’s primarily responsible for the lung organ system. A lot of times too, as physicians, they don’t write orders for the patients since the hospitalists do that. But they make recommendations and then hospitalists get to decide to follow her recommendations or not.

So you can have a specialty service and admit people to that specialty service. ¬†That means there are other patients there that consult other specialties. Taylor explains that for cystic fibrosis patients, they are the primary physicians for the patients when they’re in the hospital. She actually feels like they’re their primary care physicians too, although they do require that their CF patients have a primary care physician outside of the pulmonologist. Unless they come in with a complaint for another organ system, these are different services and Taylor can just consult for those patients.

[10:53] Clinic versus Inpatient

Taylor illustrates how clinic setting is being a little bit more low-keyed than an inpatient. For clinics, it’s nice to be able to get longer appointments. For instance, they can spend 45 minutes with an asthma patient for the first time. They’d figure out what’s going on and what they can do to help.

CF patients come in one specific day where they have a multidisciplinary clinic with a social worker, a dietitian, a specific CF nurse, pharmacist, and respiratory therapist to all help with the care.

In regular pulmonary clinics, they see a lot of asthma and all different respiratory complaints. They take care of patients with sleep disorder, breathing, and sleep apnea. They also have patients who are on long-term ventilators at home or patients that have a tracheostomy that they care for.

[12:10] Percentage of Patients Coming In

Taylor estimates 30-40% of the patients are new and the rest are follow ups requiring management. Especially once the asthma patients are stable, they try to have their nurse practitioners follow those patients up because there is such a high demand for pulmonologist in Fresno and there aren’t very many pediatric pulmonologists. Because of this, she’s seeing more of new diagnosis instead of follow-ups.

A typical day for Taylor would be getting to the hospital at 8:30 or 9 am, unless she has a bronchoscopy schedule where they’re scheduled first thing in the morning. They’d do outpatient or inpatient bronchoscopy. Then she’d come in a bit later in the morning to check her CF patients. She looks through her list for new consults coming in. She reviews them on the computer the night before and then she’d see all the patients and talk with other specialists she’s consulting with or on.

In the afternoon, she spends a few hours writing notes, which is her least favorite part of medicine. Then she’d get down around 5:30 pm depending on how the day goes But usually, she’s out at a reasonable hour.

[14:15] The Training Path to Pediatric Pulmonology

The first step is to match into Pediatrics residency. After you do three years of Pediatrics residency, you match to become a Pediatric Pulmonologist. This happens in the Fall of your third year. This gives you more time to do some electives and figure out what exactly you want to do. Taylor adds that you have to know what you want to do by the beginning of your second year.

Pediatric pulmonology is an additional three years of training. And most of the pulmonology fellowships require a lot of research, which is good. At her fellowship, she had almost two years of full dedicated research time and a year of clinical time, spaced out over the course of three years. So she did mostly clinical her first year and mostly research on her second and third year.

For most of the pediatric subspecialties, most of them are three years in length. Pediatric neurology can be combined to become a 5-year instead of 6-year training program. Even pediatric emergency medicine is another three years of training. So it doesn’t matter where you’re going to, since it’s going to be six years in total.

In terms of competitiveness, Taylor doesn’t think it really is a very competitive field compared to other programs. When she was matching, half of the spots were unfilled each year because there are so many spots and so few people who want to go into pediatric pulmonology.

The reason for the few applicants being that the pay isn’t that great in pediatrics. A lot of time you spend mastering your subspecialty and when you go out, your paying potential isn’t that great. Plus, a lot of people who get into Pediatrics just aren’t interested in pulmonology.

[18:15] How to Be Competitive for a Pulmonology Fellowship

Taylor recommends doing as much research as possible during your residency. Even if just writing case reports is better than nothing. Get to any research you can get involved with. She also mentions having great recommendation letters.

Ultimately, it comes down to where you would work well and where you’d fit in well. She further adds that people who are smart and play nice with others can really go far in pediatric pulmonology.

[19:45] Bias Against DOs, Working with Primary Care and Other Specialties

Taylor hasn’t really seen any negative bias towards the DOs since you’re basically doing the same pediatrics training. So when you’re applying for fellowship, you’ve already been working and doing the same thing for the last three years. So it doesn’t really matter at that point.

In terms of working with primary care, Taylor says that she feels that 90% of refractory asthma patients they get from primary care doctors are non-compliant. They’re not doing their meds and they’re lying or they’re not doing it correctly. But she gets how this can be challenging in gen peds when you’re practice in jam-packed. Taylor points out that most of the poorly controlled asthma is all about taking the meds and taking them correctly. And she’s happy to see those kids in her clinic. As well, she’s happy she has the support staff to help call and find out if families are refilling their prescriptions and picking them up.

And for their CF patients, they appreciate primary care doctors who are seeing patients when they’re sick and really working together. Taylor admits that as pulmonologists, a lot of times, they don’t have sick visit appointments. But parents will call them when they’re sick. Although their obligated to do something, Taylor says it’s nice to have someone lay eyes on the child and be able to tell them if they do look sick or not. This being said, they value the input of primary care doctors even for the complicated kids that they do a lot of management for.

In the hospital, other specialties they work the closest with include hospitalists, PICU, NICU, etc. With outpatient, they work with all the specialists in all different capacities. They work with ENT, Cardiology, GI, Allergy, Rheumatology, Hematology and Oncology.

[23:23] Special Opportunities to Further Subspecialize and Outside of Clinical Medicine

Taylor explains that you can do an extra PICU or NICU training. This would be an additional two years of training but she doesn’t really know if doing this would make you better of an intensivist. The fields are split especially in Pediatrics. So they have each their own subspecialty. Moreover, Taylor doesn’t like the lifestyle in PICU.

The opportunities outside of clinical medicine are endless for research. Fellowship requires a research project and most fellowships give you substantial time to complete the project. They really encourage you to continue research after you’ve completed your fellowship. This said, there are tons of grants you can write and funding you can apply for to do research.

The Cystic Fibrosis Foundation has all kinds of different funding pathways for physicians to do additional research.

[24:55] What She Wished She Knew and the Things She Most and Least Liked

Taylor admits there were times she was envious of NPs or PAs who started at the same time as her and they finished and are already working and making more than her as a resident even though they’re the same age. And a lot of the NPs and PAs don’t have to take calls as much as physicians do. But she’s still glad that she went through it all. It wasn’t easy. But now she’s on the other side of things, no one can take that MD away from you.

There are still a lot of opportunities too as Taylor points out. You can go practice gen peds if you want to or do urgent care and take care of low acuity patients in the ER if you want to. So she’s still happy she did it.

Looking back, she thinks it was more fun that she thought that it was. It’s pretty cool that as a 26-year-old that she was admitting kids to the hospital and deciding treatment for them with a senior resident.

The thing she likes the most about being a pediatric pulmonologist is how fun it is. Most of their kids get better. Also, you get to know the families well and see the patients grow and get better and graduate from pulmonary clinic.

On the flip side, what she likes the least are having patients who are chronically ill and not going to get better. A lot of them eventually will have respiratory problems and breathing is the one thing that can make them live or die. So they end up being involved with families making decisions whether or not to place tracheostomy or place patients on ventilators. She says that a lot of times, it doesn’t feel right making that decision. She also finds it hard if she doesn’t feel like she agrees with the family. For instance, she sees that the patient is not going to get better but the family wants to have them live as long as possible even though they don’t have a good quality of life. These are very challenging cases for her to see kids who are not going to get better and to know that they’re not going to get better.

[28:35] Major Changes in the Field of Pediatric Pulmonology

For asthma, they have some new treatments for asthma monoclonal antibodies that will target to lower IGE and kids who have allergic asthma. They have made a big difference in treatments.She thinks there will be more specific, targeted therapies to come in the future.

Also, trying to use personalized medicine to classify patients with asthma and figure out what type of asthma they have or what specific medications will work best for them. Taylor reveals there a lot of stuff that are just on the cusp of discovery.

And it’s a very exciting time for cystic fibrosis with all the new medications coming out. There are two drugs currently available and more drugs are on the horizon. She does hope the price of the therapies comes down soon too (right now, it’s over $300,000 a year). Nevertheless, it’s exiting to have new treatment options for their patients.

Ultimately, if she had to do it again, she still would have chosen Pediatric Pulmonology. Although at the back of her mind, she does wonder if she would enjoy being an endocrinologist. Having lived with diabetes her whole life has made her feel like she’s an expert so it could be easier to make a difference in the field of endocrinology.

[31:40] Final Words of Wisdom

Taylor recommends to aspiring pediatricians or pediatric pulmonologists out there to try to get as much exposure as possible, even as a med student and resident. Try to get involved. Shadow in a clinic and see what kinds of patients are seen. It’s a lot of fun and a lot of variety so it’s a good balance of having excitement and seeing patients who are sick. And there’s good work-life balance since they’re not being called in overnight to come in and do procedures. As a mom. Taylor says it’s a good specialty to pick.

Links:

The Premed Years Podcast

Cystic Fibrosis Foundation

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