Life in the PICU with Dr. Sharon Sandell

Some young nurse, she'll be like, she'll have some at the bedside and, and then we'll be rounding and she'll be like, are you Dr. Sandel's butt cream, Dr. Sandell? Like, okay, that's my claim to fame. That's kind of sad, but.

Hi, everybody, and welcome to the podcast. This is Generations md. My name is Stephanie and I'm joined.

Here by my colleague Dr. Sarah Davis.

Who'S also my mother. And today we have a very special guest, Dr. Sandell. She is a board certified pediatrician and board certified in crit care. And we are so excited to have you on the podcast today. Welcome. Welcome to kind of back up and get started. I always like to ask guests, when was the first time that you thought about being a doctor?

You know, I started saying I was going to be a doctor when I was a very little girl. And to be honest, I have no idea why. There's absolutely nobody in my family that's in medicine. Don't know where I got the idea, but I said it when I was little and just kind of did it. When I was in college. I had a brief moment where I thought, well, do I really want to do this or have I just been saying this for the last 15 years? So now I have to do this. And briefly toyed with like a history professor kind of path. But then as soon as I figured out how many things I'd have to write, that got the thumbs down and I stuck with the med school idea.

So you were kind of pre med when you went into college then? I mean, biology major.

No, I knew. I mean, I knew I wanted to go to medical school, but, you know, this was one of the things that worked out really well for me in my life. Kind of accidentally. I went to high school. I went to a small high school in Colorado. There were 200 people in my graduating class and I had no idea about how college worked, especially getting into an Ivy League school and that sort of thing. So I was like, you know, number two in my class because I made a B in typing in 10th grade. That's why I wasn't number one in my class. So I was number two in my class. Oh, I'm going to go to Harvard, you know, so I applied to Harvard. Well, of course I don't get into Harvard. I mean, no one, the family went to Harvard. I'm Joe Schmo from a small high school in Colorado. So I had applied several other places and gotten accepted, all of which were good places, but none of which I really wanted to go, so then I didn't know what to do. So both of my parents had gotten graduate degrees at UT Austin. So they said, just go to UT for a year and if you hate it, then you can go somewhere else. So, you know, this being like 1978, 79, somebody told me about plan two, the honors program at UT. And at the time, the woman who was sort of the administrative head of it was this lady named Dawnette Moss. So you could just like, never do this now. But I call up the office, I speak to Dawnnette Moss, I tell her my tale of woe. She's like, yeah, you sound great. Send me your stuff. And so that's kind of how I got into plan too. Very late in the game. Back door, which really turned out to be the best thing that ever happened to me. And it's sort of one of the things I use for my kind of like two big pieces of advice that I always give anybody that asks me about medical school. But I was lucky because I was in an honors program. And what I chose to do, it was a liberal arts honors program. And what I chose to do was, yes, I took all the prerequisites to get into medical school because I knew that's what I wanted to do. But the vast majority of my time in college, I spent doing everything else that I knew I wasn't really going to have a lot of time for later in life. When I graduated from college, I spoke Spanish and French and German and I took classes like European intellectual history. And I did all this reading that I just knew I wouldn't have time to do later and have, have never regretted that for a second. Now, that being said, when I got to medical school, which, when I got into medical school, you know, they go in phases. Sometimes they're very science, science, science and who they want to admit. And sometimes they're all about well rounded. And luckily I got in. And when it was a well rounded phase. So there were a lot of people in my class that were like me, not science majors, my group of friends that I'm still close with. Like, one was a philosophy major, one was a French major. So the first year of medical school, then, you know, trying to compete with people who had been heavy duty science majors and for whom all this information was not necessarily hearing it for the first time. You know, it wasn't pretty. It was sort of the classic, you know, you go from being one of the smartest people, you know, to the first year of medical school. I made a C in everything except for medical ethics, which I made A in that, and Introduction to Patient Evaluation, which was, you know, at the time, the way they started you off with patient care, you know. And then the second year, I pretty much made a B in everything. And then by the time we got to the clinical stuff that actually involves your social skills and, you know, your thinking, you know, then I started making an A and everything. But it was. It was not the easiest start to medical school. For that reason. I was not a superstar that first year. But even in retrospect for myself personally, I would not do it another way. I wouldn't have wanted to miss out on, you know, the broad swath of things that I was able to expose myself to during the four years of college before I started down the medicine path.

Yeah, I think that's a really important topic to bring up. Like, I was a psychology major in college, and I really enjoyed it, and I kind of explored that to see if maybe, you know, that might be a path that I want to go down. Do grad school in psych or something else. I think college is a great opportunity to be able to explore different paths. I think a lot of the times people can come in and have this idea of going into medicine and just take the prereqs and not have the opportunity to explore other things. So I'm glad that you pointed that out. And I'm also glad that you pointed out that maybe at the time, the first year or two, you're like, oh, I don't know, did you feel like, oh, I should have been a biochem major or I should have done this? But then a couple of years out, maybe you look back and were like, okay, no, I'm glad that I got to have those college experiences.

No, I never felt that way, mainly because, like, my core group of friends was. Was all in my same boat. I mean, I knew we were all really smart women and that we would all be good doctors, but, I mean, to this day, we laugh about being the 52 Club. There was this one physiology exam that, you know, probably all eight of us in my friend group made a 52 on. Not our shining moment in medical school, but. And in fact, the person who was number one in our medical school class, who had been, you know, a science person in college, he just was not a I can interact with patients kind of person. And he ended up being strictly a research person, which is great for him. He's smart. I think people that do research are probably the smartest of all of us. And not something that I'm equipped to do. But, yeah, what kind of grades you make in basic science aren't in any way indicative of how skilled you'll be as an actual physician, interacting with people, taking everything, you know and putting it together.

I'd like to see a graph on that. Like, is it an inverse correlation or certainly. Or just no correlation? Because I can't imagine that the way you do in the first two years really is very reflective of what kind of doctor you'll be.

Stephanie, you can speak to this more, but I know medical school is set up much differently now. I mean, you are. From what I understand, from talking to people that I know who are in med school now, your. Your actual interacting with patients kind of experiences starts much earlier. It's not. It's not held off until the third year. Correct me if I'm wrong on that, but that's what I understand.

Yeah, my school does it a little bit more traditionally, but for the most part, yeah, the general consensus is, yeah, the first two years are mostly pass fail. They don't really emphasize your grades as much, even when applying to residency. Your first step one is now pass fail as well. So they really put like, all the grades and the basis of your residency application is after you kind of start those clinical years, much better.

I agree. I agree. And the other thing that I, to me is just so important, especially when I'm talking about people who are wanting to get into med school in the first place, is it truly does not matter where you go to school. You know, I mean, I know people that are so focused on it has to be this particular school or it has to be Ivy League or it has to be this or that. That's just. That's just a fallacy. And you're just. You're just hurting yourself. I have a really good friend, she's exactly my age, and Chinese woman, you know, her mother's a tiger mother, the whole thing. And, you know, she went to undergrad at Harvard, she went to med school at Harvard. And in our adult lives, and I went to all public education, ut, utmb, Galveston. But in our adult lives, we are doing exactly the same job in exactly the same setting for exactly the same salary, like, it just doesn't matter. Especially if you are, you know, live someplace like Texas where you have this plethora of places to choose from, just wherever you get in. If as long as you're going to a reputable, accredited place and you learn what you're supposed to learn, you'll be fine. That's all that matters. It doesn't matter where your degree is from. I'm a strong believer in that. I mean, somebody who's a Harvard Med School grad may disagree with me. I mean, maybe the only way it conceivably makes a difference is if you are pining for a career in research, then maybe if you go to someplace that has substantial research facilities and big name people and you can meet them during your education, maybe that's a foot in the door. But otherwise, go where you get in, put your all into it, learn what you're supposed to learn, and you will be just as good a doctor as anybody who went to school anywhere else.

Yeah, I think that's a good point. And it's funny to me because med schools supposedly in the application, they're like, oh, well, are you a good fit for this med school? And they're kind of trying to say, this is different. I'm like, the whole point is that they are all the same. They were all learning the same stuff so that when you're a patient, you don't have to research, well, where did my doctor go to school? If they've got a license and they're board certified, that they're all going to be, you know, a high quality professional. And that's, that's why we do it that way. So kind of having these schools distinguish themselves in different ways is, I don't know, I just think it's kind of a joke.

I do too. And, and it's, you know, just like with me being 17 and so obsessed with the Harvard thing, it's, it's hard to take somebody who is 17 or 21 and make them see that truth. You know, this whole where you go matters so much ethos is like beaten into you so much, I think as a student, more so now than ever, honestly. And it's, and it's a little hard to make people see beyond that. Sometimes I think, yeah, I, that's why.

My mom, when I was like looking at medical schools and stuff, she was always. Both my parents were like, it doesn't really matter where you go. You're gonna have the same experience wherever you are. And I'm like, I want to be in a city, I don't want to be in a small town and stuff. And they're like, it doesn't really matter. You stay in the bubble. And now I really do see that. I don't think my would be any different if I had the same group of friends in any other geographic location.

Right? Absolutely. I mean, you know, I lived in Galveston. We didn't have air conditioning in our apartment. You sweated in the shower, but, you know, but you. Like, we were on the beach, and it was a great place to be when you, A, had no money and B, had no time. And, you know, every year, I. I still travel once a year with a group of seven women that are friends from med school. It's. Yeah, it's not. It's not about where you are. It's about who you're with and what you're learning. Yeah.

The only column that I. That I thought was the most important in the statistics for the medical schools is the cost column. You know, I was like, how? And that's. For me, that was the biggest factor. I went to the cheapest med school that I got into. I didn't have as many loans as I would have if I'd gone somewhere else, was able to pay them off quickly. And it just makes all the difference in then kind of getting ahead financially. And so same thing up with. With Stephanie, it was like, okay, look, we're going to look at how much these things cost. That's going to be a big factor in the decision process.

Unquestionably. I mean, when we. We have, on occasion, like, hired somebody just out of fellowship into our practice. And it's interesting because it's always the men, not the women, but the men, like, they will come in and they will, out of fellowship, have, like, $300,000 worth of debt, which I wouldn't even be able to sleep at night. And then as soon as they get their first real job, and then they're immediately buying a house, buying a fancy car. It's just, you know, not the way I manage my own finances. But I agree again, especially, like, if you're lucky enough to be someplace like Texas, which. What do we have now? Nine medical schools, 10. I mean, something ridiculous. There's just. There's no reason to go out of state and bankrupt yourself, or if you're lucky enough to have parents that are paying for it, bankrupt your parents. There's just no justification for it.

Yeah, 100%.

So tell us. So when you started going through your rotations, how did you decide on your specialty?

Well, it was kind of a process of elimination. I figured out pretty early on that I didn't want to do adult medicine. Of course, this is a gross overgeneralization and not true, but kind of in my mind, sort of like adults are gross and they don't listen to people. And so many other problems are their own fault. And, you know, and I don't want to come in first thing in the morning and, you know, have to look at somebody's poop that they saved for me in the toilet because they were so proud that they took this big dump. I just, it just wasn't. So then I knew I wanted to do something in pediatrics and, and I kind of knew even in medical school that I didn't really want to do general pediatrics. I mean, I like kids and I enjoy. I liked the idea of continuity of care, but just sort of the idea of spending my life looking in ears and giving in immunizations, I didn't have the patience for that really. And retrospectively, another reason that it's really good that I didn't make that decision is I'm slow. I'm methodical and I'm slow, and I'm sort of obsessively detail oriented. And in order to make any sort of a living in a normal outpatient setting these days, I mean, your setting, Sarah, is different because of your practice model. But to be like a normal pediatrician, you would have to see so many patients in a day, and I just can't do that. Like, in my ICU, I have a maximum of 20 patients. And when the ICU is full and I have 20 patients to see, I never get out of there on time. And I have a 12 hour day. So, you know, the idea of having to see twice as many kids of that, I just couldn't do it. And I initially was really thinking about neonatology, mainly because there was a neonatologist at UTMB that I just absolutely worshiped the ground this woman walked on. She was like this, you know, towering figure, literally and figuratively, and so smart, just, you know, hung on to every word that came out of her mouth. But I eventually moved away from neonatology also, again, because it seems sort of limiting. It's like, yes, it's challenging and gratifying, but, you know, the preemies kind of have the same half a dozen problems over and over and over. So then I landed on pediatric critical care because we do kind of neonates all the way up through early 20s, wide variety of problems. And even with critical care, I mean, most of the kids get better. Our successes far outnumber our failures. And it's just all these many years later still held my interest. I still work full time. I don't have retirement anywhere in sight. So it was the right decision for me.

Can you talk a little bit about the typical patient that you see.

Sure. I mean, that's sort of one of the nice things about pediatric critical care is, I mean, depending on the season, sure, there's typical patients, like when it's viral respiratory season, which sort of used to be the winter, but now it's barely even seasonal anymore. It's kind of all the time. I could sort of have the same history and physical that I could crank out for 60% of the kids, I admit, during that period of time. Kids that come in with some sort of viral bronchiolitis, RSV or adenovirus or para influenza or whatever it is. And even, you know, even just the advent of something as simple as high flow nasal cannula, you know, the vast majority of those babies would have ended up intubated in the past, and now they're not, you know, so their whole ICU course, hospital course, is so much different. In my, in my hospital, the pediatric ICU does the, the extracorporeal circulation, the ecmo, then the NICU doesn't do it. So any baby that needs ECMO comes to the picu. So we have those kids. The hospital, my particular hospital, has a big craniofacial reconstructive surgery program. So we get a lot of those patients, the kids with aperts or crouzons or whatever that come in and have major craniofacial reconstruction. They spend a couple of days in the ICU afterwards. We have trauma kids. We have, you know, you get a lot of sepsis in the ICU setting. So, yeah, it's a lot of variety, which I like. Variety in diagnosis, variety in age, just.

Because in adult medicine, a lot of times you have the surgical ICU and the medical icu. But for you, it's all those things. They come to you after surgery. They come to you from trauma, they come to you from medical. It's just all children that are there in the hospital that are ICU patients.

Yes. The only thing that's, well, the newborn icu, the preemies all go there. Anybody that's hot off the press just born, unless they need ecmo, goes to the nicu. Within the last decade or so, the trendy thing to do has been to separate out the cardiac patients. Most places will now have a pediatric cardiac ICU as well, and the cardiac surgery kids will be there for years. It was all combined. I did cardiac care for decades. And then they decided, oh, you know, we need to have cardiac intensivists, which actually sort of meant that you did like one extra year of fellowship in, in A cardiac setting. So it was a little testy for a while because it was hard for those of us who'd been doing it literally for decades to understand how somebody who had done a fourth year of fellowship and was 32 years old, you were thinking, was preferable and more qualified to somebody who had actually been doing this at the bedside for the last 25 years. But as a generalization, most cardiac surgeons are people that you could kind of take or leave spending a lot of time with anyway, so since I'd already done it for a long time and wasn't missing those people in particular, it was fine. But that is separated out in my institution. So there's the nicu, the picu, and then the pediatric cardiac icu.

Okay, I'm taking my pulmonary exam in two days. So all of these rsv, parainfluenza, ecmo, like all of these are, are triggering. But, but really, based on my curiosity, how have you seen advancements or things change in the critical care setting since you've been there?

Well, I mean, just, I, I finished my fellowship in 1993, so, you know, I've been doing it as an attending since then, and certainly ventilators are much better. As I said, high flow nasal cannula has been a game changer. Like, I run the pediatric continuous renal replacement therapy program at my hospital. So like our ability to dialyze and do renal replacement therapy on, you know, kids as small as 1.82 kilos, that's been kind of a game changer. Even our understanding of basic things like how to use inotropes. I mean, I can remember when I was a medical student, the nickname for norepinephrine, brand name Levophed, was leave them dead. Well, now I use norepinephrine as kind of a first line drug. I mean, the reason it had that sort of bad reputation is because people didn't understand how to use it. They didn't start to use it until way too late in the kind of sepsis, circulatory collapse process. So even sort of better understandings of drugs that have been around for a long time have made a big difference. Of course, ecmo, I mean, ECMO has been around a long time, but we use it for more indications now. You can do veno arterial ecmo, you can do venovenous ecmo, and so broadening use of that.

Oh, can I interrupt there? Can you just briefly explain what ECMO is? Because a lot of our listeners don't know what that is.

ECMO stands for extracorporeal membrane oxygenation. And it's basically a longer term equivalent of the heart lung bypass machine that they use in the operating room for somebody that is having heart surgery. So if you do this procedure where you have one of the big blood carrying tubes in a big artery and one in a vein, then this circuit of circulating blood outside the body can take over the function of both the heart and the lungs. If you're in a setting where the heart is functioning fine but the lungs are out of commission for some reason, you have some horrible pneumonia or something happened, then you can put both of the big blood carrying catheters in veins and then the machine is only able to take over the work of the lungs and not take over the work of the heart. And you know, it used to be that that sort of thing was used, let's say, just as a bridge to transplant. You sat there on this machine that was doing the work of your heart and lungs for you while you were waiting for a heart transplant. But most of the time we use it now, it's, it's a very time limited setting and ultimately you, you know, come off the machine and get better and go home. But that's. If you, if you need that sort of out of body, you know, extra circulation, if that were not available to you, you would certainly be dead. Yeah.

And I, I know that a lot of that was used more during COVID Right. Kind of introducing.

Yes. Yeah. A lot of, a lot more adults probably than ever before were, were on ECMO during COVID and I'm not sure their outcomes were particularly good. But. Yeah, I mean there are certainly some, some Covid survivors that would not have otherwise. Absolutely. We actually in the pediatric ICU had very few kids with COVID My friends who are adult physicians, like especially my friend who is an adult infectious disease person at a big hospital in New York City, like her life was a nightmare. I mean her day to day reality was the refrigerated trucks full of dead people. In the pediatric world, we really did not have that so much. My experiences were more like good friend of mine from med school, big, healthy, strapping guy who got Covid and died, that sort of thing more. So what was happening to adult friends and adult colleagues? What actually happened within the setting of my own unit?

I guess pivoting though. Yeah. What does your day to day life hours look like kind of outside of. Outside of medicine?

Sure. Well, the first five years I was out of fellowship, I had an academic job. I was at East Carolina University in Greenville, North Carolina. And I liked that job. I liked the hospital. Greenville was a pleasant place to live. I love the people I worked with. But you know, as I mentioned before, I'm just, I am not a research oriented person. I wasn't going to have a lab, I wasn't going to write papers. And it just became clear within that five years that I was never going to be a person that was going to be successful in the academic setting. At that time, they didn't have sort of just a clinical track. Everybody was kind of expected to do everything. And on the days that I wasn't attending in the unit, like, I kind of didn't really have anything to do, but I was still expected to be there. And I had a really pretty office, the only time I've ever had a really pretty office of my own. And I had, you know, as we called it, a nice I love me wall with my diplomas and everything on it. It was great. But I would sit in my pretty office in front of my I love me wall and have nothing to do. So, so I left and moved to Dallas and joined a private practice. And my group were anymore. We're sort of getting to be a little bit of a unicorn because we're just a group of seven physicians. We're not a part of any big sort of practice management thing. We're not like, you know, PED with an X or envision or any of those things. And that certainly has its pluses and its minuses. I mean, for us, the positives outweigh, the negatives mean the positives are. We decide who we hire, we decide how many people we hire, we decide what our salary is, we decide what our benefits are, we decide what our schedule is. I mean, we sort of have control over everything that affects us in terms of how we run the practice and how our daily lives are. The negative about it is it can be financially tricky. Of course, in critical care you take all comers and so we always have at least 60% or so Medicaid, which will turn into 60% nothing. The way things are going, you know, even if you're self pay or no pay, obviously if you need to come to the icu, you still come to the icu. Dealing with insurance companies, it's, it's slow, it's tedious, they don't pay you on time. So there are certainly, you know, months where we feel like we're looking under the couch cushions for, you know, for money to get everybody's salary paid. And I'm one of the two senior partners and so if somebody is going to get paid late, it's myself and the other senior partner or last October there just was not enough money to pay either one of us. So neither one of us got paid in October. And then we kind of gradually got the money from October over the next six or seven months. Like I just got the last of it last month. But then there have been years, you know, where there's been, you know, lots of money and we've been able to do partner bonuses. I mean, those days are sort of long gone and. And periodically we talk about, well, would it be better, would it be safer to join one of these bigger groups where at least your salary is guaranteed? But everybody we know that's in one of those bigger groups, they sort of regret it and hate it. And so were just holding out and still trying not to do that. I do the scheduling for our group and we kind of made a decision a number of years ago. When I first moved here, let me back up a little bit. When I first joined the practice in 98, we had a repeating template kind of schedule. It was a six week repeating template. And so your schedule was always the same, it repeated and you always knew what you were going to be doing, which the predictability of that was nice. The big downside of that was if you wanted to go away, if you had a family event, if you wanted to take a vacation, if you wanted to go to a conference and it didn't align with a period of time that you were already off, then you had to do a lot of trading to do that. And it was just complicated and annoying. So then we decided that we were going to build our schedule around everybody's time off requests. So I make the schedule, I make four schedules a year. We do it in 13 week blocks. And everybody gives me in advance, you know, all of their time off requests. And it can be anything from, you know, I need three weeks off because I haven't seen my parents in India for a long time. To don't put me on this night or do put me on this night. You can make I do want to work these day requests or I don't want to work these days requests. So I have a software program that I could not live without. And I punch all those things in the yes work, no work, and then I punch in the tallies need to work this many days, this many nights. And then I have a software program that then fills in the rest of it for me, which otherwise would be impossible with seven people and each day containing a 12 hour day shift, a 12 hour night shift and a 24 hour backup shift. There would just be no way to do it by hand. The person who did it before me, before we had this software, her husband was a pilot for American Airlines and she somehow on the down low got into the American Airlines scheduling system and would use that. So, you know, it's, it is not onerous for the. If you are a full time person in our practice, like a 1.0 FTE in that 91 day block, you'll probably have 15 or 1612 hour day shifts, 15 or 1612 hour night shifts, and 15 or 1624 hour backup shifts. So let's say you have 45 to 48 days that you are scheduled to do something out of 91. So it is not onerous. That is definitely the plus side. The minus side is there's no predictability to it and you sort of get stuck working around other people's being there or not being there. Like in June or in May rather. Pretty much everybody is kind of in town until the end of the month. So I'm barely working at all in May, June, so many people are out of town. So I'm working a ton in June. We also, it's not uncommon at all to work days and nights in the same week. You know, maybe you'll work a couple of days at the beginning of the week and then you end up working a couple of nights at the end of the week. I'm used to it, it doesn't really bother me, but a lot of people wouldn't be thrilled with that. But on balance, for our group, it works very well for us and certainly allows for plenty of life outside of work. Because if you are not scheduled to be there for a 12 hour day shift or a 12 hour night shift, unless you're the backup person and you get called in to help, no one has any expectation of seeing your face.

Yeah, that's nice. Yeah, I think that's, that's really important when people are choosing their specialties. We were speaking with somebody in, you know, an emergency medicine doctor and she was talking about that same thing. I mean, the nice thing is when you're off, you're off. That's great. And you do have a fair amount of time off, but your time on is not always the time that, you know, sometimes you're working when all your family and friends and everybody else is off. So it's just, and, and then the doing the night shifts as well. So I think just kind of factoring that stuff in there. And sometimes when you're young, you think, okay, that'll be fine. And then you get to be a little older and you go, oh, I don't know. I don't know about working these nights, but it sounds like you're still tolerating it just fine.

Yeah, I mean, with the people, as people have retired, like in our practice, people have gotten sort of toward the I'm 70 now age range. Usually the first thing they do is stop working at night. That's the kind of the precursor to retiring altogether. And, you know, for me, we are very good in our practice about maternity leave. I mean, I had two babies working in that practice. Lots of people have had babies working in that practice. And, you know, we sort of give the standard six weeks of paid maternity leave. But what I did and what pretty much every other pregnant person has done is I worked a fair amount extra during the time I was pregnant. So then after I had my kids, then I stayed home for 13 weeks because I got my six weeks, you know, that I got. And then I had worked an extra seven weeks worth of shifts during the time I was pregnant. And as I explained, I mean, seven weeks doesn't mean, you know, 49 shifts. It means whatever I would have worked during that seven week period. So, yes, it was some extra, but not a heinous amount of extra. So then I had that much paid time off because I had worked those extra shifts during the time I was pregnant. So I was, you know, able to get still my full salary during the time I stayed home.

That's nice.

And the other advantage to having a really small group like that is, you know, as you know, my husband had cancer for a long time and, and died two years ago. And there were two different times during the six years that he was sick, where he was so sick that I had to take several, several months off of work and stay home to take care of him. And, you know, because I was in this very small group that I, you know, kind of the head of and had been with since 1998, when I had to take that time off, everybody else was just like, okay, you do what you need to do. Now, obviously I forfeited my salary and my money went to the people that were working for me. But still, I mean, if I had been in a big sort of like pediatrics kind of situation, there's no way I could say I'm going to stay home for six months and then I'm going to come back to my same job that just would not have happened. Whereas in my setting, you know, everybody was very supportive. They just sucked it up and, and did it. And that happened twice during the six years.

Yeah, well, I'm sure you had built up a lot of goodwill over all those years that you were there, you know, and then something happened and you know, you would have done the same thing for any of your partners in a similar circumstance, which probably did happen. You know, other people have other things.

That happen for the length of time I needed to be gone. But yes, I mean, somebody had a miscarriage or somebody dies. I mean, there's always things that come up and, and it is nice to know that you have that sort of built in goodwill within your small group that if something comes up, whether it's emergent or whether it's sort of pre planned, that, you know, you know, they will make it happen for you.

Yeah.

The kind of a theme that we've talked about before on the podcast of this idea of kind of being a medical student. You, you just want so, so hard to just get into a med school and you're in med school and you work so, so hard just to like get to the residency and like, just take me, just take me. Then when you finish residency, really thinking about kind of like what group do I want to try to join, not just kind of like taking the first job that's offered. So I really like this conversation of talking about kind of the nuances that a lot of people don't really know how to independently contracted groups work, or a lot of people just think, okay, I'm gonna go work for this big hospital system. But I appreciate you talking about kind of the different ways that you can be employed, I guess.

Right. And, and it depends too, where you live. I mean, in, in Texas, theoretically you can't legally be employed by a hospital.

So I'm glad you clarified that because that's what I was really confused about because in South Carolina it's all PRISMA health. Like everybody just works under prison charisma health and they kind of have a monopoly. But if you want to clarify a little bit more about.

Well, in Texas they have, I think it's called a 501A and it's sort of a, you know, kind of a legal construct where so you're sort of employed by the hospital, but not really employed by the hospital. And there certainly are physicians at the hospital that have, have taken that route as well, you know, and the other thing that you have to keep in mind too is there are certain practices that are money makers and bring money into the hospital. Like, for example, we sort of jokingly refer to the pediatric cardiac ICU as the empire because lots of state money comes to hospitals, lots of state and federal funding comes to hospitals for cardiac ICUs, for oncology things. But pediatric ICU is a classic money loser. So in addition to the money that we make from, you know, from our billing and collections, you know, every two or three years, we also have to negotiate a contract with a hospital for additional funding to come to us from the hospital because we couldn't support our practice, which is seven doctors, two nurse practitioners and two office staff. We couldn't. And there's no conceivable way we could support ourselves on just what we earn. You know, sort of eat what you kill. We'd all be starving. Because, because there is such a big population that pays minimally or doesn't pay. It's just, it's not a specialty that you are going to be able to sustain yourself in without some, whether it's from an academic institution or, or a private institution, you're going to have to have some other source of funding. So there has to be somebody in your practice who is good administratively. You know, I mean, it's a multi million dollar business and you have to have somebody that knows how to run that business. And in my group, I'm not the one who does that. The other woman senior partner who's phenomenal at it, she's the one who's done it for many years now. But there's that facet of things also, I think even if you don't want to have a career forever in academia, it's not a bad way to start. You still have a lot of people around you to learn from, to mentor you. Because when you're a baby attending, you still have a lot to learn. And I do. I liked teaching medical students, I liked teaching residents. I do miss the teaching aspect of it, but not enough that I was willing to stay in academia. So there's lots of things to be factored in.

Just talking about when we're talking about money and billing, I see this all the time on various groups that I'm on about. People talking about pediatricians not making much money at all, even in the pediatric subspecialties. Is that true? And if so, like, why is that true?

I mean, I think pediatricians don't make a whole lot of money as compared to some other specialties. Now I'm probably in critical care. I mean, I make more than a general pediatrician does, I imagine. But I mean, partly it's. Partly it's volume. Partly it's again, like, let's say you're a pediatric endocrinologist or a pediatric whatever. It sort of depends on how much of your population is Medicaid and can even pay you or what the reimbursement you get from Medicaid is. I mean, it kind of doesn't matter. I can say, you know, I mean, this is not what we charge, but let's just say, you know, on my billing sheet, what I charge for one day of critical care is $2,000 or something like that. I can put $2,000, I can put $8 million. But that doesn't affect the, you know, $12.5 or whatever it is that you get paid. Yeah, we get paid. Right. But that's true. I mean, it's partly about volume, partly about reimbursement, partly about payer mix. But yeah, nobody goes into any kind of pediatrics because they think they're going to make a lot of money in our practice. Like, I belong. There's a Facebook group called Women Physicians of Critical Care Medicine. And you. It's interesting to read sort of like different billing models and different payment models and that sort of thing. In our group, we're salaried if you are. If you're a full partner and you are full time, everybody makes exactly the same amount of money, which is fair because we all work exactly the same amount of shifts. And you know, we decided early on we're not doing it based on RVUs or number of patient scene or anything like that, because that's the luck of the draw. You can be there Monday, Tuesday, Wednesday, and the units pop and there's 20 kids. And then you have sort of this big exodus of kids that are ready to leave the unit. And maybe the end of the work person, the end of the week person has eight or nine kids. Well, you know, you don't have your salary docked because through no control of your own, there's only nine kids in the unit instead of 20 kids in the unit. Yeah, and likewise, you know, we, the nurses and everybody are all employed by the hospital. They are not our employees. The only ones that are our employees are our two nurse practitioners. So even though I have 20 beds that I can potentially fill, if my hospital has only staffed the unit to cover 12 patients or 13 patients, that's all the patients I can have. And that happens all the time. You. We're very limited, as is every unit in the hospital. Honestly, you're very limited by our. Is the unit fully staffed or not fully staffed. And you can complain about that till the cows come home, which we do, but you still have no, no control over it. You know, if I only have enough nurses to say to safely take care of 12 patients, then when I get outside transfer request calls, I'm having to turn away patients. Yeah. Really frustrating.

Yeah. Yeah, but that makes sense. You don't have, you don't, It'd be really impossible to do an RVU type system when you don't have any control over that.

Right, right. Yeah, we decided long ago that that just wasn't. You have a salary and it is what it is. And you know, if you have an easy week, good for you as some other week, you're not going to have an easy week. Right.

Yeah, I think that's all important things to consider too. Just when you're talking about, like looking at what's my life going to look like, what job am I going to have, how am I going to get paid? All these things are important to think about. So I really like this conversation. We won't take up too much more of your time, but I did want to ask, I ask all of our guests this as we're kind of like winding down a little bit, coming to a close. I like to ask, what advice would you give to somebody like me actually finishing up their first year of medical school in about two days, but still at the beginning of this kind of like long journey towards being a doctor?

Well, first I'd say congratulations. The first year. So hard. Thank you. And I mean, I would say as, as try to have as little preconceptions as possible about what you visualize yourself doing, like really go into everything with the, well, maybe this is something I would like kind of mindset. I mean, there were certain things for me that I knew, like I knew I couldn't be a psychiatrist. I, I, I don't know if you ever saw the movie Moonstruck with Cher and Nicholas Cage and he's whining about his terrible childhood or something, and at some, at one point she smacks him across the face and she goes, snap out of it. You know, I always felt like that would be kind of my level of skill as a psychiatrist. Ruled that out right away.

Glad you didn't do that.

Right.

Good to be self aware.

Good to be self aware. But I mean, otherwise, you know, go into things with the, you know, maybe I would like this kind of mindset and I think it becomes fairly clear to you actually the funnel sort of process. I Like adults versus I like kids. I like care that provides continuity and I can see people over many years versus I like more acute care. I mean, I often joke, although it's partly true, that one of the reasons I work is so that there's actually one setting in my life where someone has to do what I tell them because it certainly was never at home. And you know, and, and in the critical care setting, you know, you either sort of really like the. I make a decision and see right away whether I made the right decision or not because the person gets better or doesn't get better and. But there are other people who, you know, that kind of decision making pressure is much too anxiety provoking and they don't like it and they like the specialties where it's more of a slow, thoughtful. I'm going to do some research. I'm going to really think about this kind of process. I mean, I often joke that my favorite journal is n of 1. Like if I read that somebody tried something once that worked and I'm between a rock and a hard place, I'm all about trying that. And you know, and I've had some fabulous success over the years doing weird things that I came across in that way. But yeah, I would say have an open mind and really the sort of winnowing process I think will come pretty naturally. Well, awesome.

Thank you so much. And thank you so much for being here and chatting with us.

Yeah.

Mom, do you have anything else?

No, I don't think so. I guess. Do you have anything to plug, Sharon? Probably not. Your social media, you know, your Instagram, your Tick tock?

I have none of the above. Probably the biggest mistake I ever made was I have this concoction called Dr. Sandel's Butt Cream, which is, is now in use in many hospitals in many states and really never patented it. So I never got anything out of it. But that's funny. Every once in a while, like some young nurse, she'll be like, she'll have some at the bedside and, and then we'll be rounding and she'll be like, are you Dr. Sandel's butt cream? Dr. Sandow? Like, okay, that's my claim to fame. That's kind of sad. But yeah, what is it? You know, it's like it's just a concoction. It's not that hard. I actually got the. One of the reasons I didn't patent it was because it wasn't my original idea. I got the idea from a woman named Mary Fallot who was a pediatric surgeon in Louisville when I was a resident, and I forgot what her original concoction was. I think I added one thing to it, but it's just. It's like neosporin, nystatin, hydrocortisone, zinc oxide, and cholestyramine. It doesn't matter what's wrong with your butt. It will cure it. In fact, the hospital got annoyed at one point because the adult ICUs were using a lot of it, and they were having to make it in these big tubs for big adult butts. And somebody told me once that you could get it at Doherty's compounding pharmacy. I thought. So I was in Doherty's one day for something, and I said to the pharmacist, do you have Dr. Sandel's butt cream? And he looks in the computer and he goes, yeah, yeah, we do. And I said, well, that's interesting, because I am Dr. Sandel, and I know I never gave you the recipe. You must have gotten it, you know, from the hospital pharmacy or something. But, yeah, no, unfortunately, I'm like, not social media. I. I think we had business cards at one point years ago, and I gave one to my mom, and that was about all that happened with those.

Don't want to say, hey, here.

Come see me in the icu.

Well, you guys know where to find us @Generations MD on Instagram and Tick Tock. And if you have any questions, you can email us ataskgenerations mdmail.com and we will talk to you next week. Bye, guys.

Bye, guys. Bye.