So you want to be a CT surgeon_ - 5_28_24, 2.41 PM

Welcome back to Behind the Knife. My name is Jessica Millar, PGY5 general surgery resident at the University of Michigan and one of the Behind the Knife surgery education fellows. I'm very excited for today's episode where we'll be discussing the various training pathways to becoming a cardiothoracic surgeon as part of our ongoing cardiac surgery series.

Now there have been a lot of changes to the training paradigm over the past decade, and I know many students, myself included when I was a med student, have struggled when it comes to deciding what pathway is best for them. That's why we've assembled a robust team of attendings, fellows, and residents to discuss their journey, as well as some of the research that's been conducted about these different pathways.

I'll go ahead and let them introduce themselves. Hi everybody, I'm Lindsay Wessels. I'm a traditional first year fellow at the University of Virginia. I am active duty Navy and after finishing my medical school at the Uniformed Services University went on to complete my general surgery residency at Naval Medical Center San Diego, which brought me to University of Virginia now.

And hi, everyone. I'm Joel Ian Dahl. I'm the integrative

cardiothoracic surgery senior fellow at University of Virginia. So that means I'm in my eighth year since we do two years of research between our second and third. And I trained at Emory and there's where I decided that I wanted to go into heart surgery.

And I'm Nick Teeman. I'm a cardiac surgeon at the University of Virginia. I'm also one of the associate program directors of the traditional and integrated retinity programs. And my training background is that I did a seven year general surgery program at the University of Michigan. Followed by two years of cardiothoracic training at UVA.

All right, now, before we begin with our questions, I just want to start by providing a little bit of background regarding the different pathways that are currently recognized for certification by the American Board of Thoracic Surgery. So there are technically three ways in which you could become a cardiothoracic surgeon.

The first is by successfully completing five full years of general surgery training approved by the ACGME, and then completing an ACGME approved thoracic surgery residency program. Alternatively, you could

complete a six year integrated thoracic surgery residency program. This integrated pathway has been around since about 2007, and it graduated its first residents in 2013.

And last, and probably not the most common way, is you could actually do a ACGME approved five year vascular surgery integrated residency program. followed then by completion of an approved thoracic surgery fellowship. So now that we're all kind of familiar with the different training pathways, I want to start with Lindsey and Julian.

And Lindsey, if you want to go first, can you talk a little bit about why you chose the more traditional training path? Yeah, absolutely. I actually didn't know that I wanted to be a cardiothoracic surgeon. Surgeon until my third year of general surgery training. But even if I had, the Navy would have still required me to do a general surgery residency beforehand, which I think I would have chosen anyway.

I wanted to kind of have the widest breadth of training and have all my options open going into this. Even though it would have been chosen for

me, I think I would have done it anyway. But that's why I did what I did. For me. I was fortunate enough to get good exposure to cardiac surgery in medical school to be able to know that I was interested in doing it.

I think that certainly is a prerequisite for deciding to go into a field from medical school that's so highly specialized. And so when applying, I wasn't only interested in integrated pathways because I was fairly pragmatic. I thought that both pathways are legitimate and worthwhile ways of being able to end up as a heart surgeon.

And so I applied to both integrated residencies as well as general surgery residencies with a mind to, you know, general surgery residencies that would be able to prepare me well for the traditional track. Given that you both have gotten to cardiac surgery different ways, can you talk about some of maybe the challenges or even some of the advantages you encountered because of your training path?

Yeah, absolutely. So general surgery training can be frustrating. It is long and it is hard. And when you decide that that's not going to be the ultimate thing that you're doing, it can be challenging in and of itself just to get through that. That being said, I think it was well worth it, and it created a more well rounded surgeon in myself for having completed that path.

But as I mentioned before, I decided my PGY3 year, which was after two years of research. So it was five years into training that I made this decision to do cardiothoracic surgery. I, and I had actually just had my first baby. I had two babies during residency and I was a little bit burnt out and I just kind of wanted to get to the end of the road.

But I had several more years to do before I could, you know, finally get to CT. And that was a major challenge for me. I've always told people who have asked me though, Oh my gosh, it's such a long road. Why? You know, you're still in training. Aren't you a doctor yet? That's what my family asked me in Michigan.

And I tell them,

yes, I am, but I'm still in training. What I tell people is that the time's going to pass no matter what. So do what you think is the best decision for you. So at the end of the road, 10 years, from now or 15 years from now, you're not upset or you're not, you don't feel like you've missed out on anything, but I will say it was a challenge just trying to stay focused in general surgery, trying to learn how to do hernias correctly and bowel surgery correctly, knowing that, well, at the end of the day, what I really want to be operating on is a heart.

The other challenge was. Showing up here, not having the background that the I 6 residents have and I think a lot of that comes into play with like cardiac imaging, basic things, looking at echocardiograms and interpreting them knowing your cardiac physiology down pat so you can manage sick patients in the ICU, it's extremely difficult when you haven't even thought about those things really ever, except for, you know, the three months that I did cardiothoracic surgery as a general surgery resident.

And no matter what anyone tells you,

thoracic surgery is not general surgery of the chest. It is hard and it is different. And it's a new skill to learn for sure. And so it's all brand new. And after having completed a whole seven years of a different It was hard coming into this and trying, you know, feeling like a newbie all, all over again.

So, I guess, speaking to the advantages already, Lindsay alluded to the main one, which is as an I6 resident, I got. Very early exposure and experience in cardiothoracic surgery. Smattered around my first four years and increasing in frequency and duration. I'm getting to scrub cardiac cases, getting to do components in cardiac cases, scrubbing and getting larger and larger components of thoracic cases.

And so that's a big advantage of an integrated residency. And apart from that, because I'm able to focus and have the freedom to focus on that. You know, didactic learning and clinical skills

learning certainly ahead of my co fellows when I started out. But I think that being at a place like UVA, where we have all, three major training paradigms and that we have integrated residents, we have four, three residents in most years, and then we have the traditional track residents get to see.

How we all come into a program with different backgrounds, different strengths and weaknesses, and how we all compliment one another. And so, you know, it all evens out in the end. And that kind of helps me see what some of the challenges were for me as an I 6 resident, because the big difference between, you know, say me as an I 6 resident and.

My co fellow, Zach, who's 4'3 and did his general surgery training here, is he did a chief year where he was the chief resident of a service every month, 12 months, and responsible for running that service,

doing all the big cases, making sure that everything went smoothly for those patients. And as an I6 resident, I certainly did months in my fourth year as a chief on various services.

But I certainly didn't spend my entire 12 months as a chief of every service. And so I was certainly behind, you know, Zach and Kim, my, my co fellows when it came to being able to run a service and all of those important skills that are vital. But again, those advantages helped me be ahead in some ways, and those disadvantages and those challenges, you know, helped me be able to realize what things I needed to focus on, and what ways I could help my co fellows come up in their training.

Yeah, I couldn't agree with Julian more and saying that it all evens out watching his class progress this year and seeing where everyone is kind of landing as they've almost finished. I do think it all evens out nicely, which is reassuring because I think each pathway is going to be

ultimately bring you where you want to be.

I was extremely nervous coming into training here with I6 residents because I thought I'm going to seem so far behind them, but it was a huge advantage to me because they were able to. Help me out so much. You know, if I had questions if I didn't understand something, I just go to my co fellows, especially the I6 residents who, who have been doing this stuff for years.

And then, when they have questions about, because cardiac patients don't just have cardiac problems, right? They have abdominal catastrophes. They have all sorts of things that happen. So, there are oftentimes where we're having conversations back and forth. For things that are very general surgery relevant, and we're able to help each other out in those ways, and I think that's the huge advantage of having an integrated not just an i6 integrated, but an integrated training program all together with the four, three, the, you know, traditional, traditional, and then the i6.

program. I especially like Lindsay,

the point that you brought up about how it kind of all evens out in the end, which actually is a perfect lead in then to my next question, which is for Dr. Tiemann. As an attending, do you notice any differences, good or bad, when you are working with the different trainees on these various different training pathways in the operating room?

So I think it's very clear that we've done a good job of training Julian and Lindsay because what they've just said is exactly what I tell prospective students when they're, you know, when I'm asked this, you know, I get asked this all the time. And that's exactly right. So, so at UVA, like they said, everyone funnels into the final two years being the same.

So whether you come in just for two years or whether you've been there for eight years, your final two years of training are going to be the same. And as a gross generalization, again, this is just, you know, A, this is just my opinion, and B this is not, you know, applicable to individual residents, but as a gross generalization, at the start of those two years, the I6 residents are better at sewing small circles together, they're better at reading echocardiograms,

they're better at interpreting cardiac casts, they're certainly much better at that than I was when I started my cardiac surgery training and that's because they've been immersed in that, and they've been going to the didactics and everything else for years.

And again, as a general rule, the traditional track, the folks that have done a general surgery training program do come in with those additional leadership skills that Jolene described. You know, they're used to kind of managing people and managing a team and delegating and kind of cover, you know, making sure a busy service gets taken care of and everything else, kind of controlling the room and owning the service.

And it's so fun to watch because the, those skills do meld together and it really is. exactly what Lindsay said, which is by the end, it all evens out, but it's such a different path to get there. And so I think the bottom line is if you want to be a cardiothoracic surgeon, you know, it doesn't matter whether you do the I 6 program or 4 3 program or traditional program, it matters that you go to good places that are going to train you well to be able to do those things.

And if you go to good places, you're going to end up being successful. And the path that you take to get there,

It doesn't matter. You could, I mean, I know plenty of people that are very successful, very excellent surgeons who started out in another field, you know, and decided they wanted to do surgery and they did it, you know, prelim years.

There's no wrong answer to getting to that point as long as you're picking good places that are going to train you well. My last question before we get into kind of the nuts and bolts of like applying, it is called Cardiothoracic Surgery Fellowship or an Integrated Cardiothoracic Surgery Residency, but how much thoracic is there actually in these different training programs?

Thank you I will say, you know, as again, as one of the associate projectors and kind of counseling a lot of folks this is not universal, but my general recommendation to people that are really interested in general thoracic surgery is that you probably get a better experience going through the general surgery.

Training program to get to that point. You know, learning laparoscopy, learning, endoscopy, all of those other kind of skills that are, you're gonna do more of that in your general surgery training and more. Most of the I six programs are kind of geared more towards cardiac leaning

people. So you're gonna spend time in the cath lab, spend time with the cardiologist, that sort of thing, which may not be exactly what you want to do.

Now, obviously there's a lot of overlap and there's exceptions to all these things, but as a general rule. The kind of the, I personally think that the best way to get a really great general thoracic surgery training is to a general surgery training program and then do a quote unquote thoracic surgery residency program, but with a thoracic track, you know, so a lot of programs have different tracks and like, for example our program, our thoracic track resident spends two thirds or three quarters of their final year just doing general thoracic surgery and not as much on the cardiac side.

I agree with that too. I mean, when I was coming through med school, you know, granted I was interested in cardiac surgery, but the mentors that I had, the discussion about thoracic track interested folks was general surgery training probably is better to do prior to going into traditional track, you know, thoracic track fellowship.

I want to

move a little bit into applying for these different pathways. Most people are probably well aware that integrated residencies are more competitive, so I want to ask a little bit about some of the additional requirements that, you know, make applicants competitive or less competitive, starting with research.

Compared to traditional applicants, CTI 6 residents tend to have greater publications, so do you find that having additional research experience or even taking a dedicated research year? is something that would be required to be successful or be competitive in an I6 match? Compared to all the applicants that I've interviewed and looked at their CVs over the years for I6, like my CV now is barely as good as most of theirs.

So it's pretty impressive what med students are doing these days. Teaming will have a much better idea of, you know, looking at all those applicant pools. And being able to really make those tough decisions comparing them, but I would say that,

you know, because it is so competitive that having research on your CV can help you stand out.

Granted, I really don't think that's the, an all be all. I agree with that. So, you know, the, it is truly amazing to me every single year. How competitive the applicant pool is for the i6 training programs, you know, I look at every single application that comes to our program and it just blows my mind blows me out of the water every single year.

It just gets more and more impressive what the students are doing these days. And that's coupled with the fact that there's less and less objective data. In these applications, right? So step one is now pass fail. Many medical schools don't rank their students anymore. Many medical schools have gone to pass fail for all of their clerkships.

Many medical schools don't participate in any way anymore. So as a, as somebody who's evaluating the applications, it's harder and harder to get objective data to compare people. And so the things that we have to use to compare students are personal statement

letters, recommendation. And then evidence of scholarly activity or other things, you know, extracurricular activities and things like that.

And so I, again, this is just my opinion. I don't speak for the UVA residency program or anything else, but my personal opinion is that I expect to see some evidence of an interest in research. That doesn't mean you have to take a year off. It doesn't mean you have to do a PhD. It doesn't mean any of those things.

But if I look at the box where it says research activity and there's nothing there, then That is, that's a red flag to me. And so it obviously the more you can do, the better, the more publications, the better, the more cardiac surgery research that you can do the better. But let's say you decide late that you want to do cardiac surgery and all your research is in, you know, dermatology something like that.

I don't hold that against a student. You know, again, what I'm looking for is some. interest in the academic process and some evidence of the ability to do extra things on top of medical school, which is obviously already very difficult. I feel the same way whenever I look at general surgery residency

applicants.

I'm like, I would never get into my program nowadays. There's absolutely no chance. Speaking though to how competitive especially integrated programs are, I feel like students always seem to ask me, should I dual apply? And they'll often come saying that they've gotten some mixed opinions about it. So what are y'all's opinions as far as should students do apply?

Will it really hurt them if they do apply to both general surgery and i6 programs? Will it help them? What are your thoughts? I think that it's an extremely smart move to make and that you should optimize your chances of getting into a residency program because both pathways will lead you to where you want to go.

And I think it's silly not to actually, I don't know, that may be a controversial opinion, but because it is so competitive to get into an I 6, why would you put, you know, all your eggs in one basket? Yeah, I agree. I don't think that's a controversial opinion. I think if you're applying to i6 programs, you have to apply to general trigger programs.

Also, I don't think in my mind, it's not an option. It's a mandatory thing.

But here's what I'll say. I'll say that there it is not risk free to do will apply. Meaning like if you are and I don't mean this personally, but if you're a marginal applicant for residency program and you're interested in cardiac surgery and you say, well, I'm, you know, probably gonna end up in general surgery, but let me just try for I six programs.

Also, I strongly encourage you not to do that. I think that there are some programs in the general surgery world. that will rank you lower or not interview you if they know or sense that you are dual applying because, you know, for whatever reason, whether that's justified or not, I don't think it's justified.

I don't think that makes any sense. But I can tell you that I know for a fact that that's the case. And so the issue is that if you, you take somebody who, you know, has the potential to match into a general surgery residency, and now they are hurting themselves at some programs by dual applying and end up matching.

Nowhere. And every, almost every single year, since I've been counseling students, I can recall a

student that I'm shocked that didn't match into either program. And the only thing I can attribute that to is the dual application. So if you are a strong applicant, then I, and you're dead set on cardiac surgery, then by all means apply for the I 6 programs.

You have to also apply for general surgery. You can't just apply to the I 6 programs. I don't, I just don't think that's an option, but if you're not, you know, a very strong candidate. And that's where having good mentorship and good advising at your institution is absolutely critical if you're not the strongest of candidates for an I six program, then I really, like Lindsay said, there's multiple ways to get there.

I would just apply to general surgery and then make your personal statement all about how you have an interest in cardiac, but you're not, you know, all you want to do is be a good, well rounded general surgeon, the general surgery programs will love you and you'll match somewhere and then you can be a cardiac surgeon down the road.

Lindsay and I were kind of talking a little bit about this before we started recording. One of the reasons why I chose general surgery was I was young. I hadn't experienced all the different types of surgery that

there are out there, like vascular and trauma and surgical oncology. And I remember having panic attacks thinking like, Oh, I always thought I was supposed to be a cardiac surgeon, but what if I'm really supposed to be like a trauma surgeon?

And so, Me personally, I chose general surgery because it sort of left all the cards on the table, just in case I changed my mind later on. But what are your options if you do an I 6 residency and you decide, actually, maybe this isn't really what I wanted to do? Everything's an option. You know, if you decide that your life choice is not what's right for you, then there is no shame in trying to go and get matched into a different residency, right?

The people that are responsible for training you, right? Recognize that you're human. That can make mistakes or, you know, make decisions that they no longer agree with and will advocate for you to find whatever you need. Yeah, I mean, I don't think that's a fear that's unique to an I 6 resident, right?

There are plenty of general surgery residents out there that are finding out in their second and third years that they're just, It's not for them for whatever reason. And I think that that really speaks volumes to the strength of your program, how your program handles that situation in that it's addressed early.

Everyone feels free to talk about it. It feels comfortable to talk about it. No one is reprimanded for it. I mean, these are your life choices, right? This is what you're going to live with for the rest of your life. So you have to be happy with it. And the biggest shame I think that can happen is allowing someone who has identified in one way or another, that they're not going to make it through the program to make it to their final years.

And then that's when you decide or they decide or the program decides that this isn't just going to work out because you could have clearly addressed that two to three years prior. And I think it's a hard thing for the individual to do because you feel like a failure, but it definitely, like I said it's

a challenge.

It's your life's decision. And if you decide it's not for you, it's not for you. And you just got to step up and say that. And hopefully you have strong, a strong program director and assistant program directors to kind of redirect you into another pathway. You know, that raises a good point, though, you know, about the interview process.

One of the things that I always try to get for when I'm interviewing students, particularly for the i6 program, because it's kind of a leap of faith, is getting a sense of whether they have any idea what they're getting themselves into. You know, and there's times where I'm talking to applicants, and it's kind of very clear that they kind of have no idea what this entails and just haven't been, you know, kind of involved and engaged with the cardiac surgeons at their medical school or anything like that.

And that's, that's really important. I think the more you can kind of express through your personal statement or through the interview process, a kind of level of maturity that you kind of understand what you're signing up for and that you have some insight into that process really goes a long way for making us feel more confident that, that you're going to be able to get through the program and that you really want to do this, that you really know that this is what you want to do.

One of my last questions that's kind of more tailored towards I 6 training pathways. There have been a couple of studies that have shown that I 6 residents tend to publish more research during their residency than, say, their general surgery counterparts. So, do you find that there's a greater emphasis on research, specifically in I 6 programs?

And kind of a follow up you know, if you're not interested in research, then should you maybe not do an I 6 training program? You know, I can only speak to my training here at UVA, and we do two years of dedicated research time, which gives us lots of time to be able to explore that side of academics.

So, it really depends on the program. I don't know how many i6 programs don't have dedicated research time, but I do imagine that any i6 program may, encourage academic pursuit, you know, outside of the program. clinical duties more so than, let's say, a general

surgery program that doesn't have dedicated research time either.

But, I can't speak to all the training paradigms and programs. I think that data is a little tricky because all, if not all, of I 6 programs are associated with a major academic center. And there are plenty of general surgery residencies that are community based. And that don't involve research here.

So you can't really compare the two groups on their own, right? You'd have to match them to academic centers because a lot of it boils down to opportunity. But that being said, I think that those research years, whether you do it in a general surgery residency or in an I 6 residency. are key if they're available to you, not only because it allows you to kind of take a break mid training, a break, I say in quotations, because it is extremely busy.

And you'll often hear research residents say, how do I feel busier now than when I was an actual clinical resident? But in some strange way you do. But I think they're key because you get to take a little bit of a breath. and have more

normal work hours, be able to do some life things while also contributing to your specialty.

And like Dr. Tiemann was saying, it looks really suspicious whether you're going on to apply to just an I 6 residency from medical school or you're going on to apply to another fellowship after general surgery residency if you don't have any scholarly activity whatsoever. Yeah, I completely agree with both of y'all said.

I think that the decision, you know, to focus on research should be made independent of the training pathway. There are plenty of I six programs that have built in research and there's plenty that don't. Similarly, there are plenty of general surgery programs that have that opportunity as well.

So if that's something that's important to you, then you can make that work in either pathway. And if it's something that's not important to you, that you're not particularly interested in doing dedicated research time, then you'll have excellent clinical training programs in both pathways. Also We've talked a lot about i6 training pathway and how competitive that can be.

I want to talk a little bit about how competitive it is to obtain a cardiothoracic surgery fellowship. People have probably talked about

how competitive CT surgery has become. Lindsay, I know you've done Most recently went through this process and Nick, you actually had a great way of sort of breaking it down for me to sort of calm.

So some of my fears I had about applying this upcoming year. So I'd love to hear from both of you your perspective on how competitive it is to obtain a fellowship in CT surgery after general surgery training. Yeah, it was kind of doubly hard for me because a year before I was going to apply to the ERAS program, I had to ask the Navy and the Navy only lets one person go through every couple of years.

So I had to do a whole separate application process for that, but I won't go into detail except for, you know, the few probably active duty military people that are listening and know what I'm talking about. But so I did that and they said yes. And then the following year I was able to apply and it was competitive and daunting, but I think at the end of the day, it was a 46 percent match rate my year, which was more competitive than plastics and pediatric surgery, the most competitive

fellowship that year.

I don't know what the stats that was in 2022. So I don't know what they've been the past two years, but I imagine similar. Yeah, you know, it really has gotten more competitive over the last several years, you know, back when I was a medical student, I remember hearing stories about many, many programs going unfilled and a shortage of cardiac surgeons and everything else.

And the pendulum really seems like it's kind of swung back the other way and it's definitely becoming more competitive. I will say kind of as a general rule, again, kind of a gross generalization, just my opinion, I do think that the general thoracic pool is a bit more competitive. Yeah. You know, there's just many really qualified general surgery residents coming out that are interested in thoracic surgical oncology and lung transplant and things like that.

And so I think that pool is maybe maybe a little bit more competitive than the cardiac leaning group from general surgery. That being said, I mean, that shouldn't discourage you. Again, if you're getting a good general surgery training you know, I encourage you to do some research, to reach out, establish relationships with the cardiac surgeons at your residency program,

spend some time in the cardiac ORs you know, I really do believe that people that are really, that this is what they for sure want to do and are, at good training programs that can set them on the launch pad to, to moving forward I think that people are, you know, are still going to be able to match, but there are, I mean, there are good applicants every year that, that don't match.

I mean, it is, it certainly has gotten more competitive. Kind of as an extension of that, there are also opportunities to do what we call super fellowships, where you can get extra training in aortic congenitals, probably one of the most common ones. But how common is it for traditional pathway like fellows to do these types of super fellowships, and how common is it for I6 residents to do these types of super fellowships?

For traditional, I mean, it seems pretty common. I don't have any numbers to quote, but the Navy is already asking me, what are you doing for your third year? And I said, I want to be an attendee. Can I finish trading, please?

But we'll see, you know, what's in store for me, but it seems pretty common. It seems that it's a lot to learn in two years, but I think at least half, if not more, And I'm just kind of guessing there. Pursue a super fellowship. Yeah, I mean, my take on this is that I think that's the importance of choosing a really good quality training program for your cardiothoracic surgery training.

I mean, I think that certainly there are people that want to become internationally known for certain things and go be like the aortic person at a major academic center. And I think that you certainly a super fellowship will help you in that regards. But for most people your two or three year thoracic surgery training programs should prepare you to go out and do.

anything in the world of cardiothoracic surgery. So, I mean, that's kind of my bias and that, you know, I came into residency convinced that I was going to be doing a heart failure transplant fellowship and quickly realized that I was getting a good enough training that I didn't need that. But there are certainly the purists and other folks out there that feel strongly that that's a necessary part.

But again, you know, the

majority of cardiac surgeons are going to be practicing in the community. The majority of cardiac surgeons are not going to do super fellowships and they're going to be very well trained from the their two or three year training program. Yeah, my take on it is similar to Tiemann's, which is I'm very happy with my training and I'm going right into practice.

Well, in our last few minutes here, my last question is, would you do the training pathway that you did again? I would absolutely do it again. Especially being in the military I can deploy as a general surgeon, there will be general surgery issues that I'll be expected to be able to handle. And so because I wanted to be a military surgeon, it's the only pathway that, that I saw for myself and I'm very happy with it and would do it over again and again.

I would definitely do I six again, but I see myself being just as proficient and just as happy if I went through a traditional track as well. So it's kind of a non answer, but regardless I think that

you can't go wrong, right? If this is your decided path. For me, I mean, it's kind of cheating and not to date myself but when I was applying for a residency programs there, it was the literally the first year that any program was taking anyone into the I 6 program.

And so not only was I not sure that that was the path for me. But also there's no way I would have been competitive for those three spots that were there in the country at that time. So I would 100 percent do what I did but I also really, I got an excellent general surgery training. I did a surgical critical care fellowship during that training.

And now I, you know, practice as a cardiac surgical intensivist in addition to being a cardiac surgeon. So for me and the pathway that I wanted to go down, I think it was the right choice. I'm very happy with how, how I did things to get to where I am. Those are all of my questions. Thank you guys so much for your time.

If there's anything else you guys want to share to any students who may be listening who are kind of deciding which pathway to pick. So I'll give the listeners the advice that I give to every student that talks to me about career advice and development, which

is I firmly believe that, and maybe this is just me being naive, but I really firmly believe that the hardest part of this whole process is deciding exactly what you want to do.

And I think , when you decide what you want to do, We can create a pathway for you to get there and it may not be the most direct pathway. It may be, there may be some bumps in the road. There may be some additional applications and things like that. But you know, that getting to there is not as hard as deciding, you know, so figuring out if, is this what you want to do with your life?

And if it is, then we can work with you to, to get you there. And that's been my philosophy ever since I was a medical student. Well, thank you guys so much for your time. I really, really, really appreciate all the time you guys spent answering all of these questions. It was our pleasure.