The Neurophilia Podcast
Neurophobia is "the fear of neural sciences and clinical neurology" that is often experienced by medical students and young healthcare professionals. The Neurophilia Podcast is our attempt to help dispel the growing issue of neurophobia in the medical community. We engage in meaningful, interdisciplinary conversations with leading physicians to better connect neurology with other fields of medicine. Our hope is that with each episode, our listeners learn to appreciate, and perhaps even develop a love, for clinical neurology. Hosted by Dr. Nupur Goel, Neurology Resident at Mass General Brigham, and Dr. Blake Buletko, Program Director of Cleveland Clinic's Adult Neurology Program.
The Neurophilia Podcast
Fellowship and Early Attending Career: Part Two
The leap from neurology residency to attending brings a critical decision - fellowship training or direct practice? In this compelling episode, Harvard neurologists Dr. Galina Gheihman and Dr. Denis Balaban share their contrasting post-residency paths, offering a roadmap for trainees wrestling with their next career steps.
This conversation offers honest, practical guidance for navigating the post-residency landscape. Whether you're considering fellowship, direct practice, academic medicine, or industry roles, you'll gain valuable perspective on aligning your next steps with your true professional passions.
• Transitioning from resident to attending involves complex role adjustments, especially when supervising former colleagues
• Establishing clinical independence requires navigating new responsibilities in outpatient care and deciding when to manage vs. when to refer
• Early career physicians lose the built-in cohort of training years precisely when facing critical career decisions
• Building support networks through regular check-ins with division chairs and connecting with fellow educators becomes essential
• Medical education lacks structured preparation for the business aspects of medicine including salary negotiation and career advancement
• Embracing uncertainty and having honest conversations with patients about complex cases is integral to neurology practice
• The most fulfilling aspects of attending life include the teaching-clinical intersection and helping patients navigate fear and uncertainty
Hosts:
Dr. Nupur Goel is a second-year neurology resident at Mass General Brigham in Boston, MA. Follow Dr. Nupur Goel on Twitter @mdgoels
Dr. Blake Buletko is a vascular neurologist and program director of the Adult Neurology Residency Program at the Cleveland Clinic in Cleveland, OH. Follow Dr. Blake Buletko on Twitter @blakebuletko
Follow the Neurophilia Podcast on Twitter and Instagram @NeurophiliaPod
Welcome back to the Neurophilia podcast, a conversational med ed podcast focused on dispelling neurophobia, one conversation at a time. We are your hosts PGY2 Neurology resident, dr Newberg-Oyle, and Program Director Dr Blake Bilecko. Today we have the absolute honor of sitting down and chatting with Drs Galina Gehman and Dennis Balaban. Stay tuned to hear our conversation regarding fellowship, training and the transition to attending life. Transition to attending life. Dr Galena Gehman is an assistant professor of neurology at Harvard Medical School and an attending physician in general neurology at Mass General Brigham in Boston, massachusetts. She attended the University of Toronto for her undergraduate studies. She earned her medical degree at Harvard Medical School and then she went on to complete her neurology residency at Mass General Brigham, where she served as chief resident. Dr Dennis Balaban is an instructor in the Division of Neuroimmunology and Neuroinfectious Disease at the Massachusetts General Hospital. He serves as a core clerkship faculty member in neurology at Harvard Medical School. In addition to his educational roles in the MGH neurology residency and advanced general autoimmune neurology fellowship. His research projects focus on neurosarcoidosis, vasculitis and optic neuritis.
Speaker 3:I'll be the first one to allow us to switch gears a little bit, and we had another topic of conversation that I think is really interesting and I remember this transition very well myself, Especially for you, Galena. You are just transitioning from residency into being an attending and my question is how has that transition been, especially with regards to working with residents that maybe you work with as colleagues and now are transitioning into being an attending with some friends, familiar faces? So, especially for people who stay within a familiar environment and are working within that environment as a junior faculty which I hate the word junior faculty, junior staff but as someone who is transitioning, what has that transition been like? What are the interactions? Have they changed for you? Have the interactions changed with people that trained you that you're still working with? How do you navigate this process and kind of put your own footing in where you're at in your career and feeling again confident and competent with where you're at, with that transition happening?
Speaker 4:Yeah, thanks for the question. It's something, of course, I've been reflecting a lot about recently. This month, april, is my one year anniversary, my one year of baby faculty anniversary. So I've had one year under my belt and you know what's interesting is I was nervous initially about supervising residents that I knew, now that I've done it, I'm very nervous about supervising residents. I don't know. I actually realized the hard thing is going to be when there's going to be an entire class of residents who I haven't had the chance to really build those like kind of entrustment relationships with. I do think it's a give and take.
Speaker 4:One of the things I've been reflecting a lot about is actually something that I want to commend our program with, and I think that we actually do a good job of graded responsibility over time. And so, coming into my roles in attending, I was fairly comfortable leading a team in the sense that I felt when I was a senior resident that the team was mine and that's something that is a culture at our institution where the attendings that I think are the most effective, or the ones who kind of had me kind of struggle a little bit like but never at a distance, you know, but kind of, let me make a decision as little bit like but never at a distance, you know, but kind of, let me make a decision as senior, then would step in to add things. And so, as I stepped into my roles at attending, it was very funny because I reflected on the attendings I had had and how I wanted to be it as an attending and in a way I actually was more silent. You know, at times I wasn't always the one teaching, I was often observing in the back, and it was also a give and take with my senior residents about what role they wanted me to play. So I'm someone who really believes strongly in mentorship and feedback, and so I set goals with my senior residents and what they wanted. I stepped back, I observed them, gave feedback, something that I heard from them not every attending does, and so for me it was an opportunity to grow not just in my clinical independence but in my role as a teaching faculty.
Speaker 4:I definitely had some discomfort around becoming colleagues with clinicians who I will continue to use not first name basis with you know they have to keep reminding me. I've now finally started to understand what they said to me, which was always been like we're just colleagues, like it's just a few years between us, like you know. And now that I'm on that side, that's how I see the residents. The residents don't believe me, but I find myself saying the same thing that my attending said to me, which is like we're just colleagues a few years apart. And I think it's because, when you get to this stage of your career, you realize that, like, residency, while so immersive and so transformational and so important, is actually a fairly small part of your career. And if you can take away these generalizable aspects of, like lifelong learning, that's never going to change, you know. And generalizable aspects of networking, that's never going to change. The open-mindedness of like reverse mentorship, in the sense that sometimes my I literally like, like it's been like six months and I went to back to the board, so they're like ordering tests like I've never heard of, it's really exciting. So, say you know, if you want to stay, ironically, like, competent and confident, you also have to stay open minded, humble, curious, and working with residents keeps you young, you know. In that sense, it keeps you engaged.
Speaker 4:Now, on the clinical front, I will add, was, I would say, a larger learning curve for me because I spent so much of my time being a senior resident, you know, leading inpatient teams. I was like, yeah, I know how to do this. But having my own outpatient clinic was a different transition. I had to learn to optimize some of the clinical. You know pathways like how do I finish my clinic on time, how do I get through my notes, how to stay up to date with my patient messages? Think about arranging outpatient follow up, reaching out to specialists, and what I would say is the biggest, let's say, growth edge for me right now is the question of like what do I care for as a generalist versus what do I refer and what's that relationship between me and my subspecialty colleagues? I still am leaning into the idea of learning and for myself. So it's shocking to me that there remain diagnoses that I even, like, say, read about or saw but never cared for myself.
Speaker 4:So I will say, you know, as an attending was the first time I myself diagnosed someone with Parkinson's disease and initiated Sinemet and titrated their Sinemet. Like I know I probably shouldn't admit that. You know it feels like strange, having gone through academic neurology, that challenge of like is it safe for the patient to stay with me as I learn, or is this getting to an edge where, no, no, the patient's best served, you know, seeing someone else, and what I've tried to do is really use the different timelines that outpatient medicine allows, which are often longer and often more stepwise, like, let's start with this test, let's start with that test, while also really leaning into these really uncomfortable, uncertain opportunities of doing something new to further my learning. I definitely reach out to colleagues. Sometimes it's an email, sometimes it's via the EMR, sometimes it's in the hallway and other times it's as a consulting referral that then returns to me with, say, a titration of a medicine or additional testing. I think it's a tough transition. It's one that has lots of new uncertainties and anxieties, also lots of new benefits, and I think if you can like kind of you know, change your attitude and see these challenges coming at you as growth opportunities, that's going to be a chance to keep growing, to keep growing.
Speaker 4:Done in a network of support makes it easier, and so I don't think you have to stay in one institution. The pros are you know. You know who's around the corner, you know who to call. They know that they answer when you call. The cons are sometimes you hear that people don't treat you as as, as senior as you are. Maybe you're you're kind of you know, seen as being on the long end of the back bench of people. But I would argue that if you know what you have to offer and you know who's interested and you ask where the department needs help, it's also a chance to raise your hand and get involved. And I've definitely appreciated staying here and love to see my juniors now graduating soon. It's exciting and I feel like I'm starting to get the get to know the new residents very well and already excited that in a blip of an eye they'll they'll be the seniors.
Speaker 3:So many nice girls in there and you know, I just I guess, as I'm getting older and transitioning to early mid career, I guess is my definition Now I'm like, well, really like, really like what's happened along the way and it makes you reflect a little bit and you know to your point, even having conversations with center directors and people that you have to talk to about what does your schedule look like and what do you want out of your career and what is your salary like, right?
Speaker 3:That's another motivating thing when you're attending is now you're making more money than you've ever seen to be able to care for patients and makes you innately take a little bit more ownership and double check yourself on everything that you're doing. But it's also all these things that go into making sure that you're setting yourself up for success. If you want to do a fellowship, a med ed fellowship, and you know how much time you're going to need having those sometimes difficult conversations when there's some pull from an institution or a center of what they really need and want and what's best for you and how to have those conversations with people that either trained you or were above you in some way, shape or form and now you're on the same level. I see that happening with a lot of people and just that transition.
Speaker 4:So yeah, I was just curious about all of that and I should talk out loud, as they say, as a good educator, and offer some advice. I was worried about that transition because I wanted to be successful and so some of the things that I did that I can offer advice on. So the thing is you have to kind of advocate for yourself. You have to look out for yourself. People are very well-meaning and as soon as you ask for help they'll give it. But at least in our institution I've sometimes found you have to ask for people to say yes, and so one thing I asked for was setting up a monthly meeting with my division chair, initially just to say I just want a sense like I only want a place where I can come and be like I'm confused by this or I need this, and sometimes I don't even have an agenda, but we just check in and little things that are kind of you know something, pebble in your shoe. I wouldn't have mentioned it, but like maybe now I'll mention it and I get that support or we address some administrative issue or I learn about some opportunities. So that's something I recommend people do is sort of creating like a peer support network with either your division or other young faculty.
Speaker 4:I think the other thing is looking for places like turning to the people that you know and getting their support, like one of my favorite places, like the reason I love precepting clinic is not only do I get to see the residents but I get to meet with my fellow educators.
Speaker 4:So you know, dennis and I will often precept together, and those in between is that interstitial time that really helps you connect and, you know, get address questions, and so I do recommend people find you know where can you meet your people so that you're not so alone. It's also been a chance to get to know some of my more senior colleagues in a more again flexible setting, because we're kind of like hey, wow, we're both preceptor. That's kind of weird. Like I kind of still see myself as your resident, but in that setting where the residents are talking to you and you're being seen by your colleagues as now among them, I think can be helpful as well. So kind of looking for places where you can kind of stand up, as you know, with your faculty shoulders spread out and then also looking for support, informally and formally, as you make this transition.
Speaker 2:You did such a great job of walking us through the transition and things that you've learned along the way. Now, looking back, as when you look at the way that residency education is structured you know there's not a lot of didactics that are centered around salary or negotiation or ways to sort of make it up the academic ladder per se, you know do you have reflections on how residency education can be improved to sort of help that transition from you know either resident to attending hood or fellow to attending hood be smoother for generations to come?
Speaker 4:I'm so glad you asked that question. I think the theme tonight has been making the implicit explicit. It's what we call the hidden curriculum, and there's so much that is left unsaid, and it's something that I've been learning a lot about, and I think one of the big motivating factors that I have, as an educator, broadly defined, is smoothing the path for those that follow behind me, because there's just so many hiccups along the way and obstacles and mistakes and learning points, learning challenges, right Learning opportunities. Two years ago, when I was the chief resident my year, we actually created something we called Well-Rounded Wednesdays. It was a curriculum that taught para-clinical skills, so skills like leadership, teamwork, career development, professional development, teaching skills as well, you know, generalized teaching skills that every resident should have. And so it was really this statement of putting our foot down and saying we're going to like walk the walk, you know, not just talk, to talk like, oh, our residents graduate as teachers. Oh, our residents graduate and have excellent career opportunities. Like no, no, let's. How do you actually do this in practice? And so I think that there's a lot that we could do in preparing our residents. I mean, yes, you guys are trainees and you're students, but you're also in your career. It's the first phase of your career and, thinking about our duty, looking back, I think we have a duty to raise the next generation.
Speaker 4:I'm starting to do it small. I love your podcast and direct introduction. You know, one conversation at a time and I think one conversation if that's all you can have can help. You know, I've learned a lot through the early career process about salary negotiations, getting your first job. Actually academic promotion as well is something that I started to explore in this last year and I'm just trying to do my best to help my colleagues, as well as the trainees that come behind me, to get to know the things I didn't know, the things that you can negotiate for, the things that you should get started on your CV. Yesterday is what I learned in terms of getting ready for promotion, and so that's at a small scale.
Speaker 4:I would love to see our programs do this at a larger scale. I have a little bit of a role in our residency program with doing the medical education certificate program, so for those residents who have a more dedicated interest in medical education, I can offer a little bit of that career mentorship, guidance, thinking about how to get that protected time going forward. We're trying to do more at the national level to support trainees. There's more sessions on yeah, like you know, how do you get into industry? What are the different fellowship options? How do you get your first job? What can you negotiate for? But I think that I don't know that I have an answer for you. I have lots of ideas, but I think we as a field are you know really should take on this task to make this better for the future generation.
Speaker 3:The thing that I would say to you that I remember as an early career physician is it's the first time in a very long time that you don't have a built-in cohort with you. So if you think back all the way from elementary school, all the way through medical school residency, you have a cohort of people that are going through shared experiences at the same exact time. You're all in this together. You have a lot of shared experiences, and then you hit attending life, and, unless you're transitioning into that with a lot of shared experiences, and then you hit attending life, and, unless you're transitioning into that with a lot of people that you know or with a big group of people that are all starting at the same exact time, which is very rare you are basically on an island at one of the most critical points of your entire life, uh, at a very inopportune time. And so I think to your points of relying on the networks around you, making sure that you feel comfortable in the place, that you're taking that first job, because I don't think we talk about this enough, and I think that there's again, for the first time, that you really feel like you're doing this on your own, and so it makes me think about.
Speaker 3:Even you know how do we do a lot and we're focusing a lot on the residents, the medical students, but what happens with early career physicians, what happens with mid-career physicians? The changes that you go through in those periods, all of us are doing it, but we don't have cohorts of people where we're having these conversations and talking about what this means and doing shared experiences. So anyway, I just I remember that very vividly of like, oh my gosh, like where did all my people go? I have people, but where did all my people go? I have people, but where did, like, my exact people go? It's just me, you know, it's just me in this space. Or they hired somebody in epilepsy. Maybe I can, but you just never really interact the way that you do with your, your cohort, to that point. So anyway, that was a big transition for me that I remember from early career remember from early career.
Speaker 4:This is such a key interest for me, this is like the interest of the moment. I remember transitioning and thinking like, wow, I think there's like a lot we can do for medical student education, there's a lot we can do for residency. And then I got to career and I'm like we are the forgotten audience. Like where is my education? Like where who's helping my career development, who's helping my uh, lifelong learning? Like there's, it's like the wild west becoming an early career, you know attending, like there isn't really a guidebook, there isn't really a textbook and the mentorship isn't so clear and the cohorting is not so clear.
Speaker 4:And it's so funny because, having not done a fellowship, I like leapfrogged my class in getting a career and or getting a first job, let's say, and they've a lot of them have been reaching out and it's actually so funny that that I've been able to have this role. But I think you're entirely right that this is a forgotten learner, it's a, it's a huge area for in need of development and I think early career development is so crucial because when you think about kind of that trajectory, it really sets you up for the coming years. You really can lose a lot of time and effort and struggle in the early stages, and so I think, at least for those who are, you know, where I have a little bit more experience, kind of thinking about career development for medical educators, something that me and a group of individuals are all trying to help improve but I wish there was something similar for others to again smooth that path.
Speaker 1:I couldn't agree more. The way I picture this in my head I like putting things into visual metaphors where I can it's like after your training ends, you have just jumped off of like a pad, and the early career is well, where do you land? Do you land on an even higher pad that allows you to jump even higher, or do you land on something that's hopefully soft? Are you just kind of hanging in midair and I'm wondering? It's kind of cloudy and foggy at the bottom, like where am I landing actually? Them like where, where, where am I landing? Actually? If there were more structure and mechanisms to make that clearer, to find where the next leap pad is, um, I think that would be such a wonderful curricular innovation. I will say, though, some people do thrive on that cowboy mentality. Some people absolutely love that wide, open frontier and they can just go, which is wonderful for them, but not everyone is built that way.
Speaker 3:I know our listeners maybe not at this point, but eventually everybody will be at this point, and it's kind of the first time that I remember just being like deer in the headlights of like, oh my goodness, like what happens next.
Speaker 2:Dennis, the last question I wanted to ask you and this kind of ties us full circle to something you said very early on about what area of neurology you're specifically interested in, in diagnoses that you would have to pull out from like the back of a textbook are the things that interested you, things that you're seeing that you might not get the chance to see anywhere else, especially practicing at a place like MGH, when you're having a very complex case where you might not really know or have seen it in fellowship or know exactly what to do? Who are you reaching out to, like how are you, how are you sort of running your cases by people? Are they your co-fellows that you sort of went through that process with? Are they the senior attendings that you worked with in fellowship? How often are you in communication with other you know neuroimmunologists regarding your cases that you're seeing, regarding your cases that?
Speaker 1:you're seeing, I would say, if it's something that I am unsure of, how to treat them.
Speaker 1:Next, I am very quickly reaching out to my co-fellows, my mentors, other people across the nation who I know may have more experience than me in certain circumstances.
Speaker 1:So like, for example, that patient with primary CNS vasculitis who didn't really respond after steroids and cyclophosphamide I reached out to, like some of your colleagues at Cleveland Clinic, actually asking like hey, there's a situation I'm curious how would you approach? And I asked some of my rheumatology colleagues as well who are in the vasculitis center, and it's interesting the breadth of answers you will receive when it comes to these like frontier patients in a way, and those are very. I appreciate those conversations so much because it gives sort of a shape of a treatment plan. It gives a shape of a conversation that you can have with the patient and their family and you can explore these different options, counsel them on how there's really nothing written about it and hear the risks and benefits of these different treatment approaches. What makes the most sense here? What would be, even if we don't know if it's the correct treatment, what seems like the right treatment? That's how I approach those clinical situations.
Speaker 3:Dennis, I'll just chime in a little bit to say too that also you could talk to as many brilliant minds as you want. And to Dennis's point, sometimes when we see these patients you still end up going back to the patient and just saying I don't know, I don't know what you have, I don't know what the correct management is. Here's our best thoughts, here's where we think we're heading. Here are some possible management strategies that we could pursue. What do you think? And then I think it's always going back to that shared decision making, especially in these cases where there's so much uncertainty, and sometimes someone will have a brilliant idea where it's.
Speaker 3:I remember when I was a resident, we saw this patient. No one could figure out what was going on. Seen by so many different specialists. We had one of our neurologists walk into the room and say this is CNS Whipples. Boom, bada-bing, let's get a biopsy. And I'll be damned if it wasn't CNS Whipples.
Speaker 3:But this patient had been seen by countless people in different areas, just because the symptoms were not straightforward. So having a different set of eyes on patients and having collaboration is so important, but you still may come back and not have all the right answers, and I think that we have to be comfortable in medicine to still have that uncertainty and say I don't know, but this is what we think and this is what we're going to try and ultimately have that conversation with the patient. And I worry sometimes more about whenever I see people having to feel like they have to over-explain or over-diagnose or over-manage, and I think sometimes patients aren't looking for that, even if they come to all these academic facilities for all the answers. Sometimes they appreciate you saying something that maybe they've already heard, because then it verifies to them that something's going on that we don't really have all the answers to.
Speaker 1:I couldn't agree more. I think if someone is going into neurology, that's an implicit comfort with some uncertainty, and that can be dialed up or down depending on area of neurology. Perhaps I'm very open with my patients and families who I see I don't know the answer to this yet, but I have a plan of how we can try to figure that out. I'll be honest with the tools that we have we might not figure it out, but we can try, and even if we don't, we will come up with a treatment plan that we will discuss together and we'll find a way forward.
Speaker 2:And we'll find a way forward, because we don't know, we don't have all the answers in neurology and we still have to put a pin in this conversation, but probably so many realms for topics and conversations in the many months to come. And so I just want to say from the bottom of my heart Dennis and Galena, thank you so much for being here and spending this time with us. You both have done incredible things in your careers thus far, and seeing the paths that you've taken that have led you to where you are today, the impact that you're having on young trainees who are coming after you and making the path easier, I just I feel honored to know you and have this chance to have you on the podcast. So thank you for being here.
Speaker 2:The last part of our interview and then I promise we'll let you go is our no-brainers, and these are going to be five rapid-fire questions that you can respond to with one word or one sentence maximum. And so, galena, I'm going to ask you first, and then, dennis, you provide your response and we'll go through every single question all at once. Are we ready to go with your no-brainers?
Speaker 1:Let's do it.
Speaker 2:Okay, the first no-brainer is what was your favorite part of this conversation?
Speaker 4:The last part about uncertainty.
Speaker 1:Wisdom that Galena dropped effortlessly.
Speaker 2:If you could give one piece of advice to your resident self, what would it be?
Speaker 4:Keep going.
Speaker 1:Dance more.
Speaker 2:Way to bring in the salsa what has been the most fulfilling part of your job so far, part of your job so far, I think, resident clinic where I bring together the teaching and patient care in one room all at once.
Speaker 4:The flow, the flow state of kind of teaching on the fly.
Speaker 1:A tough one to pour. The first thing that popped into my head was the moments with patients and families where they come in with a lot of uncertainty and fear and, through a conversation, can bring that down to a level of comfort and a semblance of control.
Speaker 2:That's a very good answer. What is one thing you're excited about in neurology right now?
Speaker 4:about in neurology right now.
Speaker 1:I'm excited about the fact that I can't even imagine how this field will change in my lifetime. Yeah, neurology is a pluripotent stem cell that has so much potential. Agree.
Speaker 2:And the last question I have is what are you most proud of?
Speaker 4:what are you most proud of? I feel like I need to explain this. I don't know if I'm most proud of, but I am proud of being assistant professor of neurology at Harvard Medical School. My grandparents were professors in Moldova at the university and I think I always wanted to be an educator and to teach, I guess, be a professor. So I've stepped right on the way there.
Speaker 1:Really hard. What has brought me the most joy is meeting my fiance and my Advanced General Autoimmune Neurology Fellowship and with all the different things that I was trying to do with, like learning and career, wisely making the time to build that relationship and not missing the best opportunity I've ever had in my life.
