Space X-rays, Deciding on a Specialty, and Tips for Residency with Chief Resident Dr. Adam T. Miller

🚀Blast off with this out-of-this-world episode of the AMBOSS Podcast: Beyond the Textbook! Our host Dr. Tanner Schrank sits down with Dr. Adam T. Miller, a chief resident at the University of Southern California and soon to be a fellow at the University of Wisconsin-Madison. Tune in as Dr. Miller shares his journey from medical school through radiology residency, including his experience of sending a device to space to study x-rays! Plus, find out why he chose radiology as his specialty, and get invaluable advice for medical students looking to hit the books less. Buckle up: it's time to go Beyond the Textbook! 

Read more:
Adam T. Miller, MD: https://twitter.com/atmillermd

American College of Radiology Bulletin June 2023: Patient Care Among the Stars: https://www.acr.org/-/media/ACR/Images/Bulletin/2023/June-2023/June_2023-Bulletin_WEB.pdf

Keck School News: USC works with Polaris Dawn to study in-flight space medicine:  https://keck.usc.edu/usc-works-with-polaris-dawn-to-study-in-flight-space-medicine/

Polaris Program Science & Research: Keck School of Medicine of USC: https://polarisprogram.com/science-research/

AMBOSS Qbank Q: https://next.amboss.com/us/shared/questions/64O-j4sxV/1

Book rec: https://bookshop.org/p/books/this-is-going-to-hurt-tv-tie-in-secret-diaries-of-a-young-doctor-adam-kay/17362465?ean=9780063228481

Fun fact: https://www.space.com/microgravity-vision-effects-astronauts 

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Read more at the AMBOSS blog: https://go.amboss.com/blog-ambosspod. 
Find out more about the AMBOSS podcast: https://go.amboss.com/int_podcast-23.  

Transcript

Tanner 0:22

I'm your host today, Dr. Tanner Schrank, and in this episode we'll be discussing radiology research in space. How to pick a residency specialty and advice for med students and doctors from Chief resident, Dr. Adam T. Miller. Before we start our interview, I'll give you the ambos question, bank question of the day, and then at the end of the episode we'll find out the answer along with a book recommendation and a medical fun fact. Here's your ambos question, bank question of the day. In the discipline of radiology, a 34 year old man is brought to the emergency department by paramedics. 30 minutes after he sustained a stab wound to the left chest. During an attempted robbery on arrival, he is alert and oriented to person and place, but not time. Vital signs are within normal limits. Exam shows a knife in situ that enters the thoracic wall just above the seventh rib in the left mid axillary line. The right lung is clear to auscultation. Auscultation of the left lung and cardiac examination remain inconclusive as the patient does not tolerate being examined near the entrance wound. Abdominal examination shows mild diffuse abdominal pain without guarding or rebound. The remainder of the examination shows no abnormalities. Five minutes later, the patient becomes unresponsive. Repeat vital signs are temperature 36.9 degrees Celsius, 98.4 Fahrenheit. Pulse 2120 beats per minute, respirations 28 per minute, and blood pressure 88 over 50 millimeters of mercury. Which of the following is the most appropriate? Next step in management, a emergency tube. Thoracostomy. B, extended focused assessment with sonography in trauma or EFAs C, emergency pericardiocentesis D, removal of the knife with direct pressure on the wound or E CT scan of the chest and abdomen. We'll get the answer to that at the end. All right, and now let's get to the interview Dr. Adam Miller and I are actually from the same small town in Wisconsin. We were in the same high school class and even worked together at our local public library. Since then, he's gone on to medical school. He's done residency, and he's recently been selected for a fellowship. Musculoskeletal imaging and intervention during his radiology residency at the Keck School of Medicine university of Southern California, he worked with a team that sent radiological experiments into space to study in-flight medicine. So Adam, welcome to the show and we're very thankful that you could join us.

Adam 3:14

Thank you very much, Tanner for that introduction and it's a pleasure being here.

Tanner 3:18

So for our listeners, could you maybe go through your journey through medical school and residency to where you are now?

Adam 3:25

Absolutely. So I guess I will start at the beginning Grew up with Tanner in Wisconsin. I went off to undergraduate for four years at Johns Hopkins University in Baltimore, Maryland. I was a neuroscience major there. After graduating from Johns Hopkins, I spent two gap years before I applied to medical school. The first gap year, I did research in a neurology research lab at Johns Hopkins, and the second year I was a scribe in the emergency department at a hospital in New Jersey. So during that time, I did some interviews for medical school. I ended up getting accepted to Medical College of Wisconsin in Milwaukee. So I returned to Wisconsin for those four years my fourth year of medical school I matched into radiology residency. And as part of that, we do an internship for one year. So I had, I did a transitional year program at Gunderson Health System in Lacrosse, Wisconsin for one year And then for the last three years now I've been in Los Angeles at U S C as Tanner mentioned, doing diagnostic radiology residency, which is four years total. So I just started my chief resident year and then I will be going to a one year musculoskeletal fellowship at the University of Wisconsin in Madison. That'll be starting in July of 2024.

Tanner 4:38

Awesome. this is a very exciting journey you've gone on. Let's zoom in on the radiology residency specifically. How did you come to choose this specialty

Adam 4:48

So I definitely didn't go into medical school thinking that I wanted to do radiology. I think what initially drew me in is at the Medical College of Wisconsin, we had a. Radiology interest group for medical students. And so I started going to lunch meetings during my first year of medical school. And I thought they were really interesting because the. Lead attending who did these meetings would go over interesting cases that he had seen and just talk us through the anatomy and the pathology of patients, mostly through the emergency department. So I found that interesting. And then when I was a third year medical student I did my clinical rotations and I found little things about each rotation that I ended up enjoying. So whether it was pediatrics or family medicine or obstetrics, there were things about all those rotations that I liked, and I felt that radiology was something that encompassed all the specialties that I rotated through. And would also give me the flexibility to, vary what I was doing on a day-to-day basis more so than other fields where you become very sub-specialized and, kind of end up doing one particular thing your whole career. So I really liked what radiology had to offer in that way. I also liked the work life balance that's afforded by radiology. In particular now with the pandemic, you know, we've seen that teleradiology or working from home is definitely a, viable option with radiology practices. So I think in general I,, feel like I made a good choice and I've been very happy with my residency experience so far, and I'm, looking forward to continuing this. I think that's another benefit of radiology is you can practice well into your, you know, sixties, seventies. I've even worked with attendings in their eighties. So, there's a lot of longevity in the field.

Tanner 6:24

Yeah, that makes a lot of sense. And also it lines up perfectly with your time in the emergency department as a scribe. Like you see different patients, different issues, and it goes across systems, across specialties

Adam 6:38

Absolutely. Yeah, with radiology, you can truly see everything from head to toe and connect the anatomy and the pathology and bring it all

Tanner 6:45

Mm-hmm. So for any med students listening who may be thinking about going into this, or maybe they've been debating whether they want to pursue radiology as their specialty, do you have any tips you might give them?

Adam 6:57

Yeah. So I think my main advice would be just to be open-minded during your clinical rotations. Not to go in thinking, oh, I have to be a neurosurgeon, or I have to be a pediatric cardiologist. Treat every rotation as a new experience and try to learn something from each of your rotations, even if it's something you might be dreading. you'll find yourself actually enjoying your work a lot more, and you'll probably figure out a lot about yourself and what you want to practice in the future by doing so. In terms of radiology in particular, I think my main advice would be if you don't get a chance to rotate through radiology in your program, you should seek out an experience either shadowing in radiology or ask if you're able to do a rotation. in radiology. I find that a lot of people who end up in radiology Mentioned that they didn't get to rotate in it until much later in their medical school career, or even not until they were a resident and they end up switching from other fields into radiology once they realized, oh, this is something that I'm interested in. And I never really got to experience it during medical school. So I think it's worthwhile for everyone to try to do a rotation in radiology if you're able to. And if not, maybe something more informal, just like shadowing and see if it's something that you find yourself interested in. We're always willing to have people in the reading room and come by and see what we do.

Tanner 8:10

just dip your toes in and see if it's for you?

Adam 8:12

Exactly.

Tanner 8:13

So as you were going through med school you were studying for your university exams and of course the US medical licensing exam, while also preparing to see patients in the wards. How did you juggle all of these? I.

Adam 8:26

I think that something that's really important is for anyone who's going through the medical pathway is to realize that you shouldn't sacrifice who you are as a person just because you're on this long journey of studying and nonstop, you know, working hard, long. Odd hours and spending time away from your family and loved ones, you still have to find the things that keep you grounded to keep you going. So for instance, if you like cooking or you like exercising, those are things you need to keep with you throughout medical school, throughout residency. There will always be time to study, there will always be time to, brush up on your medical knowledge and see patients and learn how to do procedures and things like that. Because if you lose sight of that, you're not gonna find any fulfillment from the work, and you're just gonna get bogged down and, constantly being stressed about studying. So I think for me, The key was finding that balance and finding out my study habits, what worked best for me and that kind of Developed as I went through medical school and residency and beyond, because the studying never really stops, at some level you just become a professional test taker. Something we like to joke about after you take step one, they all just feel like more questions. And it's almost like going to the gym. As long as you put in the reps, you know, you'll get the gains out.

Tanner 9:40

Yeah, and this aligns very well, I think. With some advice I've heard from people at the end of their careers I wish I hadn't worked as hard, because they wish that they had spent more time with their family.

Adam 9:51

Absolutely.

Tanner 9:52

So, What would you say has been the biggest challenge for you, whether that's in medical school or residency?

Adam 9:58

I think that one of the biggest things that I found challenging is that you switch topics every single month, when you're studying in your preclinical years, you know, you start with anatomy one month and then you have physiology the next month, or you go. Between the organ systems, you're doing cardiovascular and then you do neuro the next month. And then when you're doing clinical rotations, the same thing. You'll do internal medicine for a few weeks or a few months, and then you'll switch to surgery. And it just feels like this constant whirlwind where you just get your feet set beneath you and you feel like you're know what you're doing on rotation, or you understand the material really well. And then you're whisked off to the next rotation, you have to almost start from scratch. So I feel, like that was very unnerving initially, and it still continues now into residency. We change rotations on the first of every month, so I might do neuroradiology for four weeks, and then I do musculoskeletal radiology for four weeks, and then I'm on pediatric radiology. But after a while, you start to develop a foundation. You start to synthesize information and you start to see how all these things are interconnected. And I think that's one of the coolest experiences of medical training is when you start to put those things together. And even if it's not necessarily something that you're super interested in, you realize it's relevance and you use the information that you've learned to apply to a clinical scenario and actually, make a difference in patient care. So I think that's what it all comes back to, is. A lot of the times you feel like you're getting bogged down in the details of learning some really advanced disease process or anatomy or physiology. But when you actually see a patient that has what you learned about, then it all comes together and you really have these light bulb moments that make all the studying worth it.

Tanner 11:38

Definitely. I think a lot of people can resonate with this where in med school you're studying in blocks. You are very into one thing like cardiology for weeks and weeks, and you feel like you're a master at it, and then you get something new thrown at you and you have to focus on the next thing. But I really like your point that you can connect things and then see where it impacts the patient. So. what do you say is the most rewarding aspect?

Adam 12:04

So I think for me it's looking at it as though I'm. Treating, 60 patients, if I'm reading 60 chest x-rays, I might never get to meet the patient face-to-face, but I am impacting their clinical care and I am coordinating with their clinical services to help them out, either establishing a diagnosis or changing of the treatment regimen or ruling out something that they were worried about. So, at the end of the day, I do feel like you actually get to impact a lot more patients in radiology than a lot of other fields because of. The nature of what we do. Aside from that there are a lot of misconceptions about radiologists, you know, only sitting in a dark room and just, reading images, talking to themselves and their dictaphone. But I do see patients on nearly a daily basis where I'm performing biopsies. I'm. Doing image guided drains or, yes, I'm consulting with the clinicians. They come down to the reading room, ask us questions about a surgery that they're planning, ask us about a treatment response for patients receiving chemotherapy, So I really do think that people use the term to describe radiologists as the physician's physician. It's kind of like, I don't know, being the quarterback of a team in a way where you're very central and a lot of people are waiting on radiology reads to make their clinical decisions. But I do appreciate that aspect of the work, and I think it's really neat when you are able to, make those decisions and help out so many patients and so many other clinicians.

Tanner 13:29

Yeah, You're really vital to the whole cross-disciplinary team in that way.

Adam 13:33

Mm-hmm.

Tanner 13:33

That's really cool. So let's turn to your research. Um, you describe what this whole space Medicine experiment was?

Adam 13:41

Sure. So first of all, I have to give a shout out to my colleague Dr. John Choi. He's the one who recruited me into this experiment. I, did not go into residency thinking that I'd be. Doing much research at all, let alone sending things to outer space. So John was an engineer at the Jed Propulsion Laboratory just down the road here in Pasadena, California for a few years before he decided to apply to medical school. And so he approached me about a year and a half ago now and explained his idea that he was working on which entailed. Literally, sending a device to outer space to try to detect if there's enough ambient radiation in outer space to produce an x-ray,

Tanner 14:22

I think it was Dr. Choi, he explained it in one of the articles in the show notes. You can kind of think of it like taking a photo and instead of using a flash, just use the natural light around you there's x-rays in space already. So we should theoretically be able to take an x-ray by using the x-rays that are already there. Right.

Adam 14:42

exactly. back in the day, X-rays used to be taken on a cassette film. You shoot the x-rays through the film and there's an intensifying screen in the cassette that fluoresces when the x-rays hit it, and then whatever is, on the other side of that screen. If it blocks light, then it makes a contrast of the image, right? So we found an old cassette with the intensifying screen and we cut out a piece of it and we created an apparatus to hold this piece of the intensifying screen. And then we had to figure out a way to. capture the image that was produced when we hit it with the x-ray beam. and what we came up with is Actually just using a D S L R camera to take a picture of the exposure of the intensifying screen after hitting it with the x-ray beam. And so we had to make something that was, replicable with minimal training. And that would still accomplish our question, of, you know, is there enough ambient radiation and space to make this screen glow? So, the general premise of where things are going. I guess with the long-term goal of one day, if we have manned missions that are going to the moon or to Mars or wherever, In theory, if they're out there for years, they're going to need medical care of some sort. And radiology is a key component of, healthcare in general. So we want to, see what imaging in space looks like in the future And so as part of that, we first had to figure out, well, how are we gonna get something to outer space? So we did our research and we found that SpaceX had the Polaris Dawn program. We were able to submit our experiment to them for review and explain what we were hoping to accomplish. We were very fortunate to be accepted as one of their experiments. And after that started working directly with the folks at SpaceX accommodate our experiment with the logistics of a launch, so we had this prototype device that we had made, that we had tested. On site, in the radiology department. But we had to adapt things to fit with, what SpaceX's limitations were.

Tanner 16:48

Yeah. To think about making an x-ray that not only takes up a tiny bit of real estate because on a spaceship. Pounds and square footage is thousands of dollars, right? Not only that, but you're also put on your engineer hat. And you had to make this for people not trained at all in radiology, So they have to be able to do this as easily as taking a picture. And then you're balancing all this with using what's available to you out in space to perform this really important medical function for people while they're in space. that's so cool. I really like the idea that. You have everything on board. Like they talk about this one scenario where someone had a blood clot in the International Space Station and they had to deal with it there. Right? They couldn't just send them back to Earth and get treated and then go back. And luckily for them was treatable or at least diagnosable with an ultrasound, and they had one available. But like you said, for the moon and Mars, we're definitely gonna need better radiology, so we better figure this out before we go there.

Adam 17:55

Yeah, and I think there are some other experiments that will be going up with the Polaris Dawn mission that will also help us out. I think just in general, detecting how much radiation there is in space, what types of radiation are in space. These are all things that, you know, we've been going to space for what, 60 plus years now and we still don't know the answer to. So I think just establishing that baseline. Will be very helpful for, a multitude of reasons, even beyond radiology. And so we're all very excited to see, where things go with what we find out from these initial experiments.

Tanner 18:25

Well I love this research. This is super, super interesting. And it's showing an especially cool side of medicine where you can learn a lot by putting yourself in a new scenario, You can even picture the dividends that we're gonna receive on earth from this research if you just have to make an x-ray device that's smaller and lighter and cheaper and easier to use. So I really like that. Looking back, is there anything you would change, redo, or you regret doing on your way to getting where you are now?

Adam 18:56

I personally don't feel that I have any regrets. I was pretty confident that I wanted to go into medicine from pretty early on in my life. So I would say if you can call it a regret at all, my only regret would be not exploring careers outside of medicine. you know, If you are. Really into music or film, or there's something outside of medicine that you really like, definitely explore that as an option as well. There's nothing wrong with being well-rounded in medicine. You can't go wrong with that. And I think it is important to, to be well-rounded and look at your hobbies outside of academics and outside of medicine and not let medicine get in the way of them. So I guess that would just be my kind of stance on things as I wish I had explored a little more outside of medicine. just take things at your own speed.

Tanner 19:43

true. So important to be well-rounded. you just wanted one more gap year. Just throw one more in there.

Adam 19:48

I will put a plugin for the gap year, a hundred percent. One at bare minimum, if you want to take multiple, there's no penalty. Actually, medical schools nowadays, I think prefer if you take a gap year. It makes you more interesting as an applicant. I. It allows you to mature and, develop skills in the workplace or, volunteering. And then when you get to medical school, You've had a year away from studying and taking exams and, doing the things that you were doing during undergrad. So I think that really goes a long way into keeping you from burning out.

Tanner 20:20

Yeah, totally agree. Like you said, it makes you a more well-rounded person, and that's what's really important. All right. Well, You've given us so much good advice already, but I wanted to ask, because we ask all of our guests this, finally, if you could give our listeners any advice beyond the textbook, what would you say?

Adam 20:39

I would say I want to kind of center this on patient care, so always try to put yourself in your patient's shoes. we're all human beings and patients are going to come to you in their most vulnerable times. And provide you with details that they might not have shared with anyone else. So always try to Empathize with your patients. get to know them. Treat them with respect and try to, understand where they're coming from because you will provide much better care if you're able to do that Medicine is not a formula. Humans are all different, and even if they do have this disease, there are a lot of different factors that go into how they're managing it and how it affects them. So try to appreciate the nuances of how every patient is different and the patients will be very grateful for it, and I think it'll make you a better clinician.

Tanner 21:29

Yeah. like that advice a lot Treat your patients. I. Like people because each one is an individual person and they're coming to you when they need help. Alright, Adam, thank you so very much for coming on the show and for giving us all of your insights and advice.

Adam 21:44

thank you so much. It was a pleasure being here. My door is always open for anyone that needs advice, applying to medical school, applying to residency. If you just want to chat about space research if you ever have any questions, you can reach out I think that's a very important point too, is that. No one who goes through medicine would get where they are without having a lot of support. And so don't be afraid to rely on your support system to get you through.

Tanner 22:07

Yeah, we'll definitely put some links in the description for that and really appreciate you being available to mentor anyone or answer any questions. And let's get back to that ambos qbank question of the day. Your key info was a knife in situ. The left lung exam was inconclusive. The patient became unresponsive. Their pulse was one 20 beats per minute, and their blood pressure dropped to 88 over 50. Your attending tip for this question says, this patient has sustained penetrating chest trauma, which can result in a number of potentially life-threatening conditions. For example, pneumothorax, hemothorax, hemo, pericardium, Hemoperitoneum and organ laceration. Since the patient has become hemodynamically unstable exhibited by his hypotension and tachycardia, speed and comprehensiveness in assessing and treating the underlying condition are essential. So with all of this in mind, you should have selected answer. B, extended focused assessment with sonography in trauma, e fFast, and the ambos explanation says E fFast is typically used during the primary A, B, C, D, E survey and subsequent reassessments of patients with penetrating chest trauma. To establish a diagnosis and guide management. E fFast is especially useful for hemodynamically unstable patients. Because it is fast, comprehensive, including a view of the heart and both HESIs to detect cardiac tamponade, hemothorax, and or pneumothorax, and can be discontinued at any point in cases of hemodynamic instability, when there is a strong clinical suspicion of cardiac tamponade. For example, muffled heart sounds, distended neck veins, or tension pneumothorax, for example. Absent breath sounds hyper resonance to percussion on the ipsilateral side. Then emergency pericardiocentesis or tube thoracostomy respectively should not be delayed by imaging And this week we're recommending the book, this is Going to Hurt by Adam K from 2017. It's an eye-opening and painfully raw account of his life as a junior doctor with the N H Ss in the uk. And finally, here is your medical fun fact, which Adam alluded to earlier. Earth's gravity seems to keep our eyeballs in a constant shape, along with X-ray experiments, the Polaris Dawn Space Program. We'll be investigating is called space flight associated neuro ocular syndrome, A microgravity induced change in the shape of about 70% of astronauts eyes. And that's it for this episode of the Ambos Podcast Beyond the textbook. Thank you so much for listening. Be sure to subscribe to our podcast for more insightful episodes, covering everything in healthcare and medical education. I'm Dr. Tanner Schrank. And this has been Ambos Beyond the Textbook.