Training Grounds

Born to be an otolaryngologist: The preclinical years

Sat, 8 Jan 2011 21:30:13 -0600

So far I’ve covered the reasons otolaryngology originally drew me in, and how you can improve your residency application by doing research. Those are all great and everything, but how about the nuts and bolts stuff of the timeline to match day? Let’s say you came into medical school knowing you were born to be an otolaryngologist. What can you do during the preclinical years to help make that notion a reality?

You know the deal with any competitive specialty and years 1 and 2 of medical school – you have to do well. Those years can seem supremely important as you are in the midst of them, but having the advantage of hindsight so far removed from them I can say: yes, they are important, but not as important as they feel when you’re progressing through them. It’s easy to get caught up in the drudgery and intra-class competition as you are barraged with massive amounts of information and exams. But I would caution you to take pause and keep perspective in the matter.

What do the pre-clinical grades of medical school distill down to? Really, nothing more than a class rank (or quartile, depending on your school). Your individual grades in histology and cardiology don’t mean a whole lot (unless you fail and have to remediate). Will your class rank help you get interviews come application time? Not likely. The caveat to this is that if you are in the bottom half of the class, it can be considered a red flag about why there is such a discrepancy between your preclinical grades and beyond. The preclinical grades (and subsequently, your class rank) are more about supplying a necessary component of your application rather than making yourself stand out. Otherwise stated: if they are good, that is adequate, and if they aren’t, that is a deficiency in your application you must account for.

So really, focus on yourself and doing as well as you can. Don’t get caught up in comparing yourself to your classmates – but if you find yourself struggling, address it early. Your goal should be to be in the top third/quartile of your class. But ultimately, the main reason to strive to do well on your preclinical classes isn’t necessarily your grades, but rather because preclinical grades are the best correlate for Step 1 success.

Yes, the mighty Step 1, able to slay the medical student with merely a glance. I would be lying if I didn’t say your Step 1 score is important. Heck I’d be lying if I didn’t say it was really important. If there is one aspect of your application that can immediately close doors before they are open, it’s your Step 1 score. This may not be fair, but from the perspective of the residency program, who is attempting to compare students from schools with a wide variety of grading policies and rubrics, it is reasonable. Seen here below is the NRMP data for the 2009 match showing Step 1 scores and applicants into ENT:

What can be distilled from this chart? First of all, if you bomb Step 1, there’s still hope. Individuals matched into otolaryngology with board scores well below average. But if you breakdown the segments, the match rate is: 211-220 = 60% match rate. 221-230 = 71% match rate. 231-240 = 81% match rate. 241-250 = 90% match rate. 251+ = 97% match rate. The rub: adding 10 points to your step 1 score can increase your chance of successfully matching by 10%. That. Is. Substantial.

There is a gluttony of information and advice about studying for Step 1 on the internet, by word of mouth, and in books. I’ll gladly defer the nuts and bolts here, but I will say the main keys to success are: (1) know yourself, how you best study and learn, and how quickly your study and learn (2) formulate a very specific and thorough plan/calendar/timeline based on your study qualities (3) start early, work hard. This is your one shot, so make it count.

Beyond academics, the preclinical years are a great way to get involved outside the classroom. While extracurriculars are not nearly as emphasized in residency applications as they are in medical school applications, programs like to see applicants that have interests outside the classroom, can hold positions of leadership, and are altruistic. Find a project or clinic to volunteer with. Organize an event or help with an interest group. Attend a conference. Run for student government. These are the years of medical school when you have time for these things. But ultimately, don’t get involved because you need things for your residency application. Get involved because it makes you a better medical student and a more well-rounded individual. Stick to projects that you’re invested and interested in, and don’t become overwhelmed. Remember, in the grand scheme of things, you’re here to learn medicine, so don’t sacrifice academics for extracurriculars because you “need” them on your CV.

But really, that’s all that is required the first two years of medical school. Do well in your classes, do well on Step 1, get involved in a few things that interest you. Easy, right?

I know, it’s not easy. But set small and reasonable goals for yourself along the way, and you can do it.
  Bobby  aka MedZag

So you wanna do research huh?

Mon, 4 Jan 2010 21:27:52 -0600

So I recently somewhat stumbled onto two research projects, which are currently eating up a lot of my free time, and thought to myself “Self, this would be a good topic for a post.” So here we are.

When applying to medical school, many students become adept at “fluffing” up their CV on their AMCAS application. So what if you only went to the Save Ugandan Tortoises Interest Group meeting once? It looks great to application committees; add it to your activities! Luckily (or unfortunately, depending on your fluffing skills), residency programs are much less interested in having you fill up your ERAS application with BS and are much more interested in firmer aspects of your resume, such as board scores, clinical grades, and letters of recommendation. Research is one piece of the puzzle whose importance is highly debated among medical students. One of the first questions out of the mouth of more ambitious freshly minted MS1s, still dripping with the sweet dew of the World Outside Medicine, is “How can I get involved in some research? I need it to get into a good residency.”

There are a myriad of opinions on the necessity of doing research in medical school, whether it is more fluff or substance. There is plenty of n=1 evidence of individuals able to land top spots in tough fields without it, as well as evidence to the contrary. Like most things in life, the truth likely lies somewhere in the middle, and how much you “need” research on your resume when applying for residency is highly program and field dependent. Unfortunately, I have yet to find a good website or book with that kind of information. The best approach I’ve found is simply asking around amongst individuals further up the food chain. Residency directors in particular are invaluable resources for giving you a good sense of what you do and do not need to do during your first 3 years to make yourself into a solid applicant, as well as the tastes and preferences of various programs. That being said, the NRMP website has a plethora of data available about characteristics of applicants who successfully match into each specific field, broken up by board score, state, amount of publications, shoe size, hair color, etc. One thing to keep in mind when viewing the data is that variables such as total number of publications tend to be skewed upwards in the more competitive specialties, as they tend to attract a greater proportion of the “super applicants” with pub lists larger that the US National Debt. For example, the mean number of abstracts/presentations/etc for ENT last year for successfully matched applicants was 4.1. But the mode of the pool of successfully matched applicants is lower than the mean due to the “drag effect” of the upper crust, so it does not necessarily mean you are “below average” if you are applying into ENT with less than 4.1 pubs. However, the NRMP data is useful for broadly comparative purposes, where you can construe that research is more important to match into ENT than family medicine (avg 2.8) but less important than rad onc (avg 8.2).

So where does ENT sit on the spectrum on research-loving/research-hating? The consensus I’ve received after talking to various faculty is: research isn’t essential for matching into ENT, but it’s pretty important. The field as a whole tends to highly value research. Part of that is due to the smaller size of the specialty – it is much more reliant on broad participation in clinical research to contribute to the common knowledge of the field. Part of it is the rapidly evolving nature of the field. Part of it is that residency programs pride themselves in being academic pipelines and being responsible for training the future department chairs of the world. The simple fact is that nearly all ENT residencies offer some form of dedicated research time in their residency track, and most require their residents to be working on at least one study while in training. It is an asset when a resident has sufficient experience from medical school to be able to jump in and tackle a solid research project while at said residency’s program, rather than having to learn the ropes on the fly. Can you match into ENT without any research experience? Sure, and many have, but it requires having something else to compensate (be it above stellar board scores, above stellar letters of recommendation, etc).

So, you’re sold, you want to do research. What does that even mean? How does one even begin to “do research?” That’s the situation I found myself in my first two years of med school. My experience with research prior to med school consisted of running PCR gels in a lab, and unfortunately my school did not do much in terms of educating us of our options during the pre-clinical years, besides telling us to “get involved!” and spamming our inboxes with a bunch of vague emails. So I floated through my preclinical years, feeling slightly guilty I wasn’t in on this “research” bit but having no idea where to start. When I became pretty sure I wanted to go into ENT, I knew getting involved in some research would probably be a good idea, but wasn’t sure where to begin. Luckily, I found out it can really be as simple as sending an email. Most faculty in an academic setting have a project or two going at any given time, and at least a couple questions they would like to investigate. And if they don’t, they tend to know who in the department does and are looking for medical students to help. The main thing is to just be proactive; there’s a wide myriad of opportunities, but you need to find that point of first contact. Your “in”, so to say. Whether that is replying to a “research opportunity” email, talking to a contact in the dean’s office, or an un-solicited message to an attending you may know in a department you may be interested in, I’ve heard of successes with any and all of the above strategies. You don’t even have to commit to a project, but once you open the dialog there is often a great deal of flexibility in how much time and energy they will let you contribute. But no one is going to give you research opportunities if you don’t ask, so the onus is really on you as the student in the beginning. If you’re not sure where to start with research, the Medical Student Research FAQ over at Student Doctor Network is a good place to start.

I was chatting with the ENT program director at my school the other day and I asked how he was able to differentiate between such a large pool of highly qualified applicants, all with research on their CVs. Here were a few of the things he told me they look for:
1. The more responsibility you have over the study, the better
The ideal, of course, is that you started with a question, formulated that into a hypothesis, structured a research design to answer that question, got the protocol approved through IRB, collected and crunched all the data, worked with a statistician, wrote your article, and got it published. Of course, with both the time and resource constraints of medical school, and the limited timeline we are on to score a publication, such a scenario can be largely unrealistic. But what it comes down to is: what you end up researching is less important than the experience you gain during the process. Are you familiar with all the steps that are involved with taking research from idea-to-publication? Can you create a solid study design? Are you experienced in writing publications? The most obvious way you can demonstrate these qualities on a residency application is to be either first or second author on a publication. But first and second author opportunities are few and far between for students, and often more a consequence of luck. That being said, you will be asked about your research during your interviews, and being able to speak intelligibly about your project(s) will go a long ways towards demonstrating that you would be a competent researcher.

2. Get some funding
There’s a surprising amount of money out they for medical students doing research who are up to the task of writing an application for the award. It doesn’t even have to be a large sum, a couple thousand dollars is sufficient. But the nice thing that a grant or award demonstrates is an additional level to the vetting process of your study. It shows that an independent body evaluated your study and decided it was a worthwhile enterprise. This does a lot towards legitimizing your work in the eyes of program directors. Your dean’s office is likely your best bet if you’re looking for a few leads on some awards you can apply for.

3. Sell your experience
Like I said before, what you end up studying is much less important than your experience in doing research. PDs want to see not only that you’re competent, but that you’re excited and engaged in the research process. Being able to discuss both the skills you’ve gained through the process and what about doing research intellectually challenges and stimulates you demonstrates an additional aspect of what would make you an asset to their program.

As for my own personal experience – I got my “in” by emailing an younger attending in my department who I had gotten to know through our clinical skills class during the pre-clinical years. We set up a meeting and he laid out a few study questions he had been considering and let me pick up a project I’d like to take up. I ended up taking on two different studies (that have now evolved into three studies) and have been the point man as far as getting IRB approval, writing consent forms and proposed project protocols, collecting data, and such. Let me say, if you can snag yourself a similar experience, it’s a lot of fun. Being the person in charge of the nitty-gritty details gives you a large appreciation for the research process and causes you to ask yourself a lot of the questions that differentiate a well-designed study from a haphazard one. Plus in medical school, where you often find yourself busy with tasks that feel mundane or pointless, it’s a pleasant experience to be involved with something that feels meaningful. You get to be the master of a small subject, and you’d be surprised the many ways you can spin that into talks, posters, and papers along the way. I wasn’t particularly enthused with research before getting involved with all of this, but since then have found my clinical curiosity kick up a few notches and encountering all sorts of questions in the clinical world that would make for interesting studies.

Well, that’s it for now. Until next time!
  Bobby  aka MedZag

Why ENT? Choosing a specialty and what drew me to ENT

Sun, 11 Oct 2009 21:19:15 -0500

When you first enter medical school and begin to ruminate on your future specialty choices, there are two distinct camps which stand out. The first are the captains of the sinking ship… the physicians who for whatever reason have become dissatisfied with their practice, and their pessimism can be contagious. The second are the victims of luck… individuals who have stumbled into a field which seems to complete some deficit in their life and who love their job with every resonating electron shell in their body. Both camps can provide an impassioned argument, and it’s not uncommon to find yourself alternating between empty despair and emboldened determination your first few years of medical school. But I would argue that the gross majority of us are neither pessimists (we entered this field for the right reasons) nor lucky (it takes a little work to get what you truly want in life). Some of the best advice I’ve received in regards to choosing a specialty lies somewhere in the middle. One resident I interacted with for a brief period of time passed along a great anecdote which I think offers a great deal of insight. She bought one of those massive white boards from Office Depot at the beginning of her medical school experience and created a list of the 18 different medical residencies, along with a “Strengths” column and a “Weaknesses” column. She filled out each column for each field as she learned more about each specialty. She also kept a log of the different aspects she wanted to have in her future practice, and different aspects she wanted to avoid. For example, she wanted longevity of care with her patient base. She enjoyed simple procedures but didn’t particularly yearn for anything beyond that. As she proceeded in her years of study, she would reach a point where she could definitively say she did not want to go into a particular field, and it would get crossed off her list. With her progression through medical school, she developed a good sense of the future physician she would become as her list became steadily pruned.

I hold no stock in Office Depot, and am not saying everyone should go out and buy white boards. But I think the process is a good one to practice, in whichever way is comfortable for you. We all go through the same steps subconsciously in our own right, but it’s often helpful to have the proverbial “writing on the wall.” For example, I found myself enjoying clinical medicine much more in medical school than I anticipated. But I don’t think I could go into a field where I would never step in an OR. For the longest time, these facts simply existed in me as feelings. Feelings of unease at the hectic and sometimes superficial pace of general surgery clinic. Feelings of boredom or futility that sometimes hit me as I saw patients in family medicine. It wasn’t until I sat down and began to verbalize why I was having those feelings that I began to develop a sense of the sort of things I desire in my own future practice, and was able to develop those into criteria I could apply towards choosing a specialty. Introspection takes time and work and can be difficult, especially in the hectic pace of medical school where it can often seem a lower priority then studying for your next exam or getting enough sleep before tomorrow’s rounds. But it is an invaluable asset towards the decision making process.

So what ended up drawing me to wanting to become a “snot doc”? That is a difficult question to give proper lip service, but it’s a question I’ll be endlessly answering on the interview trail, so I’ll try to elucidate some of the factors that led me down this crazy path. There’s a lot of reasons to consider ENT, these just happen to be a few of my own and my own experiences coming to those conclusions. The first three reasons are what I consider the Pillars of ENT (must be said in dramatic movie trailer voice):

(1) Is it medicine? Is it surgery?
The divide between medicine and surgery goes back into the annals of time. As a medical student, it’s easy to become indoctrinated into the school of thought that the two are mutually exclusive. But with the explosion of outpatient and minimally invasive procedures and more specialists taking over procedures related to their respective practice, the line is more blurred than ever and a wide variety of fields offer the ability to both practice medicine and do procedures to varying degrees. However, for some people (like myself) there is nothing that can compare to being in the OR. From the ritual of the scrub and gown to the feeling of observing living, breathing anatomy spread open in front of you, the experience of the operating room can intense and immensely rewarding, almost spiritual. And there’s often a (misguided, in my opinion) sense that to commit to the OR means to forsake the clinic. ENT offers a truly unique niche where just as many, if not more, patients are managed as an outpatient as those that are treated with the knife. For me, it means having my cake... and eating it too.

(2) Variety of procedures & practice
When I say “ENT,” you say “tonsils.” True, ENT may not be as sexy as, say, neurosurgery, but in the public eye it remains a largely hidden specialty. As I learned more about otolaryngology as a specialty, I kept finding myself saying “they can do that?” That’s the beautiful thing about ENT. It’s a little bit minimally invasive surgery. A little bit non-invasive procedures. A little bit of plastics. A little bit of orthopaedics. A little bit of neurosurgery. And a little bit of good old open dissection. A little bit of immunology, rhinology, family practice, pediatrics, infectious disease, oncology. The advantage of having a specialty that is specialized on a specific anatomical region is the ability to treat the myriad of disorders associated with that region, regardless of the specific "discipline" of medicine it may fall into.  
(3) The anatomy
This is a funny one to me, because I absolutely loathed head & neck when I slogged through anatomy as a fledgling first year medical student. In the beginning of your training, it’s easy to feel overwhelmed by the learning process simply adjusting to the sheer volume of information. And with my first interactions with head & neck anatomy, I was sufficiently overwhelmed with vein, artery, nerve that the region felt damn near impossible. But hindsight is a funny thing. As you build on your foundation of medical knowledge and master basic concepts, the nuances of the brilliance of the human body begin to reveal themselves. By the time I rotated through general surgery as a third year, the anatomy of the abdomen had progressed from frustrating to boring. Head & neck went from overwhelming to elegant. The intricacy of our upper anatomy is both awesome and inspiring, especially when you consider how important the function of the region (from facial expression to voice to hearing) is to the basic human experience

In the not too recent history, I had breakfast with a faculty member in the ENT department at my medical school. Of course, he posited the classic “why ENT?” question and I spent a few minutes discussing the above 3 reasons and how they shaped my interest in the field. At the end, he smiled and said “Good. Those are good reasons. *pause* You do realize that’s what everyone else is going to say on the interview trail too, right?” We laughed, but the point is valid. Interest in the scope of practice, types of procedures, and anatomy involved in ENT are so essential to what it means to practice in the field that that are somewhat proverbial prerequisites to have any sort of substantial interest in the field. But what else about the field is unique or interesting? Here’s three others that I’ve found that really get me going:

(4) The toys The first time I saw a surgery performed with a CO2 laser, I was geeked out beyond belief. Granted, a lot of that is likely rooted in my Star Wars Nerd childhood, but my love of technology and inner geek are two things I have tenderly fostered over the years (granted, more quietly at certain times than others – namely, high school). One of the advantages of working with structures in the body which are accessible from one of its orifices is it provides such a unique access to pathology. ENT is a field which has warmly embraced the cutting edge of technology. The strides it has made in recent years are sometimes awesome to observe, and there’s no indication that the field has any intention of slowing down. If you like gadgets, there’s plenty of things to keep your hands busy in ENT. Plus, there’s something sexier about a flexible laryngoscope when compared to its colorectal brethren.

(5) Surgeons that don’t want to operate?
I am hesitant to paint entire areas of medicine with broad strokes of generalities, so I preface this section by stating: this is based on my own experiences and is part of my own story of what drew me to ENT. While I was on my general surgery rotation, I was somewhat disconcerted with the flippant way in which some attendings would approach the decision to take their patient to the OR. Clinic felt more like a screening process to determine if the patient was fit for surgery, rather than an assessment of if the patient truly needed the surgery. I've seen enough complications from simple surgical procedures to have developed a healthy respect for the degree of stress that general anesthesia can place on the body. At the first ENT rounds I ever attended, one of the attendings discussed a case where a patient suffered a permanent complication from a relatively straightforward and simple surgical procedure. His take home point: "Surgery is still surgery. Never be complacent when placing someone under the knife." It's an attitude I've found to be consistent within the field. One of the advantages to ENT, with a myriad of therapeutic and diagnostic procedures that can be done on an outpatient basis, is that there is there is a lot than can be done to treat patient's conditions which keeps them out of the OR. One surgeon is particular I have worked with really enjoys the challenge of engineering new ways to effectively treat patients as outpatients. Its a refreshing attitude within the surgical subculture, and one which I would hope to maintain in my own future practice. 
(6) The personalities
The stereotype of the gruff, domineering surgeon has been around for generations. While it is dangerous to think solely in stereotype, and there are plenty of examples of exceptions to the rule, there is often a certain amount of truth hidden within stereotype. Stories of surgeons throwing instruments in the OR often inspire terror in young medical students facing their first experience in the OR. I personally had an experience on call where I watched a trauma chief publicly berate an ED attending in the middle of the emergency department, ending her tirade with "I'm the CHIEF of trauma surgery! That is beneath me!" I was told once by a cardiothoracic surgeon I preceptored under (a very gentle man who was very un-like the stereotypical surgeon) that "Surgery is full of ego. Just because it is, doesn't mean you have to be egotistical. But you have to be able to interact with colleagues who are to still enjoy your work." The stereotype of ENT, from my interactions with docs in various areas of medicine, is that of the "nice surgeon," and like many stereotypes, I've found quite a bit of truth in that assessment. The field tends to attract a kinder personality, and job satisfaction is very high comparative to other fields. If people have told you that you are a nice person, and you enjoy working with other nice people in turn, you would not find yourself adrift in the field of otolaryngology.

These are just a few of my own personal reasons I've fell into ENT. The website has also outlined several others in their "Why Otolaryngology?" page which I thought were very insightful. In conclusion, there's three key things when it comes to choosing your specialty which I have learned are invaluable to ensuring you end up in a field which will bring you satisfaction in your professional life. (a.) Be proactive. Don't write off a field just because on first glance it doesn't like you would be interested in it. Shadowing doesn't stop when you get into medical school. Use the flexibility of your schedule the first two years of medical to get exposure to a wide variety of disciplines. Don't depend on only your core clinical rotations to get you the exposure you need to determine your future. There's a lot more out there than your medical school exposes you to. (b.) Know your strengths and weaknesses, your wants and do-not-wants. It's easy to fall into the trap of liking a field because you had a good rapport with one specific physician. If you find yourself liking a specific clinical experience, ask yourself why. And write it down; put it into words. Same if you find yourself loathing one. After enough time, you'll have a good sense of what aspects of practice are important to your future satisfaction and happiness. (c.) Ultimately, you're in charge. Be aware of other field's opinions of the fields you are interested in. There is some truth to them. But don't let other people tell you what you do and do not want to do. When push comes to shove, you are the sole authority on yourself. Don't let people tell you a field is too competitive to match into. Don't let people tell you that you won't be happy in a specific field. I'm a big believer in personal initiative and determination, and if you have your sights set on something, trust that with hard work and perseverance will get you where you need to go.  Best of luck, and until next time.   Bobby  aka MedZag

No intro required... MedZag has added an extension to his already popular blog

Tue, 29 Sep 2009 19:26:42 -0500

Hey all. This being my first post here at Headmirror, I wanted to take an opportunity to introduce myself and talk a bit about what I hope to accomplish with this column here on the site. So without further ado, *ahem*....

My name is Robert Morrison and I'm an MS3 at Oregon Health & Science University, tucked away in the upper left corner of our nation in eccentric Portland, Oregon. I was raised in the area, and as such have adopted many of the common practices of Oregonians. I never carry an umbrella, despite the fact it rains 180 days a year. I recycle. I use paper bags at the grocery store. My nalgene bottle is BPA free, and my wardrobe would make a good magazine spread for REI. But I do shower daily, I promise. I was not an "otolaryngologist from birth" to say the least. Frankly, my extent of knowledge of the specialty coming into medical school consisted of something along the lines of "aren't those the guys who take out tonsils?" I entered my training convinced I was en route to a general surgery residency, and my interest in the field of otolaryngology blossomed somewhat late in the game (as late in the game third year could be considered, anyways). There's a couple of things I'm hoping this column can contribute as I progress through the various aspects of discovering, rotating through, applying, interviewing, and *crossing fingers* matching into ENT.

(1) Give a sense of the journey
The 4 years of medical school are intensely productive, and when looking at everything you must accomplish in between your first cut into the cadaver in anatomy lab and opening that envelope on match day, the journey can seem exhausting and overwhelming. Easy to become lost in the forest from the trees, to borrow an oft-used cliche. I hope that providing a chronicling of the journey as I progress through each step can help lend some insight into each hurdle in the obstacle course and provide some reassurance that getting everything done that you need to is most definitely possible.

(2) Dispel common misconceptions
Yes, ENT is quite a competitive field to match into. To downplay that fact would be a disservice to the realities it takes to match into the field. However, with the blessings of the internet and all the information it affords us, there is the same amount of misinformation out there. I hope to provide a good sense of what the baselines requirements are to make it into ENT and hope to dispel some of the notions that it is impossible to match into a competitive specialty like ENT. I can assure you, there is nothing particularly incredible about myself (despite what my mother will tell you); I'm just like the majority of the 17,000 other medical students out there trying to do my best to succeed within the rigors of medical school.

(3) Provide good resources
Along the lines of information and misinformation, one of the most difficult things in medical school is finding the right places to learn the sort of things you need to know in terms of choosing a medical specialty. Unfortunately, such things are not handed to you on a silver platter, with a note stating "You are going to be an otolaryngologist.” My "exposure" to ENT my first two years of medical school consisted of a one hour lunch talk and the luck of having an ENT surgeon lead one of my physical exam small groups in my clinical medicine class. There is often a dearth of good information about learning a realistic overview of a given specialty, and opinions from docs in other fields can often be skewed by personal opinion and misconception. Along the way, I hope to give some good resources you can reference to better frame your expectations and desires for how you want to practice medicine as a career.

(4) Crack some jokes
Yes, medicine can be a stressful and demanding field. But as our friend Freud so excellently described: humor is one of the mature psychological coping mechanisms. It’s good to have a little fun along the way.

So, I hope you stick around for the journey. Grab your popcorn, or favorite multi-grain bar of choice, and stay tuned. I hope I can shed some light on what it’s like... becoming an ENT surgeon (dramatic dimming on lights).