HCDM 26 | Tactical Physician

 

If you’re like most people, you would have heard of an ER physician, but you probably don’t have the slightest idea of what a tactical physician is. As it turns out, one of Dr. Richard Marn’s old friends and ex-roommates does both of these specialties. The super-smart Dr. Jeremy Ackerman has a lot of things that he is doing in his career and his life, but this episode focuses on two areas: his being an academic ER physician and being a tactical physician. Briefly defined, a tactical physician is someone whose job involves planning for assisting and analysis of the use of force in a tactical way. Learn how this specialty is helping police officers, soldiers keep in good shape to do the jobs that they are trained to do. Plus, learn about what an emergency physician’s job entails on a day to day basis, particularly one who is more on the academic side.

Listen to the podcast here:

The Eclectic Doctor With Tactical Physician & Academic ER Physician, Jeremy Ackerman, MD, PhD

Have you ever heard of a tactical physician or someone in tactical medicine? I doubt most of us even know what that is. In this episode, we’re going to talk to someone that’s doing that. My next guest is a friend of mine who I’ve known for a long time, since our college days. He’s one of my ex-roommates, Dr. Jeremy Ackerman. I’ve had a bunch of roommates over the years and I would say, he’s one of the best roommates I’ve ever had. He’s also a super-smart guy, as you will learn from this episode.

In fact, there’s a whole bunch of things that Jeremy is doing in his career and his life that we don’t have enough time to talk about. We’re going to focus on two areas. That is him being an Emergency Medicine Physician and a Tactical Physician. Jeremy went to college at Washington University where we were roommates. He also earned a degree in System Science and Engineering as well as Biological and Engineering Sciences. He then went on to the University of North Carolina, Chapel Hill for his MD-PhD degree. He got his residency training in emergency medicine at Stony Brook University Medical Center in New York. He then went on to Emory University where he is now an Associate Professor in the Department of Emergency Medicine in Atlanta, Georgia.

He is also an Associate Professor at the Georgia Institute of Tech at Emory University School of Medicine in the College of Engineering. He is a Tactical Physician and Medical Director for the Fulton County Police Department, Special Weapons and Tactics SWAT in Atlanta, Georgia. He is a board-certified emergency medicine physician, has several patents, loves to teach, does some great research, has tons of papers, won numerous teaching awards, received several grants and does community outreach programs for the Boy Scouts of America. Let’s jump into this and meet my good friend, Jeremy Ackerman.

Jeremy, how are you doing? Thanks for joining me.

I’m doing great. It’s a pleasure to be here.

You are in Georgia, I’m in New York so we’re doing this virtually which is a thing to do nowadays, but I want to jump right into it, Jeremy. You’re an Academic ER Physician. What do you do?

It’s a great job because there are all kinds of things that I get to do. The academic physician component means that I work for a university. I get involved in teaching medical students. We have a residency program so we take doctors who’ve completed medical school who want to specialize in emergency medicine and we continue their training so that they have the additional skills and knowledge that they need to work as an emergency physician. The other big piece, beyond teaching and the actual patient care that I do as an academic position, is I do also get involved in the research.

Is there an amount of time that you spend that’s doing clinical, teaching, versus research?

It’s a little bit variable and it depends a lot on what kind of funding. For example, if I have an idea for a research project, I might find a funding source like a grant that helps me to do the research project. My clinical time would be reduced in order to compensate for that. I do have an unusual situation in that I teach outside of my primary university, I teach at an engineering school, and that is funded. I have a contract to go and teach courses for engineers as well.

That reduces some of my clinical time. Emergency medicine is interesting in the academic world because my clinical time is dependent on how much money I’m bringing in. My boss knows exactly how much it costs for my time per hour. If I get a contract or a grant, I go to my boss and I’ll say, “Here’s an extra $10,000.” He goes, “That’s going to reduce your clinical schedule by this much. Here’s how many fewer clinical shifts you’re going to have to work over the next couple of months.”

How much clinical time do you spend on average for the typical month or week?

I’m typically in the ER about three shifts per week. Depending on funding, that might be as high as about four and a half-ish. At times, I’ve been as low as only two shifts a week.

How longer shifts?

Those are eight hours. At least on the calendar, they’re eight hours. You’ve got to get into shifts a little bit early because you have to figure out what’s already happening, you have to take the sign out from the doctors that are there, particularly if they’re very ill patients that have complex care. That process of sign up often lasts beyond the end of your clinical shift. Often, I’ll be there an extra to an hour or so after the end of the shift. A shift is ultimately more like 9 occasionally 10 hours.

Will those happen in any old time of the day like you could be doing from 12:00 to 8:00 in the morning, 8:00 to 4:00 in the morning or is this very variable?

Emergency medicine is a specialization that prides itself on being able to do a little bit of everything. Click To Tweet

They can be. The thing about emergency medicine is we’re covering the emergency department. If you’re hurt, sick, injured or whatever it is, you expect there’s going to be an ER doctor there. That means we have to cover it 24/7. We’ve got our eight-hour shifts that are scheduled at different times of day. For us where I am primarily, we have a shift that starts at 7:00 in the morning. It goes to 3:00 in the afternoon. The one that starts at 3:00 and go to 11:00 at night, and then we’ve got an overnight shift from 11:00 to 3:00. We also have other shifts that start at times that are intended to line up to when we have the most patients present. We have other shifts that start at 5:00 in the evening and go to 1:00 in the morning to try to get additional coverage.

There’s some overlap, if you will.

There’s a little bit of extra overlap and you have extra personnel in place when we’re at our peak patient arrivals.

There are a lot of TV shows that have highlighted the ER life and ER doctors but in your words, what does an ER doctor do?

An ER doctor does everything. When I try to explain what I do as an ER doctor, usually right after somebody goes, “What are you going to specialize in?” I go, “I’m board-certified in emergency medicine. This is what I am trained to do.” To offer a little bit more explanation. One of the things I often tell people is my job and my skillset, I can keep anybody alive for about ten minutes. For the sickest of the sick patients, I am trained and I do the interventions that keep them going long enough for us to figure out what else we can do and who else we need to call in.

The reality is there are lots of things that specialists do that I don’t know how to do. There are a lot of things that specialists do that I do know how to do and sometimes have to do. Ideally, if I can temporize and wait a little bit, and call the specialist in, that would be better. Sometimes, I have to do what the specialist would do because the intervention needs to happen quickly. There are some things that the specialists, we call them up and they’re like, “That’s a waste of my time to come in and do that. Why don’t you take care of it?”

We also have to recognize what it is we need the specialist. Going back to that issue of “don’t you specialize,” we are a specialty that prides itself on being able to do a little bit of everything. We are the only doctors that would transition between delivering a baby and doing a resuscitation on a newborn. The next patient I see might be 100 years old. In a single shift, I might take care of orthopedic injuries, something surgical, maybe a patient with appendicitis, a stroke patient or a heart attack. We take care of all organ systems and the patients that come to see us have all sorts of medical problems.

A patient who might be taking care of multiple specialists, if they have illness or injury on top of whatever is going on, they still go to the ER. We have to figure out if all of their complicated underlying problems are somehow change what we need to do. In one of the hospitals I used to work in, we would take care of a lot of patients with organ transplants. It’s a complicated patient to take care of. Sometimes, an organ transplant patient will do something like sprain their ankle. Depending on which organ, that might change how you manage that. One of my favorite patients of all time was a patient who came into the ER and her chief complaint was a hangnail. It’s one of those things where you go, “Why is this patient here?” When I walked into the room, I noticed quickly that she had these two large suitcases on wheels that were with her.

Is that normal?

That’s not normal. Particularly, they seem to be connected to her. I looked quickly at her medical record and saw that she, twenty minutes before, had been in one of the cardiologist’s office. It was a cardiologist that takes care of complicated congenital heart defects, complicated cardiac patients. She had been discharged from the clinic and she was fine for that clinic note. I walk in and I say, “I’m Dr. Ackerman, how are you? What’s going on?” She goes, “I was leaving my cardiologist’s office and my finger got caught on one of the doors as I was going up to the parking deck and it tore my fingernail. It’s bleeding.”

It is a hangnail. I’m looking, not saying anything and she goes, “You need to call my cardiologist, infectious disease and hematology.” I pause and I’m like, “Why?” She goes, “See the suitcases. That’s an external mechanical heart, not an LVAD.” It’s battery-packs and her external. That’s in a highly specialized medical center. There are only a handful of patients that have left hospitals with devices like that. That’s the kind of stuff that we, as ER docs, it’s not that anything about taking care of that but we have to recognize that we’re in a situation that may be complicated.

I first called her cardiologist who said, “Please call the hematologist and infectious disease.” From an infectious disease standpoint, you have a point of entry of bacteria and stuff that wouldn’t normally grow inside a person can live on those mechanical surfaces of a mechanical heart. With the artificial valves in that mechanical heart, she is on a weird anticoagulation regimen. She’s bleeding, clearly not going to bleed to death from her hangnail, but there was the real question of do we need to do anything about it. It’s a great example of a super complicated patient. Thankfully, there I was at a hospital where her cardiologist was and I had all the specialists who know all those things. Sometimes, we get patients that end up at the wrong hospital, they’re out-of-town. They come in, and they’ve got all these crazy things. We have to figure out what to do because we’re the doctors there.

When you’re in the situation, are you often surrounded by residents and medical students because you’re at a teaching hospital, or not usually?

It depends a little bit. That hospital that I was describing being at, although it’s a large hospital and the academic center for emergency medicine, it’s not one of our primary teaching sites. At that hospital, out of the 24 hours in the day, we would have one resident for eight hours corresponding to one of our shifts whereas my hospital is now my primary hospital. It’s an urban safety-net hospital and it is the primary teaching site for our residents. It used to be that as an academic physician, I rarely would see a patient by myself.

There almost always was a medical student or resident who would go and see the patient. We encourage them to get to the patient first, as opposed to me running and seeing the patient and the residents are trying to keep up with me. What’s happened at that hospital since I’ve been there is our patient volumes have gone up rather substantially. Our number of residents hasn’t increased. Now there’s a greater expectation. We even have scheduled shifts where we’re in a part of the department or we’re in a role there where the expectation is we will be seeing patients by ourselves, we might ask a resident to get involved if a procedure needs to be done, or something like that where there’s more of a learning opportunity.

HCDM 26 | Tactical Physician

Tactical Physician: An ER doctor does everything. For the sickest patients, they are trained to do interventions that will keep them going long enough for the team to figure out what else to do.

 

Increasingly, the bread and butter not likely to be very sick patients, they’re trying to get a schedule so we see many more of those patients ourselves. It helps with efficiency. When a resident or a medical student goes and sees a patient, they go and see the patient, they come back, they talk to me, I see the patient, then we have a discussion. We can build in some efficiencies by letting the residents start ordering things. At the end of the day, we’re not going to get them out of the door admitted to the hospital until both me and the resident or sometimes, the medical student and the resident because we engage our residents in that teaching process as well. Some patients get seen by the medical students, seen by the resident, and seen by me. That definitely can slow down the overall efficiency of that department.

With the pandemic going on and since you are on the front lines in Atlanta with the whole Coronavirus, were there times where you regretted going into this specialty because of what you’re being faced with?

I wouldn’t say regretted going into the specialty. I did have days that I briefly considered standing up, walking out of the hospital and quitting. Particularly early on, there was a big disconnect. We’re already seeing at that time what was happening in Italy and what was starting to happen in New York City. Early on in our hospital, there was a bit of hoarding of PPE where everybody knew we were going to need to lock down the PPE. They were not handing it out when it was needed. I had a couple of times where it was like, “Do I go and get into a shouting match with the nurse manager or do I throw up my hands and walk out of here because I can’t do what I need to do to keep myself safe?”

There were a couple of those times that it was more of a solidarity thing. They were willing to give me PPE but they wouldn’t give it to the nurse who was in the room where we were doing the same procedure. We’re in the ER, we saw a good number of either COVID positive or suspected COVID patients that needed to be intubated. As you’re aware, when we put the tube down to the patient’s throats so we can put them on the breathing machines, it creates a lot of aerosols. We have to get our faces relatively close to the patient’s face. It is from risk to provider standpoint, the most dangerous thing that we can do. I did get into two shouting matches where it was like, “We are not protecting our staff adequately. This is not appropriate.” People weren’t hearing what I had to say so you say it louder.

I asked that because for people that are reading and don’t know much about medicine. They’re like, “These ER frontline worker, is this something I want to get into?” Do people regret or have second thoughts about their career choice because they are now thrust into this pandemic at the frontlines?

I have a little bit of a different history with this thing and some of us in emergency medicine. This is not the first time in my career that I have faced a high-risk situation in simply coming to work. I did my residency on Long Island. If you recall back a couple of years ago, we’ve had a couple of anthrax scares where people were getting on envelopes with white powder. Some of them were tested and had anthrax. We had 3 or 4 of those cases that were in New York City. I was a trainee at a time where we were on high alert.

We were looking at every rash, extra careful and going, “Have you opened any suspicious packages?” Anthrax is a deadly disease that’s why it’s a candidate for weaponization. We had that and thankfully, I never got close to that. There weren’t any cases near where I was. It was something that we were on fairly high alert. We were reading, in some cases, the daily updates from the CDC about what we know about it, what to do about it, how to protect yourself and what to do about suspected exposures. The other one, which is much more what we’re looking at now, the other name for COVID is SARS.

I was a trainee on Long Island during SARS. We would get regular reminders during that SARS outbreak that we were to come to work with two weeks of clothing, toiletries and medications because if there was a SARS case or suspected SARS case, the plan was to lock down the hospital and we would not be permitted to leave. Of course, the other part being an emergency medicine, if we had a SARS case, how they would get into the hospital is through the ER. As much as COVID is bad, SARS was a different disease, not nearly as easily passed from person-to-person but much deadlier.

That meant that well before COVID came up. Unfortunately, every couple of years, I have had conversations with my family, “When I go to work, there may be reasons that I could get sick or might not be able to come home as a result of that.” That’s something that I’m doing for a conscious reason. My view generally has been, the best way for me to protect my family and keep them from getting sick is for me to keep on doing my job, me being good at what I do, being the ER doc who goes, “I got exposed to Ebola but at least I know that I found a patient with Ebola so I have to go into quarantine or even need to be treated.”

That’s the better place to be. That’s not something that everybody who chooses to go into healthcare necessarily thinks about. Unfortunately, not everybody who chooses to do emergency medicine necessarily thinks that through all the way. It makes it much easier to go to work every day having had that background. With my family, they already knew what my decision was going to be. We needed to have a discussion about what the risk was and how likely it was. With COVID, we had to figure out what level of precautions coming home would make everybody feel comfortable because I’m going to work and I’m coming home.

Some of my colleagues were stripping naked in their cars before they’d go into their houses. Sometimes, without garages that they’re getting their cars into, because their family was worried about them bringing potentially infectious material into the house. We decided that I could keep my clothes on, go directly from the car to the shower, strip, get all the clothes into a bucket that could be handled without touching any of the clothes that could be dropped in the laundry machine. That was acceptable. As we’ve been learning more about how COVID is spread, we’ve definitely de-escalated. We still have the bucket but I don’t always go and change right away. My scrub top and my mask go into the bucket quickly. I don’t necessarily change everything else instantly.

With that in mind, because that sounds risky especially for young people like, “This is what you’re doing?” What are the rewarding parts of your job whether it’s pre-COVID or after COVID?

There are a lot of things and some of them are obvious and some of them are a little bit weird. I’m going to start with the obvious things. ER docs get paid well. The funny thing about physician salaries is physician salaries generally have been decreasing. Before anybody gets too upset, we’re still played plenty. There’s one specialty that has had increases in salary consistently for many years. That’s emergency medicine. Going along with that, the number of patients we’re expected to see, the actual demands on what we do have definitely been consistently increasing as well but the pay is good.

Sometimes, that’s not the best reason to pick doing what you do. It is one of those things that it certainly helps. When it’s a bad day and everything is going wrong, you go, “At least I’m getting paid good.” It’s a nice thing to be able to fall back on. I like the variety of what we see. I go to work and I don’t know what I’m going to say until I get there. Depending on where I’m assigned the time of day, I might be able to predict a little bit. If I’m assigned to work a shift in the part of our emergency department where we mostly see trauma, I know I’m going to see car crashes.

Unfortunately, I’m going to see a couple of people who got shot, stabbed or beat up and a couple of broken bones. I can predict a little bit. If I’m in our medical department, I’m going to see somebody having a heart attack or a stroke but I don’t know when they’re coming, how bad it’s going to be and what interventions that I’m trained to do that I’m going to get to use. I love that variety. There are times, I don’t always like the elements of surprise. There are times that surprises are not good. Having that variety and having enough surprises that you have to stay on your toes. Having the variety means that there’s a lot of medical literature that I have to at least be somewhat knowledgeable about.

Money may not be the best reason to pick something to do, but it certainly is something to fall back on during the bad days. Click To Tweet

The best thing about having that diversity, being an academic medical center, is I’ve got all these learners, medical students and residents, that I have to try to be smarter than, which is hard because emergency medicine has turned into a competitive specialty. The residents that we get, their test scores are higher than mine ever were. Some of the residents that I get to work with, it is humbling, though. The stuff that they know that they already understand as a second-year resident, I’m still not necessarily comfortable.

That does provide a bit of a challenge that you’ve got to stay current and know what they’re talking about. That way, you hopefully have something to teach them and also can help guide them a little bit in their management of patients. Again, we have these complex patients spanning multiple medical difficulties, and that that can be a little bit difficult to work with. I love that aspect of it’s a little bit of everything. The teaching, I chose to be an academic medicine. In academic medicine and most specialties, you don’t get paid as much as being out in the community.

The folks in the community will tell you that we don’t work as hard. That’s partially true. We don’t see nearly as many patients but we have that additional challenge of trying to make sure that somebody else who’s learning how to do the care that we know how to do doesn’t make a critical mistake and doesn’t do something that insanely increases the cost of care. We have our own challenges. If you want to make about 20% to 25% more money, don’t be in academics. You’ve got to love the teaching and the other opportunities that you get there.

One thing that you’re doing is that you’re a tactical physician. When you told me about this, I had no idea what the heck that was. Could you tell me what a tactical physician is?

A tactical physician is a physician whose job involves planning for assisting and analysis of the use of force in a tactical way. That may happen with civilian law enforcement or that may happen as part of military operations. What we do as a tactical physician can vary all over the place. There’s a preparation component where you get involved in training and that may be training medics, individual soldiers, and officers and that may be me, as the tactical physician, training myself. There’s a lot of force readiness things.

That’s making sure that your operators, officers, and soldiers are healthy enough to do the jobs that they’re training to do. There are a lot of things involved in mission planning where we figure out what equipment needs to be used, where stuff is staged up, what the plan is if somebody is injured to get them out. Multiple stages of planning. During operations, things can vary from being available by phone or by radio to sitting in an ambulance or squad car nearby, to sitting up and putting on body armor and going in as part of the team.

I remember you telling me that you would be training almost as one of the officers as well. You learn certain law enforcement tactics as you work with one of these SWAT teams.

As I started getting involved in doing tactical medicine, I realized quickly that it’s hard to train somebody or advise somebody when you don’t understand what they’re doing. The team that I started becoming involved in was asking me, “When we’re doing an operation, can we have you sitting in a squad car nearby? Can you be there just in case something happened.” Quickly in that process, I told them, “I’ll do that but the deal is when you have your training days, I need to learn about what you’re doing.

I don’t know how I’m going to advise you what to do if I don’t understand at all what it’s like to be inside a building with a hostile subject who’s armed and shooting at you and all of those crazy scenarios that they might get themselves into.” The best way for me to learn about that, since they would train regularly and they simulate doing many of these things in training, was to go to the training days. Once I said, “You’re going to teach me,” they said, “Okay.” It developed into a partnership where they’ve taught me about how they work. In many ways, I can function as a tactical officer. In most situations, I shouldn’t be because they’re going to do it better. If I’m injured in doing something like that, then there isn’t another me standing by to help save the situation. That’s been an interesting learning curve to understand all that and try to get to that level of training.

How many technical physicians are there in the country? Is this a big or small group of people?

It is bigger than you would imagine but it’s not a huge group. It is large enough that the American College of Emergency Physicians has a subgroup within them that is specifically for Tactical Physicians. I don’t know the membership of that group. It’s a small enough group that as I started getting involved in doing this, most of the people I’d say, “I’m doing tactical stuff.” They’d say, “That’s weird to have a physician doing that.” I go, “I didn’t even invent this. Other people do this. I’m getting in on this game.”

Many people were surprised. Every once in a while, when I’d have one of those conversations, somebody would go, “Do you know my friend Steve?” I now know, without getting into the American College of Emergency Physicians section, specifically on it. I know about a dozen folks who would describe what they do in part as tactical physicians. They come from a variety of specialties. I know folks who are orthopedic surgeons and family practitioners. I know a neurosurgeon who works with the Las Vegas Police Department.

You don’t need to be an ER doctor to get into this very small niche group of tactical physicians.

Not with a couple of caveats. The nice thing about emergency medicine is some of what tactical physicians do is part of the core of what we do in emergency medicine. That quick resuscitation, the small number of procedures in the field are helpful, are part of what we already do in the emergency department. We already are conversant in the procedures. It’s learning how to do them in a different setting. Emergency medicine also is more likely to get involved in tactical medicine, because a subspecialty of emergency medicine is EMS, Emergency Medical Systems.

That part about preparing and training tactical operators is similar to preparing and training paramedics and EMTs who are out as part of ambulance crews. There are a lot of management issues and writing protocols and things like that which is the domain of EMS as a subspecialty of emergency medicine. A lot of ER docs get involved in tactical medicine because SWAT teams that have their own paramedics will need to have a physician, a medical director that supervises the care that they deliver. That becomes another route that ER docs tend to get involved in tactical medicine.

HCDM 26 | Tactical Physician

Tactical Physician: If there’s one specialty that has had increases in salary consistently for many years, that would be emergency medicine.

 

Finally, the other big route that gets physicians involved and many of the physicians who are tactical physicians already have a background usually military, occasionally law enforcement, where they already know something about what the teams that they’re working with do. Unlike me, they don’t necessarily need the training of how to be a tactical operator to understand it. They already know that part. They know the medicine, they need to refine the “what do you do in the field” component of it. Many of the tactical physicians that I know had been Army Rangers or had other roles like that where they had quite advanced tactical training and in many cases, experience. They’re comfortable with the tactical part and have to do some adjustment over time of like, “How do I do the medical stuff?”

Jeremy, just shifting gears here. Were you always thinking about being a physician when you were younger?

Absolutely not. Funny things happen as you go through growing up and going through school. I’m going to blame my high school Biology teacher. I had high school Biology and I hated it. It felt like all we were doing was memorizing stuff like genus and species and stupid stuff like that. We got into a little bit of microbiology, cell biology, but rather than learning much about how cells worked, we were memorizing names of cell parts.

There was little that to me seemed to be useful because we were learning about the language of biology. It seems boring, I hated it, and I didn’t like the teacher either. The reality is a lot of us end up liking things that we have a teacher or a mentor that we like because we want to be them. I definitely didn’t want to be like her in any way, shape or form. What I did get excited about was engineering. I liked, at the time, and I still do, building stuff. More importantly, I like solving problems which gets back a little bit to what I do as a physician. If you think of, there’s a patient here and something hurts, they have a problem. My job is to figure it out and solve them.

I found that using math, engineering and computer science, I got to solve neat problems. It was fun and I didn’t have to memorize a whole bunch of stuff. I finished college and I was like, “I’m never doing anything else biology-like. I would never want to go to medical school.” I had a lot of people that suggested, “You should do medicine.” I have a medical condition. I have diabetes and it’s something that I’ve spent a lot of time with doctors, thankfully, very little time in hospitals because of it. Often, people would hear about diabetes and say, “You’re smart, you have diabetes. Of course, you want to be an endocrinologist so that you can take care of diabetes better.”

My response always was, “First of all, I hate biology. By extension, I hate medicine. I spend enough time worrying about diabetes trying to take care of myself. Why the heck would I ever want to do that to myself?” That was how I started out heading into college. In college, I had a lot of advanced standing. I’d taken courses at a community college. I’d done a whole bunch of AP tests. I started college credit-wise as a sophomore which gave me incredible flexibility to take extra courses. Where we went to college, there were a lot of pre-meds. If I remember correctly, in the incoming freshmen class, we were around 30% pre-med.

They’re all taking biology too.

During my 1st and 2nd year in college, there are all these people who are like, “Pre-med is awesome. Biology is awesome.” They’re taking all these Biology classes. At one point, I was like, “That’s weird.” All these people who think Biology is awesome, I think it sucks, I may have missed out on something. I decided that I was going to take a Biology class to figure out if there was something that I missed in high school. I have a habit of not taking on easy challenges. My wife took in college, a great Biology class, a Botany class, where basically, each day they had a fruit and they dissected the fruit and talked about how the fruit grew.

They learned a lot about trees and fruits and then they ate the fruit. Rather than taking a class that’s great, fulfilling and requirement to graduate, I’m like, “If I’m going to figure out if Biology is interesting or not, I’m going to take what’s the best thing to take.” The conclusion was I should take the pre-med intro to Biology class. I sat there for the semester and then the second semester and I’m like, “This is cool.” There’s a little bit more to it. I don’t know how I ended up getting a good grade in that the first semester because I wasn’t taking it seriously. I go to class, I’d go to the study section and then I take the tests that I wouldn’t study for it.

It was like, “Let’s get through this.” I had that as a little bit of a backdrop. I realized that there was this other program within the school of engineering where you could get a minor or a second Bachelor’s degree in Biology from the engineering school. I started taking more advanced Biology classes. Partway through college, I realized I’d much finished my engineering degree. I started working on a Master’s Degree in Engineering. I had good scholarships and I decided that if I didn’t finish my undergraduate degree, I could use my undergraduate scholarships to do a Master’s Degree.

That way, I didn’t have to work as a graduate teaching assistant. I was starting my sophomore year but junior and senior year, I was taking a good number of graduate courses. With a total number of courses, more an undergraduate, so large number of courses, but had these graduate courses. At some point, it was in my junior year, I realized that as much as I was good at what I was doing, the Master’s Degree, I didn’t like it.

You’re getting another degree but not thinking about, “Is this interesting to me?”

I was looking at what the job market was like. I wasn’t interested in the jobs that people who had done an advanced degree within that area of engineering were getting. I started doing a little bit of self-reflection and I realized, “All this biology stuff has been interesting.” I had the good fortune of having a mentor. I’ve made a habit through my career of having multiple mentors who were very senior in this department. I went into his office to tell him, “I’m not doing this Master’s degree. I’ve got to do something different.”

I went into his office, it was dimly lit and he had a deep Hungarian accent, which I can’t imitate. He also smoked a pipe and the campus was recently tobacco-free, but there was an exemption for his office. He had this exhaust fan. It was a key moment in my life. An important realization happened here. I’m in this dark, smoky room with this guy with this deep accent. He goes, “There are two ways in life you can always make money.” This has my attention. “You can kill people or you can cure people.”

He asked me if I would be willing to help him write a white paper for a company that he was doing some consulting for that had been making anti-tank missile systems. They’re realizing that they don’t have a business model that works outside of the cold war. They’re looking at other things they can use their technology for and they have this idea that they could use their anti-tank missile technology somehow in medicine. The idea was that they would use their technology that would find and identify camouflage tanks and use it to read pap smears.

You don’t want to go to medical school unless you want to go to medical school. Make sure you’re doing something that’s right for you. Click To Tweet

These are tests that women get done to screen for cervical cancer. Growing up, it was a big deal. There were women that were dying. We’ve got a vaccine for the virus that causes most cervical cancer. It turns out in high school, I had a friend whose mom died of cervical cancer. Her cancer had been missed for more than a decade because her pap smear either had not been read or had been misread. This was a problem that was a little bit close to my heart. It was a medical issue that impacted somebody I knew where it appeared the technology would work to address the problem.

I had that a-ha moment that like, “I know how to do engineering but there are other directions that I can go with doing engineering.” I rapidly transitioned from doing a Master’s degree in stuff to do missile guidance systems to thinking about how do I get involved in using engineering to solve medical problems. In that transition, a friend of my dad’s said, “This thing called an MD-PhD program, you could do a PhD in biomedical engineering, and go to medical school because otherwise, as an engineer, you’re going to be dependent on having clinicians to work with and find as collaborators. You could be both yourself.” I’m like, “That’s a neat idea.”

Initially, I started looking at medical school with that idea. I only want to go to medical school if I can do both a PhD and an MD. When I told my parents this brilliant plan, they were not enthusiastic. My dad, in particular, who had had a lot of pressure from his parents that he should go to medical school, which he didn’t end up doing was like, “You don’t want to go to medical school unless you want to go to medical school. You’ve got to do something to make sure it’s right for you.” That winter break, and this was my junior year, I volunteered in the emergency department.

Our winter break was about a month-long. The hospital I was volunteering at was almost supposed to work three hours at a time. I’d go and I had nothing else to do for that month other than hanging out with my parents. It didn’t seem that appealing. Quickly, as the staff in this ER got to know me and got a little bit more comfortable of me, they started showing me stuff. They will ask me to help out with things that were well beyond what a volunteer ought to be doing. I was regularly there for eight or more hours at a time. It’s an amazing volunteer experience but I came away from it having a little bit better understanding that I liked working directly with patients. This was definitely a bit of a surprise. I don’t usually think of myself as a people person.

You’re a good roommate.

Sometimes things work out. Again, I’m not the person who randomly walks up to people and starts talking. I was surprised to discover that in that setting. I could bond with people a little bit, part of what volunteers do is get people settled down, calm down, things that the doctors and nurses would like to be doing but don’t always have time to be doing. That was a wake-up moment that biology was a bit of a surprise. Not that it’s my favorite thing ever but there was something of interest there. This working directly with patients ended up being much more appealing than I would have thought. That led me to change from I want to do MD-PhD to I’m going to medical school one way or another. Hopefully, I can do the PhD.

Is that why you’ve gone to ER because that’s where you first volunteered?

It’s likely part of it. At the medical school I went to, I got a rejection letter. I was asked to interview for the MD-PhD program, which meant that my application with an interview attached got put back into the pile of applications they were considering, which led me to be waitlisted and then ultimately accepted. I have a rejection, a waitlist and acceptance all from the same year at the University of North Carolina. Again, they had an MD-PhD Program that I was interested in. I’d spent a summer during college. That was a whole other story but summer during college at UNC.

I knew about a research there who I was interested in working with. When I knew I could go there for medical school and I was happy about going there for medical school. I called up the Director of the MD-PhD Program. I said, “You didn’t take me for the MD-PhD Program but I got into medical school. If I’m coming anyway, can you help me do a PhD too?” They said, “We can’t give you any of the funding that normally goes along with an MD-PhD Program covering tuition and stipends. If you think you want to do it, will tell everybody you’re in the program, don’t expect us to pay your tuition.”

I was administratively part of the program, which was great because I got to meet all of the folks who were in the program. I got that core group. I got the administrative support. I convinced computer scientists to take me on as a graduate student. There’s a lot of paperwork that has to happen for you to take a leave of absence from a medical school. That was all stuff that the MD-PhD Program took on. I do two years of medical school, four years of PhD, then come back to medical school as a third-year medical student. My dissertation had to do with general surgery. I worked on being able to use augmented reality to assist laparoscopic surgery.

The part that you have to remember is you can play Pokemon Go and stuff like that where you do augmented reality on your cell phone. At that time, you needed a multimillion-dollar supercomputer to be able to do things like that. This was back when augmented reality was hard and people thought laparoscopic surgery was hard as well. It’s an interesting niche. I spent a lot of time working with surgeons. I went back to my third year of medical school certain that I wanted to be a general surgeon. Since one of my mentors had been a trauma surgeon, I spent a good bit of time with a trauma surgeon so I thought I wanted to be a trauma surgeon.

My clinical mentors were largely trauma surgeons. What else would I do but trauma surgery? That’s how I went back to my third year of med school. I started filling out residency applications to do a general surgery residency. It was about three weeks before the applications had to be sent out that one of my mentors, who is a general surgeon, was finishing off his laparoscopic surgery fellowship at UNC. He took me aside and said, “Why are you doing general surgery?” I’m like, “What do you mean?”

He’s like, “Don’t get me wrong, you’d be great as a surgeon but the stuff with engineering that you do all of that, you’re not going to be able to do that for another 5 or 6 years if you become a surgeon. You’re going to spend so much time focusing on being a surgeon that you’re not going to be able to do that. More importantly, you’re good at that other stuff. Basically, as a second-year medical student, you designed a medical device that I, as a surgeon, think I want to use. You didn’t do that as a surgeon, you did that because you understand the engineering, you understand medicine and what surgeons do, not that you know how to do it. If that’s what you want to do, it’s not the right thing.

The other thing is you’ll go through a surgery residency and you’ll get to the end of it. Either you will love surgery that is, you want to be a surgeon and operate all the time, or you’ll be fed up with surgery and your first opportunity to get out into industry or do something else, you’ll take it. Either way, that will be a waste of the six years that you’re going to spend becoming a surgeon. My advice, if there’s something else you like, you should look at.”

He specifically mentioned emergency medicine. Part of the point was when I mentioned what I love about emergency medicine. We do a little bit of everything. It’s almost being a medical student for the whole rest of your life. You’re on gynecology, next month, you’re on psychiatry, next month, you’re doing peds except for us, this patient is a pediatric patient, this patient has a dermatologic problem. His point that being in a field where you see a little bit of everything, you continue to have exposure to a wide diversity of medical problems.

HCDM 26 | Tactical Physician

Tactical Physician: There are a lot of things involved in mission planning where tactical physicians figure out what equipment needs to be used, where stuff is staged up, what the plan is if somebody is injured to get them out.

 

Not that to be worked with engineers or be an engineer designing a solution or problem, you have to be an expert on the problem. You have to know enough about it that you can find the experts who know something and help bridge the gap between the engineering world and the medical world. The other part of this is when I came home and proudly announced to my wife, “I was going to do surgery. I’m switching up. I’m doing emergency medicine.” This is why I’m doing my only month as a medical student.

I did one month of emergency medicine. I come home and say, “I want to do emergency medicine.” She’s like, “Of course, you are. Why were you even thinking about the surgery stuff.” It was no surprise to her. Part of what she reminded me is how much fun I had as a volunteer in the emergency department. One of the things I tell medical students is part of what I realized as a medical student is the times I was happiest as a medical student. No question. I loved being in the OR. I loved getting my hands even standing, holding a retractor and fixing someone.

I love that solving-problems. There’s something about fixing someone. It’s tangible. You know what you did at the end of the day was awesome. What I didn’t like with surgical specialties was all of that seeing them in the clinic before and after. Even seeing them when post-op day three. In general surgery, post-op day three for a lot of abdominal surgery, you’re waiting for the person to be able to eat, drink and fart. You go on your route like, “How are you doing? Let’s look at the incision. Have you passed gas yet? Keep on trying.”

To me, the pre-op and post-op in the long-term follow up was uninteresting. The part that I loved about being a medical student on inpatient services other than going into the operating room is when our pagers would go off that there was a new patient in the ER. The reason was I got to meet a new patient that had a new problem that we would figure out how we were going to fix. That’s the same whether you’re on a medicine team or surgical specialty. When the patient comes from the ER, the ER has a patient that either they don’t know how to fix, they don’t know what to do about the patient, or they do know that something needs to be done and they’re not the right ones to do it.

As a medical student where you get to explore being on a lot of different teams, the pager going off to see that new patient in the ER was the best thing ever. I will also say, and you remember this from being a medical student and being a resident, when you get that page to the ER, most people are groaning because it’s a whole bunch of work you have to do. You’ve got to go, “I’ve got to see a new patient. They’re going to have new problems. I’m going to have to figure out all their problems.” As opposed to the people who are already admitted to the hospital but we’ve got a plan, we know what we’re doing, we’re following the labs, and we’re doing the things.

There’s a little bit of a disconnect and that’s a personality issue around emergency medicine. Many of us who do emergency medicine and love emergency medicine had similar experiences. We often commiserate, it was great the first day. New patient on any service but depending on our attention spans by date 2 to 4, somewhere in there, it was old business and we’re bored out of our minds. In retrospect, there were a lot of indicators that emergency medicine was going to be the right place to go. It took me a while longer than everybody else who knew me to realize that was going to be my destination.

Jeremy, I want to ask, how can the audience reach out to you if they have any questions and learn more about you?

You can send me an email, that’s the best way. Emory has a little mini-bio, you can find my email address there. You can post it along with the podcast. The only thing that I will tell you is a university does have good spam filters. I get many emails that if it’s not from somebody that I recognize, I may not answer right away. What I tell many students that I work with, “If you want to get in touch with me, send me an email, give it about five days, send me another email.

If I see your name enough times, even if I’m purposefully ignoring you, I will eventually get curious enough to respond or alternatively, I will simply see it.” The best way is by email since I’m not big into social media. LinkedIn is the other good one. If you can find me there. There aren’t many Jeremy Ackerman that comes up. Although, I don’t check that as frequently. Many of the requests for info questions on LinkedIn, I’m more likely to read, simply because there are fewer of them.

There’s a final thing I like to do with this segment called a lightning round. These are brief questions, mostly one-word answers or yes-no. On a scale of 1 to 10, how good of a driver are you?

Nine.

How many hours of sleep do you need?

Five.

Godfather or Star Wars?

Star Wars.

Being in emergency medicine is almost like being a medical student for the rest of your life. Click To Tweet

If you could ask God one question, what would it be?

What the heck?

What’s your ideal outside temperature?

60.

Do you believe in Santa Claus or did you ever believe in Santa Claus?

Never.

Where do you want to go more than any other place in the world?

This is going to make you happy. I want to go to Hawaii.

You haven’t been?

I have not been to Hawaii.

Who is the biggest inspiration in your life?

I would say my grandfather that my son is named for.

Can you say something about yourself that most people at work would not know about you?

I am very transparent. Almost all of my secrets at this point have come out. I know how to knit.

That stands out.

HCDM 26 | Tactical Physician

Tactical Physician: There’s something about fixing someone. It’s tangible. You know what you did at the end of the day was awesome.

 

That has come up. Most people at work don’t know that. I taught myself how to knit so I wouldn’t fall asleep in medical school.

Finally, what’s something you could eat straight for a week?

There are things I have eaten straight for a week. I’m going to go with shrimp. Lobster would be even better but less practical, plus it’s a lot more work to eat a lobster.

It’s a good thing you don’t have gout.

One of these days, it might happen.

Jeremy, thanks a lot for joining me on the session. I appreciate it.

It was great fun.

To learn more about nowadays guests or other past guests, check out my website HealthCareersWithDrMarn.com or HcWithDrMarn.com. Go to my website, add your name and email to my email list. That way you can get the latest announcements and news as they arise. You can also find me on Instagram @DrRichardMarn. Thank you so much for reading and I’ll catch you on the next one.

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About Dr. Jeremy Ackerman

HCDM 26 | Tactical PhysicianI am particularly interested in designing within healthcare and training engineering and technology students about how to work with clinicians and in clinical environments.

My past research projects have included the effects of ambient noise on emergency departments, use of micro-fluidics to measure mechanical platelet activation, the difference of attitudes of field providers and medical control physicians towards the use of opioid analgesia, and the application of computer graphics technologies to ultrasound-guided and laparoscopic procedures.

I have worked extensively with faculty and students at Georgia Tech and teach an undergraduate clinical immersion course called Clinical Observational Design Experience.