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Meet Stahlman-Thomas Associate College Advisor Michael Miller, MD, PhD

Posted by on Wednesday, April 29, 2020 in Uncategorized .

by Ayesha Muhammad (G2)

Dr. Michael Miller, the newest Associate College Adviser for Stahlman-Thomas college, had no idea he would go into pediatrics during his PhD. His current clinical speciality, Pediatrics Critical Care, is a path rarely tread by physician-scientists. He got his MD and PhD from the University of Iowa and graduated in 2015, when he joined Vanderbilt Pediatrics Residency. He is interested in inflammation signaling in vascular and lung injuries. Read on to hear more about his circuitous path to pediatric critical care, his advice on non-fast tracking, and his thoughts on early career pediatrician-scientists in the COVID-19 era.

AM: How did you decide to do a combined MD/PhD degree as opposed to either MD or PhD?

MM: Like a lot of MSTPs, I was going to go to medical school. I was actually at Vanderbilt at the time, and my roommate was doing a summer research program through the HHMI. This attracted me to the idea [of research]. [During undergraduate,] everyone is looking at a good resume [booster] for medical school, so [I decided] to [get involved] in research. I was fortunate enough that I got to work with an MSTP trainee at the time (Chris Bunick ‘08), which opened my eyes to the fact that an MD/PhD was a possibility. Full disclosure, I had no idea that [the dual] pathway was even an option. Once I got involved in research, I realized I loved being in the lab, and that summer really sparked my interest in doing truly unique research rather than the lab based activities of undergrad lab courses. From there, I did some independent graduate work in the same lab that I had done that summer work, and both through the recommendations of my mentor at the time, Chris (the MSTP trainee) and the MSTP director at the time, I kinda settled into the fact that I want to do both programs, to the point that when I initially applied to medical schools, I did just MD applications and got accepted [at an institution] that did not have an MSTP, but declined so I could take an additional year to do more research and try to get into a fully funded MSTP. Once I got on the path, there was no turning around…

AM: What kind of research did you do in your PhD and how is that different from the kind of research you are doing now?

MM: My predoctoral work stemmed from a combination of two things: 1. I had met my mentor through one of my courses and he and I got along together fantastically, so I knew from a personal standpoint that I was going to work well with him, and he was doing prostate cancer research. 2. From the way our MSTP was designed, I did a two-week clinical elective course on urology prior to joining a lab. All of a sudden, I not only liked the project from a mentor standpoint, but also because [I thought urology] is [an amazing speciality]; they do surgery, they have clinics, so I was on the path to do a PhD in urologic oncology research. I looked at protein glycosylation and the pathway by which a particular protein was modified and its effects on cancer metastasis and survival. I really focused on prostate cancer and then did a smaller project on renal cell carcinoma, with the plan that when I finished with my PhD, I was going to join up the urology department at Iowa. That obviously did not work out (laughs). With leaving that field, going into pediatrics and now doing critical care, my work is more focused on something that I find clinically relevant as well as scientifically and intellectually stimulating. My work now is looking at reactive oxygen species and their role in TNF mediated signaling in models of acute lung injury and ARDS, which carries over to my clinical practice.

AM: You have opened a box of worms! You were all set to go into urology and now you are a peds intensivist. What was your thinking in choosing your speciality and what happened?

MM: I think like a lot of early medical students, when you get into the clinical realm for the first time, everything is pretty cool. The OR was fascinating to me; I loved being able to work with my hands, much more directly than in internal medicine. When I did my urology rotation, I loved the idea of some of these pretty crazy surgeries in urologic oncology, but also that you had a clinic and could follow up with these patients. But really, I wanted to be in the OR.

Obviously, I finished up [the elective] and went into graduate school, and spent the next 4.5-5ish years there. During that time, you change a little bit. You are not plugged in with the medical school community. Obviously you have your MSTP connections but we are all a bit unique in our path. When I was in graduate school, I also had a daughter. Between the separation from the medical school grind and growing personally with the birth of my daughter, I changed. You think differently than you do through any other part of medical school. When I went back, I still thought I was going to do urology. I had worked hand in hand with some of our urologic oncologists, and our urology department had planted the seed of being able to stick around. But when I went back into the OR, I kinda hated it (laughs). I’m sure you’ve heard this before, if you don’t love being in the operating room, going into a surgical speciality is a terrible idea…

[In figuring this out, I realized], I hate adults, with a passion; the stuff that adult internists have to deal with is just mind-blowingly frustrating to me. I also think it was just a timing thing — my  daughter was young when I went into my pediatric rotations, and I actually loved the thing that everyone else hated, which is the three-point model of care, where you have the physician, the patient and the parents. I think the parent aspect is a turn-off for a lot of people, but as a new parent, I loved being able to help parents in their own understanding, and it blossomed from there. Now I obviously landed in critical care, where I don’t have clinic any more. But there are a lot of procedural aspects to what we do, so I still get some of the hands on stuff, and I get to take care of patients that I really enjoy taking care of and I get to do what makes me happy to go to work every day.

AM: Did you at any point consider between the NICU and the PICU in your process?

MM: Briefly, there is increased acuity in the care of NICU patients, but for me the NICU felt like I was seeing the same 5 or 6 diagnoses over and over again (laughs). Neonatologists are fantastic providers, but I didn’t get the sense of variety that I felt like I had in the PICU. Also, I am really bad at taking care of the patients that neonatologists manage, so it’s great that I didn’t go down that road.

I also really liked the randomness of what you get in the PICU. We have a core set of patients that we see a lot of, but for the most part, you never know what will come through the door. In our training, we get a lot of exposure to the cardiac ICU and those kids are a completely different breed of sick. The PICU ultimately provided different problems that I wanted to deal with.

AM: MSTPs usually have a better idea of fellowship they want to do when they are applying for residency. Did you face any push back from people around you saying if you want to have a lab, and do the 80-20 split, are you sure you are making the right decision with PICU?

MM: That comes up all the time and I don’t think it ever stops, which is good because you need your mentors to challenge your process and make sure you are thinking through everything. For the most part, this pathway [of physician-scientists in critical care] is not very well laid out. So a lot of people were suggesting to take a step back. Even pediatrics is a much less well-represented physician-scientist pathway than internal medicine or neurology. That said, you do what makes you happy, and I knew what made me happy. For me, and I think it’s different for everybody, I needed something that was going to be fulfilling from a clinical standpoint, and also from a research standpoint.

AM: Did you do a fast track?

MM: I did not. I applied to several, and even here at Vanderbilt, the option was left open to me. The problem [I faced] is that coming out of my research, I was still considering the possibility of doing heme-onc, because I had done a lot of cancer research. I still have a soft spot for both heme-onc patients and oncology research. Because I was not able to fully commit to a fellowship, I didn’t think fast tracking would be a good thing. Now programs will say that they are open to you switching, but I think that always causes a little bit of hiccup. The other thing that worried me was starting in the PICU as a fellow being clinically under-trained, because once you come back from your PhD, you feel like the dumbest person in the room. You [are surrounded by] med students who really know their stuff, and I am looking at an x-ray going I *think* it’s a chest x-ray? So it did not do much to bolster my confidence and I didn’t have a lot of mentors that helped me see my potential until it was a little bit too late. When I decided I could [fast track], I was past the point where it was appropriate. Now in hindsight, I still recommend people [fast track], even if I didn’t

AM: What were some of the things you were thinking about when you were applying to residency programs then?

MM: For me, identifying programs that had the fast track opportunities, because I wanted to make sure that research was not a novel thing to a residency program. I am married and I have a daughter, so geography was a part of it too. We were looking at the South East primarily — I was coming from Iowa but I had no connections to the midwest. I didn’t want to be in a coastal program because I am not the type that wants to be in a highly competitive environment and wanted some place that was highly collegial. There were a few places that surprised me, in terms of, admitting that [the program] hadn’t had anybody do basic science. I was like woah, that’s not good, because i was not looking to pioneer a new program. [A lot of it] was also the same stuff that I was looking for in an MSTP. For me, the character of the program, that unspoken vibe that you get from the people that are a part of it and the people that help mentor you are very important. I had done undergraduate here so I had thought about coming back here. I also loved the people that are part of our residency program so ended up saying I gotta come back and it worked out!

AM: How is your fellowship structured in terms of research. Because in the fast track the research is built into the structure. Did you have to negotiate extra time for your research?

MM: Every fellowship will be different in how they manage this and all I can speak for is critical care. There is a certain number of clinical months that you have to get in, and our program is designed to be very heavy on the front end, so we ended up doing 36-39 weeks of service during the first year, which means I lived at the hospital. During that time, there were training grants that opened up, which I applied for, and was fortunate enough to receive. Those training grants mandate 75% protected time and the program followed with, you will be scheduled for 25% [clinical time]. So I didn’t have to negotiate. Research is all I am doing right now, minus being at home and being a homeschool teacher [for my 7 year-old daughter].

AM: Did you have a plan B in case the funding didn’t work out?

MM: Had the funding not worked out, I would have reached out for a couple of other funding opportunities, there are F awards for MD/PhD trained fellows. I am fortunate that my research mentor is also the head of the division (Fred Lamb) so had things not worked out from a funding standpoint, I would have had conversation with him about some extra time in a way that still supported the fellowship. I am in the fellowship for clinical training, and let’s not lie, to support the unit, so I didn’t want to leave them high and dry. Luckily I didn’t have to [have those conversations].

AM: I have heard the chief of the division say “you don’t see a lot of peds intensivists over 65.” My mentor is 70 and he still runs his clinic and he is still in the lab. What are your ideas in terms of burnout, and how long do you see yourself practicing in the clinical setting. Have you thought of what you will transition yourselves into once you hit that mark?

MM: I have, and all of us do, because there is no other way to do it. I love being in the unit — it energizes me and gets me happy to be going into work. That said, Fred has shared this with me multiple times that you hit a certain point where running to the next code blue is not that fun anymore and you are doing overnight call when you are 63,65. One of the nice things about doing the dual path is that you are generally going to have a lab to go to, so some people will transition to 100% research. For me I enjoy the clinical side enough that if I feel like I am not in a position to enjoy [the ICU anymore], I am probably going to step down and see if I can find a hospitalist type role while continuing my research.

AM: How do you spend your copious free time?

MM: My wife and I are into group fitness classes. At the end of medical school, I was really out of shape and not feeling great, so I have really gotten into this and really enjoy it. We do crossfit style workouts, and have a whole friend group through that that is completely unassociated with the hospital, which is amazing. Otherwise, I have a 7 year-old, most of the stuff we do is with her, teaching her basketball and soccer, playing frisbee, and going out to the park. That *tends* to be what I do with my free time.

AM: Given these unique circumstances in the world, do you have any advice for people who are in their graduate years, when everything can get so frustrating to begin with – like experiments not working – and now we are all sitting at home, thinking we can’t do our experiments. What are your thoughts on that?

MM: I also share in your frustration. I am in a time crunch as well, because once fellowship is done, I really lose a significant portion of my protected time when I just get to be a scientist. Grad school is amazing because you *just* get to be a scientist. That [being said], all the things that I have been doing are just trying to stay on top of what I can do. I spend a lot of time teaching my daughter, taking care of her and making sure she is moving forward, and that takes up a good chunk of my day. But we read together. She might read Amelia Bedelia, while I am reading the latest Nature article but we are reading together. I am working on a paper from a primary authorship stand point [to maximize my productivity]. I have data from my residency project that I am going through, reanalyzing, and seeing if there is something there that I can use to put together a small story that meets that LPU requirement (the least publishable unit). Everyone understands we don’t have control over what’s going on. A lot of people are sitting on some stuff that they can be productive with, [for example], I remember from grad school if I was having issues from a technical standpoint, I would start scouring papers: OK, who else has done this, how are they doing it differently. We have lost the ability to take that reading and put it into immediate practice, but I think now is the time to start digging into some of the problems that you have been having, and know that you have the protected time to do it. Find some sources, see what the common threads are, and the differences between how you are doing things and how other people are doing things. Reach out to people you know who you may have been putting on the back burner, maybe a collaborator who does a similar project, or something that you are looking for help with, or maybe you’re looking to try something new, and [try to] have something that you can get set up in 2 months that you can do when we are starting to head back.

AM: If you had a suggestion for the NIH about how to support early career scientists /accommodate people in your stage during this time?

MM: There is going to be a recognition that this transition period is going to be a little less productive, and it is less productive across the country, so it’s not that my individual story will be different than anybody else’s. Everybody else is out of the lab, and they are trying to do what they can do. It is going to shift the goal posts a little bit in terms of expectations and when those grants are coming in. I am not too worried about it. I would like to be in the lab and doing everything, but somethings are just out of your control, and the faster you recognize that you can’t change that, the better you’re going to be…