Genetics/congenital heart disease in PICU vs. NICU?

[wickedprophet]

Hi everyone! I'm a peds resident leaning towards a career in intensive care, either a Pediatric Critical Care or Neonatology fellowship. I have academic interests in genetic/metabolic conditions and congenital heart disease (e.g. "Terrible Ts," Pompe disease, Williams syndrome, Turner syndrome). I've ruled out peds cardiology because I want to work in the inpatient setting exclusively, ruled out PEM because I only want to care for the sickest patients.

However, given the limited time I've rotated in each unit as a resident (I only have 2 more weeks in the PICU), I'm having a hard time gauging which field between PICU or NICU will encounter more genetics/CHD. I don't have any more NICU/PICU blocks in my schedule nor away rotations at other hospitals.

I do love taking care of younger infants and even premies, and find fulfillment in providing counseling to parents whose NICU babies are born with genetic conditions with life-threatening or lifelong implications. I do find the physiology in cardiac babies fascinating, but I understand that most of the country is moving towards CV-ICU/PICU management rather than NICU management of these patients.
Of note, I do not prefer taking care of teenage/near-adult patients. Polypharmacy overdose is too sad for me, but trauma's exciting. But the acuity that CHD/genetic/metabolic conditions bring is what really brings me life.

Does anyone have any advice for deciding between NICU vs. PICU, based on these academic interests?

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[SurfingDoctor]

Hi everyone! I'm a peds resident leaning towards a career in intensive care, either a Pediatric Critical Care or Neonatology fellowship. I have academic interests in genetic/metabolic conditions and congenital heart disease (e.g. "Terrible Ts," Pompe disease, Williams syndrome, Turner syndrome). I've ruled out peds cardiology because I want to work in the inpatient setting exclusively, ruled out PEM because I only want to care for the sickest patients.

However, given the limited time I've rotated in each unit as a resident (I only have 2 more weeks in the PICU), I'm having a hard time gauging which field between PICU or NICU will encounter more genetics/CHD. I don't have any more NICU/PICU blocks in my schedule nor away rotations at other hospitals.

I do love taking care of younger infants and even premies, and find fulfillment in providing counseling to parents whose NICU babies are born with genetic conditions with life-threatening or lifelong implications. I do find the physiology in cardiac babies fascinating, but I understand that most of the country is moving towards CV-ICU/PICU management rather than NICU management of these patients.
Of note, I do not prefer taking care of teenage/near-adult patients. Polypharmacy overdose is too sad for me, but trauma's exciting. But the acuity that CHD/genetic/metabolic conditions bring is what really brings me life.

Does anyone have any advice for deciding between NICU vs. PICU, based on these academic interests?

You will see a lot of genetic disease in NICU. The ability to manage it though will be limited often unless there is some specific therapy. Obviously there is enzyme therapy for Pompes nowadays, but those diseases in general are rare. You will obviously see genetic diseases in the PICU, if they survive infancy. Generally speaking though, true chromosomal abnormalities don't have therapies often and are just a manifestation of multiple comorbidities and chronicity.

Metabolic diseases are another mixed bag. At our institution, urea cycle defects come to the PICU, even in infancy, because the NICU doesn't do IHD, but that is probably a unique situation. Also, metabolic disorders may be diagnosed after the patient has left their birth admission and have had enough time for the metabolites to build up. You will also see more therapies for metabolic diseases in the PICU, ie liver or bone marrow transplants, heart transplants or chronic enzyme replacements. But clearly, there can be patient born prematurely with metabolic diseases where those symptoms will manifest while in the NICU. Either way, you'll get exposure to both in either setting.

You will also see a lot of congenital heart disease (ie the most common genetic disease) in both setting. Here there is quite a difference though as for most places, the NICU does not manage congenital heart disease. That is left up to the PICU/CVICU. I know at our institution (also true where I did training a decade ago), there has been a greater push (based on bed availability) to get pre-op CHD to the CVICU and then manage it longterm there. I don't think the NICU fellows even rotate in the CVICU (though that model may very).

If you like infant and don't like teenagers/adults, then don't do PICU, realizing that you also won't get to do much congenital heart disease outside of temporary stabilization with prostaglandins. Often I think it's important to consider the things you don't want to do, more so than the things you do.

 

[Stitch]

Agree with everything above. Also think about what is the daily bread and butter of PICU vs NICU. Deliveries and premie babies with feeder/grower population makes up a lot of NICU. It's more long term care to get these babies home, and along with that comes social issues.

PICU is generally shorter term care, though we have our frequent flyer chronic population (which has been more rewarding than I ever would have thought going in, especially as we approach end of life issues with these families). Trauma, DKA, bronchiolitis is daily throughput. If you can find a mixed unit hearts will be part of the daily routine, but as CVICUs become more prominent, you may need an extra year of training to really get into the complex hearts. And in the CVICU, everything you do will be under intense scrutiny by cardiology and especially by the cardiac surgeon. Further CVICUs usually don't see much of other disease types.

Teens will be part of daily care in the PICU, whether overdoses or traumas.

 

[MonkeyRalph]

Or you could do CVICU and exclusively care for patients with CHD and a majority will be neonates and many with genetic syndromes. Or you could do cardiology and subspecialize in cardiac hospitalist medicine. If you truly have a passion for the inpatient care of cardiac patients, there are tons of options where you could do exclusively that without having to do NICU or PICU necessarily.

 

[wickedprophet]

Or you could do CVICU and exclusively care for patients with CHD and a majority will be neonates and many with genetic syndromes. Or you could do cardiology and subspecialize in cardiac hospitalist medicine. If you truly have a passion for the inpatient care of cardiac patients, there are tons of options where you could do exclusively that without having to do NICU or PICU necessarily.

I greatly appreciate everyone’s feedback!

CVICU is an route that I’ve intermittently thought about and am more strongly considering (especially since the patient population consists of mostly infants/neonates)- I would more likely apply for a PICU fellowship followed by brief CVICU training to minimize undesired time in other aspects of cardiology (e.g. outpatient, echo, etc). I do feel like I’m an intensivist at heart.

My only reservation is that I’ve heard from colleagues/mentors that the CVICU market is becoming more and more saturated these days. Based on family reasons, I am geographically restricted to the east coast—another reason why NICU is a good fit given the vast amount of available jobs.

What are your thoughts about the future job market of CVICU? Is it silly for job market projection to be a factor in career choice?

 

[SurfingDoctor]

I greatly appreciate everyone’s feedback!

CVICU is an route that I’ve intermittently thought about and am more strongly considering (especially since the patient population consists of mostly infants/neonates)- I would more likely apply for a PICU fellowship followed by brief CVICU training to minimize undesired time in other aspects of cardiology (e.g. outpatient, echo, etc). I do feel like I’m an intensivist at heart.

My only reservation is that I’ve heard from colleagues/mentors that the CVICU market is becoming more and more saturated these days. Based on family reasons, I am geographically restricted to the mid-Atlantic region—another reason why NICU is a good fit given the vast amount of available jobs.

What are your thoughts about the future job market of CVICU? Is it silly for job market projection to be a factor in career choice?

Generally speaking, a lot of hospital-based subspecialties are becoming more saturated. Its quick economics. The demand far outstrips the supply, because you can always train more fellows, you can't however, just build hospitals (eg see certificate of need). That being said, CVICU jobs are generally more available than PICU jobs due to the fact that many places want to have a CVICU because they are better revenue generators. It's been that way for some time. Sometimes they are willing to take a PICU fellow who has had "adequate" CVICU training, but generally speaking, they'd prefer someone who has had dedicated training. Of course, that additional training is not ACGME sanctioned at this point, and literally a certificate with an institutional stamp of approval, but thus far, there hasn't been a requirement to do so to take care of CVICU patients (ie, I take shifts in the CVICU, but didn't do extra training, I just did more than the ACGME minimum... and frankly, they were desperate at the time).

Pediatric CT surgeons on the other hand, are a little harder to come by, but if a hospital can recruit a pediatric CT surgeon, then invariably, they'll need support staff. They are the real bottleneck of the institution. That, and fetal echocardiographers.

Can that trend continue forever? No, but it has been true up until this point and I don't see a reversal of it yet. As to your last question: Honestly, YES.

 

[Step Up]

It sounds to me that you will really like neonatology. Try to get exposure to multiple neonatology jobs, i.e. different NICU settings, to get a better idea if you like it. Talk to experienced neonatologists and pick their brains about their career paths and job satisfaction. You could even shadow briefly in other nicus, albeit covid may make that difficult. These things could help you decide. Most neonatology jobs won't involve a lot of genetics. It depends what level NICU you work at. Many neo jobs are at level 3 NICUs where they transfer out genetic and surgical cases. If you work at the level 4 academic NICU, yes, you'll get a lot of genetic cases, but you will also have to be academically-oriented in order to work there. There are definitely some private practice level 3 nicu jobs where you work at the genetic/surgical referral center. Depends on your interests. One benefit of neonatology is the job market, lots of opportunities, and not all urban. Agree that you should check out CVICU. Try to rotate through it, could even be an away rotation, or shadowing for a few days. I'm a neonatologist at an academic center, btw.

 

[mytirf]

I would more likely apply for a PICU fellowship followed by brief CVICU training to minimize undesired time in other aspects of cardiology (e.g. outpatient, echo, etc). I do feel like I’m an intensivist at heart.

It is important to know that about yourself but be very careful about not getting adequate training to actually care for CHD. Just doing a few months as part of your PICU fellowship will really not prepare to care for complex CHD patients. I have seen too many PICU fellows who do a few months in our CICU and think they understand enough to care for pre or post-op CHD patients. This is just not the case. I would consider at least a dedicated CICU fellowship or dual boarding which is becoming required in many units.

I see a lot of PICU fellows who just want to "get the basics" but then make some really "basic" mistakes because they don't really understand the complexity of CHD patients. Don't be that person.....