Peds EM

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

witzelsucht

Full Member
10+ Year Member
Joined
Jun 20, 2012
Messages
475
Reaction score
728
Sorry for the somewhat general question, but why does it seemingly take so long to train a peds emergency physician? I know many hospitals have single emergency depts. with general EPs covering, and they seem to have no problem managing a pediatric population.

I guess I just find it odd that after 3 years one might be fully qualified to be a pediatrician, managing complex inpatient cases and doing ED consults, yet needing 2-3 more years for peds EM. Likewise, an EP might be able to manage peds EM in a community hospital, but need 2-3 more years to do dedicated peds EM.

Is it just the large breadth of ages and disorders which necessitates a 6 year track? Its just weird to me considering that peds neurosurg, for example extends one's total PG training by like 15%, whereas peds EM extends it by 100%.

Members don't see this ad.
 
There's a two year path directly out of adult EM if I'm not mistaken.

The three year post peds residency is really an American Board of Pediatrics thing. They insist that every peds fellow needs to produce research, whether they are interested or not. Many of us feel this steers people away from fellowship, while others feel it sparks an academic interest and investment in the field.

In terms of needing extra training, peds residency is nothing like EM residency, so yes, there definitely needs to be more. The flow of a busy ED, acute triage and disposition as well as critical interventions aren't the focus of peds residency. Peds residents are generally not trained in acute airway management or procedures (with the exception of LPs and basic suturing). What we do learn is the vast variation of normal within the pediatric population and how to identify deviation from that normal. Learning that, along with the differences in interventions does take extra time.

I think adult EPs generally do a great job of identifying the very sick kid and intervening appropriately. It's all the in between stuff that's difficult and takes practice.

The surgical specialties are quite different because they aren't really managing children. They are doing procedures on children, and those mechanical skills are learned in their mainly adult residencies.
 
Sorry for the somewhat general question, but why does it seemingly take so long to train a peds emergency physician? I know many hospitals have single emergency depts. with general EPs covering, and they seem to have no problem managing a pediatric population.

I guess I just find it odd that after 3 years one might be fully qualified to be a pediatrician, managing complex inpatient cases and doing ED consults, yet needing 2-3 more years for peds EM. Likewise, an EP might be able to manage peds EM in a community hospital, but need 2-3 more years to do dedicated peds EM.

Is it just the large breadth of ages and disorders which necessitates a 6 year track? Its just weird to me considering that peds neurosurg, for example extends one's total PG training by like 15%, whereas peds EM extends it by 100%.

I agree with your premise. As a pediatrician, I think my training in general peds was lacking for peds EM in only 2 ways: 1) airway training; 2) lines. However, in terms of what to do (i.e. decision pathways) I always felt like I knew it just as well as a peds EM person.

I think a viable alternative would be 3 years of peds residency followed by an intense 1 year peds EM fellowship focusing on procedural skills, including rotations with anesthesia and PICU. I feel strongly that general peds folks already get enough training in the actual decision pathways in the peds EM side of the field, they just dont have the technical skills to pull it off.

Some of the peds fellowships used to be 2 years, but the ABP went thru a process years ago to get them to all look the same, which is inappropriate IMHO. Peds cardiology and Peds heme/onc definitely need a 3 year fellowship. Peds EM, not so much.
 
Members don't see this ad :)
Some of the peds fellowships used to be 2 years, but the ABP went thru a process years ago to get them to all look the same, which is inappropriate IMHO. Peds cardiology and Peds heme/onc definitely need a 3 year fellowship. Peds EM, not so much.

I'd argue those fellowships could be trimmed too. Most of my friends doing peds heme/onc spend nearly 80% (if not more!) of their 2nd and 3rd years in the lab. Half of my fellowship is spent on data gathering and writing. I plan to stay academic, so am glad for the training and experience, but I don't think everyone needs to do it, especially given the dearth of some subspecialties.
 
Remember reading this in annals a while back... it could be one reason they feel more time is necessary...

Ann Emerg Med. 2013 Mar;61(3):263-70.
Abstract
STUDY OBJECTIVE:
We seek to provide current, comprehensive, and physician-level data for critical procedures performed in a high-volume pediatric emergency department (ED).
METHODS:
We conducted a retrospective study of all critical procedures performed in the ED of a tertiary care pediatric institution. Data were collected from written records of resuscitative care provided. The primary outcome measure was the cumulative frequency of each critical procedure during 12 consecutive months. Additional outcome measures included the number of critical procedures performed by pediatric emergency medicine faculty and fellows and a description of the other physician types performing each procedure.
RESULTS:
Two hundred sixty-one critical procedures were performed during 194 patient resuscitations, which represented 0.22% of all ED patient evaluations. Sixty-one percent of pediatric emergency medicine faculty did not perform a single critical procedure. Orotracheal intubation occurred 147 times and represented 56% of all critical procedures, yet 63% of pediatric emergency medicine faculty did not perform a single successful orotracheal intubation. Pediatric emergency medicine fellows performed a median of 3 critical procedures.
CONCLUSION:
Critical procedures were rarely performed in a large, academic pediatric ED. Pediatric emergency medicine faculty are at significant risk for skill deterioration, and pediatric emergency medicine fellows are unlikely to achieve competence in the performance of critical procedures if clinical exposure is the sole basis for the attainment and maintenance of skill.
 
Sorry for the somewhat general question, but why does it seemingly take so long to train a peds emergency physician? I know many hospitals have single emergency depts. with general EPs covering, and they seem to have no problem managing a pediatric population.

I guess I just find it odd that after 3 years one might be fully qualified to be a pediatrician, managing complex inpatient cases and doing ED consults, yet needing 2-3 more years for peds EM. Likewise, an EP might be able to manage peds EM in a community hospital, but need 2-3 more years to do dedicated peds EM.

Is it just the large breadth of ages and disorders which necessitates a 6 year track? Its just weird to me considering that peds neurosurg, for example extends one's total PG training by like 15%, whereas peds EM extends it by 100%.

You're right that this system is at its most absurd where Pediatircians are training to do thing that general Pediatricians already do without a fellowship. For example emergency medicine, adolescent medicine, or (my personal favorite) hospitalist medicine. Which is why in the three children's hospitals I've rotated through I've met a grand total of one true Peds EM doctor. Everyone else has been boarded in either just emergency medicine or just Pediatrics

What we need is one year fellowships like the FM guys have. Even two might be manageable. As it is we've just creating a training pathway so miserable that it doesn't seem like anyone actually goes through it.
 
Last edited:
Sorry for the somewhat general question, but why does it seemingly take so long to train a peds emergency physician? I know many hospitals have single emergency depts. with general EPs covering, and they seem to have no problem managing a pediatric population.

I guess I just find it odd that after 3 years one might be fully qualified to be a pediatrician, managing complex inpatient cases and doing ED consults, yet needing 2-3 more years for peds EM. Likewise, an EP might be able to manage peds EM in a community hospital, but need 2-3 more years to do dedicated peds EM.

Is it just the large breadth of ages and disorders which necessitates a 6 year track? Its just weird to me considering that peds neurosurg, for example extends one's total PG training by like 15%, whereas peds EM extends it by 100%.

Because All Peds fellowships are 3 years in length. Even adolescent medicine is a longer path if you do it in Peds than If you were to do it in IM. Wait please don't tell me their is a 3 year fellowship for pediatric hospital medicine...
 
Last edited:
Frankly, we should just get rid of pediatrics entirely. Family medicine physicians have been seeing kids forever.

LOL we might as well get rid of internal medicine too, since FM docs are perfectly capable of treating adults. You would need to expand family medicine residencies 10 times over to cover all those extra patients.

Most of the family medicine practices I've seen get quickly overwhelmed with sick adult patients to the point where kids make up maybe 20% of their practice at most.

Also, peds reimburses less well than adult patients, so that's another incentive against FM docs seeing peds patients.
 
LOL we might as well get rid of internal medicine too, since FM docs are perfectly capable of treating adults. You would need to expand family medicine residencies 10 times over to cover all those extra patients.

Most of the family medicine practices I've seen get quickly overwhelmed with sick adult patients to the point where kids make up maybe 20% of their practice at most.

Also, peds reimburses less well than adult patients, so that's another incentive against FM docs seeing peds patients.

Good point. We can probably knock out EM, General Surgery, and OB/GYN while we're at it. Why would they need extra training? They already see those patients. We've already established that as the gold standard for competency in this thread.
 
Good point. We can probably knock out EM, General Surgery, and OB/GYN while we're at it. Why would they need extra training? They already see those patients. We've already established that as the gold standard for competency in this thread.

I get what you're trying to say, but the three year fellowships are a great example of the perfect being the enemy of the good. If general Pediatricians are already seeing the subset of patients that the fellowship trains them for then they're not going to do an extra three years of fellowship to keep seeing those patients. Family medicine has shown that physicians are selfless enough to spend an entire year in fellowship training just to be better at the job they're currently doing. However there does seem to be a limit to how much time and money physicians are willing to invest in the quality of care they provide, and I think the dearth of fellowship trained Peds EM physicians shows that 3 years is over that limit.

No one is saying that these shouldn't be fellowship trained positions, but as long as the fellowship is three years long the majority of children's hospital EM docs are going to remain boarded in either just pediatrics or just emergency medicine. Which is a shame, because with a one year fellowship I think we would see a real improvement in the quality of care provided, and might actually have a chance of making board certification in Peds EM the standard of care for children's EM physicians.
 
Last edited:
I agree that there needs to be a more efficient pathway for training physicians to staff a pediatric emergency department. I'm just not convinced that decreasing the fellowship requirements just so everyone can be certified is the solution.

Maybe I'm living in a dream world but I think the specialty is already heading in a direction that makes more sense. Residencies are starting to implement "tracks" and transition to more customizable residencies.

Why not have in-patient, out-patient, emergency department, and rural/general tracks in residencies? By narrowing the focus a bit you could increase exposure and competency in the aspects of all the sub-specialties that intersect with their chosen realm. Granted legal concerns drive a lot of consulting/referral patterns, the end result would hypotheticalky be fewer consults/referrals, a decreased need for specialists, and a shift to fellowship trained specialists going back to leadership roles and focusing their practice on the especially difficult patients.

Filling the emergency departments with people who trained for 3 years specifically to work there seems a lot more efficient than trying to corral them into fellowships. Then maintain the fellowship route for those who want to do research, write clinical practice policies, teach, etc.
 
Members don't see this ad :)
Which is a shame, because with a one year fellowship I think we would see a real improvement in the quality of care provided, and might actually have a chance of making board certification in Peds EM the standard of care for children's EM physicians.

Now now now, hold on.
I think a year after EM might be suitable for peds EM. Just like it used to be for US, EMS, Wilderness and other subspecialties before certification.
And while I think the peds guys at my shop do a great job with the 95% or so that aren't really sick, they are terrible at the stuff that is important. They can't sedate patients appropriately for reductions, so they don't reduce, they just splint in that position. They don't understand EMTALA (and refuse transfers all the time). They don't resuscitate well, can't put in lines, are uncomfortable with IO, and their airway management consists of multiple attempts at ETT. They aren't using BiPAP/LMA.

There may be peds grads out there that are good at resuscitation, but they're outliers. Granted, most people get away with it because the PICU is there, but the PICU doesn't come down for the dislocated shoulders.

I kid you not, I've taken transfers from peds hospitals to my adult hospital (with no peds floor, service, or specialists) for the simple bread and butter EM stuff because they can't do it.

Thus, I think it needs more than a year after peds to learn those critical skills. It probably doesn't take 3, but 18 months or 2 years is probably good.
What's really funny is when the EM people go to Peds EM fellowships and on the first day, the attendings are like "have you ever sutured before?"
 
Last edited by a moderator:
I wonder if the American Board of Pediatrics would be willing to make a 4 year pathway directly out of medical school, whereby a physician would train in two years of general pediatrics and then switch over to pediatric emergency medicine, thereby being board eligible in pediatric emergency medicine only.
 
Now now now, hold on.
I think a year after EM might be suitable for peds EM. Just like it used to be for US, EMS, Wilderness and other subspecialties before certification.

A year of intense procedural training involving spending several months in PICU and OR would be good enough.

And while I think the peds guys at my shop do a great job with the 95% or so that aren't really sick, they are terrible at the stuff that is important. They can't sedate patients appropriately for reductions, so they don't reduce, they just splint in that position.

What? Are you talking about a peds --> 3 year peds EM fellowship trained person? They went thru 3 years of peds EM fellowship and cant sedate? My god, thats like saying a general surgeon completed 5 years of general surgery and doesnt know how to do an appendectomy. Procedural sedations for reductions are bread and butter of any decent volume peds ER. LMAO


They don't understand EMTALA (and refuse transfers all the time). They don't resuscitate well, can't put in lines, are uncomfortable with IO, and their airway management consists of multiple attempts at ETT. They aren't using BiPAP/LMA.

Well I'd argue that if their "training" consisted of hanging out in a peds ER waiting for stuff to come in, then NOBODY would be well trained, even if you spent 10 years in there.

Peds patients are much, much less likely to be critically ill than adults are. I saw a study a few years ago which showed that the intubation rate in adult ERs is something like 1 in 100 whereas in peds ERs the rate is 1 in 5000.

In order for peds EM training to be any good, you HAVE to spend a lot of time in PICU in OR training on intubation and lines. Even a high volume peds ER wont give you enough experience if you are just hanging out down there doing shift work.


I kid you not, I've taken transfers from peds hospitals to my adult hospital (with no peds floor, service, or specialists) for the simple bread and butter EM stuff because they can't do it.

I'm curious... what have you seen?


What's really funny is when the EM people go to Peds EM fellowships and on the first day, the attendings are like "have you ever sutured before?"

??? Suturing is something that just about every peds intern does multiple times in their very first peds ER month.

Peds residents are lacking in a lot of procedures, but suturing and LPs don't fall into that category.
 
What? Are you talking about a peds --> 3 year peds EM fellowship trained person?
Talking about the peds (not peds EM) folk that staff the majority of shifts. However, even the peds EM guys are hesitant to sedate.

I'm curious... what have you seen?
Mostly procedural sedations for orthopedic reductions. Every now and then I get the adult transfer to me simply because "we can't handle adults", which is frankly bull****.


??? Suturing is something that just about every peds intern does multiple times in their very first peds ER month.

Peds residents are lacking in a lot of procedures, but suturing and LPs don't fall into that category.

LPs they are usually good at, since they do those on the floor. Suturing they're not. They're only required to do 2 months of EM during their residency.
 
Talking about the peds (not peds EM) folk that staff the majority of shifts. However, even the peds EM guys are hesitant to sedate.

Mostly procedural sedations for orthopedic reductions. Every now and then I get the adult transfer to me simply because "we can't handle adults", which is frankly bull****.

LPs they are usually good at, since they do those on the floor. Suturing they're not. They're only required to do 2 months of EM during their residency.

OK, fair enough, I agree with everything you said. At first I thought you were talking about peds EM trained people.

How often do you sedate toddlers (age 1-3) for sutures?
 
OK, fair enough, I agree with everything you said. At first I thought you were talking about peds EM trained people.

How often do you sedate toddlers (age 1-3) for sutures?

If the wound actually needs approximation, I'll sedate more often than not. If it's on the face, I'll sedate 100% of the time.
 
Now now now, hold on.
Thus, I think it needs more than a year after peds to learn those critical skills. It probably doesn't take 3, but 18 months or 2 years is probably good.
What's really funny is when the EM people go to Peds EM fellowships and on the first day, the attendings are like "have you ever sutured before?"

I'm not sure that procedural skills and a course in conscious sedation would take more than a year to learn, and I'm not sure that at EM boarded doctor is only 1 year of training away from being ideally trained to work in the emergency room of a children's hospital. The necessary training would probably even depend on what electives the EM/Peds docs did in residency. However, regardless of what the ideal course of training would be for a Peds EM doctor, I think the most important point of a single year fellowship would be to establish fellowship training as the standard of care for ED physicians in childrens' hospitals. If we established a single year fellowship track for both EM and Pediatrics, I think that we could rapidly establish the critical mass of fellowship trained physicians in EDs that would make it legally untenable to hire non-fellowship trained physicians to work in a children's hospital ER. Once that you can raise the fellowship bar all you'd like, since the only way into an Peds EM job will be through a fellowship. As it stands, though, the standard of care is still someone with just 3 years of Pediatrics training or 3 years of EM training, and there aren't nearly enough people willing to go through a three year fellowship for a job they're already medico-legally qualified for to establish that critical mass.

FWIW, I think a single year of intense fellowship would probably be more than adequate for training both emergency medicine physicians and Pediatricians to provide the best possible care in a Pediatric ED.
 
Last edited:
I'll just say that I disagree that you can take an EM grad and a peds grad, give them both a year, and have two decent Peds EM people.

The simple peds stuff can be done by the janitor. The rest by the nurses/RTs. The only important parts are the resuscitations. One type of resident does that for the majority of their residency. They typically don't do anything outpatient. The other has nearly half their residency outside the hospital. They do 2 EM months, and 2-3 ICU months.

I say this as someone married to a pediatrician, who works in a Peds EM with both EM and Peds residents. The EM residency requirements and board certification specifically include pediatric components. There's a reason many of us bristle when we are called "adult EM" docs.

While you and I both might want all peds EDs to be staffed with Peds EM folk, this will probably never happen. I want all EDs to be staff with EM trained people as well, but this too won't ever happen. I argue that a fresh EM grad is better suited to start working in a peds ED (or an ED with 30% peds, which is what we call "the rest of the world") than a fresh peds grad.
 
I'll just say that I disagree that you can take an EM grad and a peds grad, give them both a year, and have two decent Peds EM people.

The simple peds stuff can be done by the janitor. The rest by the nurses/RTs. The only important parts are the resuscitations. One type of resident does that for the majority of their residency. They typically don't do anything outpatient. The other has nearly half their residency outside the hospital. They do 2 EM months, and 2-3 ICU months.

Wow, some peds residencies only do 2 months of EM? I always assumed the minimum number of months was higher, since my program does 5 months total in the pedi ED (we spend more total time in the pedi ED than the EM residents do). When you add in 4 PICU months, 3 NICU months, 6 wards months, and 3 night float months, plus some inpatient-heavy electives (like heme-onc and ID), we end up with almost 2/3 of our residency being inpatient-based. And my program is considered a primary-care focused program!
 
I'll just say that I disagree that you can take an EM grad and a peds grad, give them both a year, and have two decent Peds EM people.

The simple peds stuff can be done by the janitor. The rest by the nurses/RTs. The only important parts are the resuscitations. One type of resident does that for the majority of their residency. They typically don't do anything outpatient. The other has nearly half their residency outside the hospital. They do 2 EM months, and 2-3 ICU months.

I say this as someone married to a pediatrician, who works in a Peds EM with both EM and Peds residents. The EM residency requirements and board certification specifically include pediatric components. There's a reason many of us bristle when we are called "adult EM" docs.

While you and I both might want all peds EDs to be staffed with Peds EM folk, this will probably never happen. I want all EDs to be staff with EM trained people as well, but this too won't ever happen. I argue that a fresh EM grad is better suited to start working in a peds ED (or an ED with 30% peds, which is what we call "the rest of the world") than a fresh peds grad.


While I generally agree with you that the resuscitation/critical skills of EM residents >> peds residents, I must also say that the simple adult stuff can also be done by janitors.

Lets not sit here and pretend that every person coming into the adult ER needs an MD to treat them. We both know thats not true. A lot of them just need babysitting, which could be done just as easily by a high school student rather than a doctor.
 
Wow, some peds residencies only do 2 months of EM? I always assumed the minimum number of months was higher, since my program does 5 months total in the pedi ED (we spend more total time in the pedi ED than the EM residents do). When you add in 4 PICU months, 3 NICU months, 6 wards months, and 3 night float months, plus some inpatient-heavy electives (like heme-onc and ID), we end up with almost 2/3 of our residency being inpatient-based. And my program is considered a primary-care focused program!

The ACGME requirements specify a minimum of 2 months in a peds ED. Most residencies do a lot more than that however.
 
While I generally agree with you that the resuscitation/critical skills of EM residents >> peds residents, I must also say that the simple adult stuff can also be done by janitors.

I have said that my job could be done by a monkey, or even a machine. Just like surgeons say about appendectomies or cholecystectomies, we are not there for when it goes right, but when it goes wrong. We don't know which cases or patients that come through the door will be one of the 3 or 5% that actually need a doctor, but, when it is the anaphylaxis or obstructed airway or STEMI, that is what we are trained to do. Not every hit is a 4 bagger; in fact, most are strike outs, hit outs, or singles, with a fair number of walks.

Compare that to fire department and the police (especially), who do the same - long periods of massive boredom punctuated by moments of sheer terror.

You want to be the peds apologist - I get that, honestly. However, it is like the "break glass in time of emergency" - what happens when your biggest or strongest weapon isn't enough? When you break out the "BFG", you don't want it to bounce off the problem - you want it to fix the problem. What happens when the loudest sound you can make is a little, barely audible "peep"? (Exaggeration for emphasis)
 
While I generally agree with you that the resuscitation/critical skills of EM residents >> peds residents, I must also say that the simple adult stuff can also be done by janitors.

Lets not sit here and pretend that every person coming into the adult ER needs an MD to treat them. We both know thats not true. A lot of them just need babysitting, which could be done just as easily by a high school student rather than a doctor.

No doubts. But it's more common in Peds.
Where we were shipped out for peds in residency they used to joke about the ESI ratings. ESI 1 meant dying. 2 needed a doctor. 3 needed a nurse. 4 needed tylenol. 5 needed a work note.
 
I'm not sure that procedural skills and a course in conscious sedation would take more than a year to learn, and I'm not sure that at EM boarded doctor is only 1 year of training away from being ideally trained to work in the emergency room of a children's hospital. The necessary training would probably even depend on what electives the EM/Peds docs did in residency. However, regardless of what the ideal course of training would be for a Peds EM doctor, I think the most important point of a single year fellowship would be to establish fellowship training as the standard of care for ED physicians in childrens' hospitals. If we established a single year fellowship track for both EM and Pediatrics, I think that we could rapidly establish the critical mass of fellowship trained physicians in EDs that would make it legally untenable to hire non-fellowship trained physicians to work in a children's hospital ER. Once that you can raise the fellowship bar all you'd like, since the only way into an Peds EM job will be through a fellowship. As it stands, though, the standard of care is still someone with just 3 years of Pediatrics training or 3 years of EM training, and there aren't nearly enough people willing to go through a three year fellowship for a job they're already medico-legally qualified for to establish that critical mass.

FWIW, I think a single year of intense fellowship would probably be more than adequate for training both emergency medicine physicians and Pediatricians to provide the best possible care in a Pediatric ED.

The problem is that EM (adult or peds) is a specialty that's largely informed by one's confidence with procedures. There is a sliding scale of how sick someone is vs. comfort with a procedure that determines who gets what. I've seen it on the adult side where FM or IM trained docs delayed putting in central lines or intubating patients on patients that needed them out of personal discomfort until the patient crashed and their hand was forced. It exists on the peds side also with the added bias that peds training tries to minimize trauma from medical intervention which works really well in the chronically ill but creates an enertia that's dangerous in the acutely ill.

I think you vastly overestimate the number of procedures available on sick kids and at least where I trained putting in a central line was not a procedure that late first year fellows (peds to peds-EM and peds ICU) were competent in. Now if you were to develop a sim program that accurately taught monkey skill then 1 year clinically may be enough.
 
Top