Another PICU ?- Peds vs MedPeds

[Nivens]

Please forgive yet another PICU question...

I'm currently on my third year internal medicine clerkship, and it just so happens my entire team is MedPeds. Many of them, when they hear I am thinking I want to do PICU, have told me that I should do MedPeds because I will get a lot more exposure to sicker/MOF patients, codes, procedures, etc, then I would doing just Peds followed by PICU fellowship. The claim PICU is more medicine then it is peds. At first this seemed reasonable, but then I started thinking... after finishing four years on MedPeds would I really be that much better at taking care of critically ill children than a rising second year PICU fellow? Year-for-year, could a MedPeds doctor ever really catch up? I buy that MedPeds would arguably make you a more "well-rounded" doctor, but so would doing both an IM and GenSurg residency. I could suffer through two years worth of adult medicine in residency if it was going to make me a substantially better intensivist, but I'm not entirely convinced it will.

Thoughts?

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[deleted311769]

Regardless of the answer to your question on which one is better you gave yourself the answer when you said "suffer through." If you wouldn't love your medicine years as much as peds, and you have no intention of going into any adult medicine field later on, there is no reason whatsoever in doing Med-peds. In addition, although med-peds does MICU, they actually have less PICU time in almost every program (less is required). Not to mention that I completely disagree with the premise that PICU is more medicine than peds. I'm sure some of the intensivists on this board can chime in more, but to suggest that as a third year peds resident I am somehow less competent in treating critically ill pediatric patients or prepared for fellowship just seems a little silly. Being an intensivists is about being a great pediatric generalist. Yes, all roads in the ICU generally lead to shock and/or respiratory failure, but it's still all of our amazing/crazy/complicated/unusual pediatric patients. As much as I love and trust my med-peds colleagues and think they have SO much more knowledge in an area I know very little, sometimes it is noticeable that they have less experience overall in the pediatric setting. This all sorta evens out by the end, but that's it... it evens out. Not to mention that fellowship itself is when you learn how to be a fellow. A few months in the ICU and any difference there could potentially be there (if it exists) would likely be washed away. And anyway, you don't sound like you'd like the medicine part anyway. So problem solved.

 

[Nivens]

Not to mention that fellowship itself is when you learn how to be a fellow. A few months in the ICU and any difference there could potentially be there (if it exists) would likely be washed away.

This is exactly what I suspect. One 3rd year medpeds resident told me that first year PICU fellows have to shadow their first month of fellowship bc most of them don't have any idea how to do lines or run codes, whereas the medpeds people who have rotated in MICU and medicine consult are ready to hit the ground running. Again, on the surface of it, she seems to have a point, but when I thought about it, it seemed crazy to spend an extra year learning to manage chronic HTN, PVD, strokes, etc to INDIRECTLY prepare for a PICU career when I can spend that year DIRECTLY training in the unit.

Thanks for your reply.

 

[mvenus929]

One 3rd year medpeds resident told me that first year PICU fellows have to shadow their first month of fellowship bc most of them don't have any idea how to do lines or run codes, whereas the medpeds people who have rotated in MICU and medicine consult are ready to hit the ground running. Again, on the surface of it, she seems to have a point.

I dunno. I think a lot of that has to do with the hospital in which you train... At my home institution, residents do relatively few procedures in the PICU, because there are fellows who need the procedures, but half of the residents rotating in PICU are not peds residents--they are anesthesia and emergency. At places I've interviewed this year, there's a mix of not doing anything because there are fellows and doing everything because there are not. And with the ACGME requirements for an individualized curriculum, a lot of programs are allowing you to do more procedure heavy rotations (ED, PICU, NICU, etc) so you don't feel so out of place when you start fellowship.

I'd also argue that seeing an adult patient with CHF, COPD, s/p stroke, etc code is much different than seeing a former preemie with chronic lung disease code, no matter how many times you've seen the former.

 

[Nivens]

there's a mix of not doing anything because there are fellows and doing everything because there are not.

I'm assuming the former is preferable?

 

[mvenus929]

I'm assuming the former is preferable?

Depends on your goals. A resident oriented program is good in the sense that you get a ton of experience, and thus feel more prepared going into fellowship. But a program with fellows will more likely have research opportunities and other supports in place to help you get a fellowship.

It's similar to unopposed vs opposed residencies for family medicine--if you have top faculty for IM and Peds, then you'll get a good education from them with cutting edge information, but if you're in an unopposed program, you'll get more opportunities for hands on experience with managing patients.

People choose different styles of residency for multiple reasons.

 

[Stitch]

One of our current attendings is med/peds, as is one of our fellows. They are great, smart, and have a lot of knowledge that is helpful in the ICU, gained from their IM months (reading EKGs, understanding insulin management in type 2 DM) that sort of thing. But I don't think those doing critical care without IM experience are truly at a disadvantage in any way. The extra experience does help, but it's not a reason to do med/peds. If you do like taking care of adults then great, but if you really only want to see kids (like me, I would have hated every minute of medicine), then just do a peds residency. You'll be fine.

 

[Nivens]

I really think what my resident is missing is you can't compare a PGY-3 to a PGY-4 head-to-head in the same clinical scenario. The question really becomes whether the additional IM training produces a stronger clinician at, say, the end of PGY-10, when both doctors have completed fellowship and been attendings for a few years. In hearing from you all and talking to PICU people at my home program, I suspect things have pretty much evened out by then.

 

[michigangirl]

I really think what my resident is missing is you can't compare a PGY-3 to a PGY-4 head-to-head in the same clinical scenario. The question really becomes whether the additional IM training produces a stronger clinician at, say, the end of PGY-10, when both doctors have completed fellowship and been attendings for a few years. In hearing from you all and talking to PICU people at my home program, I suspect things have pretty much evened out by then.

Yes, yes and yes. You are going to be absolutely fine if you know you want to be a pediatric intensivist-- straight peds is the right choice. Unless you know you want to be in the OR, or know you want to take care of adult ICU patients, anesthesia and internal medicine will only make the first year of fellowship easier-- but it all evens out!!!

 

[Nivens]

Michigangirl has become my own personal career-counselor lol. Thank you!

 

[DeadCactus]

Sounds ridiculous to me. You could justify doing IM/Peds and then a PICU fellowship for a lot of reasons (love both, want to keep options open, want to build an academic focus on patients that straddle both worlds, etc) but it's asinine to argue that it's a better route. You could take that extra year and do a lot of other things with it that would be far more beneficial or just go straight through and build an extra year of attending level experience by finishing up sooner...

 

[mercaptovizadeh]

I am sure it evens out in the end. Don't do med-peds unless you also enjoy IM. From my interviews, my impression is that IM offers a lot more autonomy and procedures and tends to be more resident run rather than fellow/attending run, which seems to be more so the case in pediatrics. Given that, med-peds people who are PGY3-4 will probably be more confident in the ICU than peds PGY3.

I am sure the surgeons and anesthesiologists are more confident/handy in the ICU at first than the internists, but that doesn't mean every internist should also train in general surgery or anesthesia to be handier at intubations, lines, etc.