Big people vs. Little People

[mytirf]

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I'm a 4th year MD/PhD student and have been struggling for some time between choosing a residency in Internal Medicine versus Pediatrics. I see the advantages and disadvantages of each. Pros for Peds: kids get better, have interesting diseases, sometimes extremely rewarding to work with the whole family, versus dealing with annoying parents, kids who aren't so sick but in the hospital and the lack of independence with peds training. Pros for Int. Med: Excitement and fun treating complex diseases, challenge of cardiology, learning the stories of people's lives, and greater independence during training versus, people never getting better, diseases caused by smoking, being fat and not exercising and whining patients who are seeking a magic pill to fix their crappy life-style.
I realize that this is a complete simplification, but at this stage, I recognize the need for some level of simplification. Has anyone else struggled with this decision? What kinds of criteria did they use to make a final decision? I realize that Med/Peds is a possibility but I also would like to do research as well, and I really don't want to do primary care. I guess some of biggest concerns are the lack of independence with pediatrics in comparsion to Int. Medicine and how that would eventually wear on me fairly heavily. Can anyone give me a little advice on how to proceed? I have done electives in both and really do little different aspects of each. Thanks

 

[14022]

I struggled with this as well. Well, actually, it was not much of a struggle because I chose pediatrics pretty easily. I wanted to do cardiology for a while in medical school. After my trauma surgery rotation, I realized adults were so f'n stupid that I couldn't stand it anymore. Taking care of people who would get drunk and walk into traffic and hurt themselves and then threaten to sue the person whose car they walked into; people who would violently rob a bank, get shot and end up in the hospital for three months and complain about the care they were receiving when the hospital was going to have to pay for the 1.5 million dollars of helth care they provided because he didnt have any insurance. And of course, like you said, the more common situations of 300 pound 60 pack year smokers with heart disease.

With pediatrics, I felt more comfortable in the hospital. I found it easier to deal with difficult parents in peds than noncompliant patients in IM. Also, the pediatrics hospitals tend to be happier environments, brighter colors, better lighting, more art on the walls. I loved being on rounds and seeing a five year old in his little blue hospital pajamas dragging his giant IV pole down the hall on the way to the play room. This was much better than what I would see during IM rounds, such as seeing a patient harass a nurse because he hadn't gotten his breakfast yet or seeing one of your COPD patients on his way to the smoking patio, or finding out one of your patients (who had drug seeking behavior) left AMA after he got his central line so he had IV access for his heroin addiction.

All of IM is not as bad as I have made it out to be. I probably have a skewed perception of IM since I rotated through both the VA and an inner city hospital for my IM rotation, but the fact of the matter is that the most prevalent diseases in adults in our society (heart disease, stroke, COPD, lung cancer) are strongly related to life style (smoking, obesity, no exercise, poor diet). Most of pediatric illness is due to bad genes, bad parents, or bad luck.

Another thing to consider is salary. If you want to be a specialist, you are going to make significantly more money in IM. But this mainly applies to private practice, for which the opportunities are more widely available for IM subspecialties. So if you want to do research and stay in academics, the salary difference is less significant. In terms of research, you can still do research in academic primary care if you choose, so do not shy away from med-peds for that reason.

My recommendation would be to do electives in both IM and peds. For IM, try to go to a smaller community hospital in the suburbs and see if you have a different perspective. Best of luck to you!

 

[14022]

By the way, what do you mean by "lack of independence with peds training?"

 

[antoniop]

Any new thoughts on this debate?

 

[thos]

I think the OP sells Peds short by stating that IM offers "excitement and fun treating complex diseases, challenge of cardiology, learning the stories of people's lives, and greater independence during training," implying that Peds doesn't offer these (maybe I'm reading it wrong). What's a more complex Cards issue than congenital heart disease where everything is hooked up backwards? As for independence, I don't see any difference between the two.

I think a lot of people struggle with the decision between IM and Peds. They're such similar fields, it often comes down to which setting you like best. Sometime during second year I started to consider Peds, and solidified the idea by my Peds rotation. However, IM would sneak back in to my thinking periodically. I'll admit I was concerned that Peds isn't taken as seriously in an academic sense compared to IM, but seeing the great children's hospitals I visited during interviews immediately put those concerns to rest.

Med/Peds can offer some very exciting opportunities that are not just limited to primary care. For instance, some adults with CF are still cared for by pediatricians because IM docs haven't traditionally had to work with this population since they didn't make it to adulthood. Adults with congenital cardicac defects are another good example. In my case, after talking to some Med/Peds residents I realized many will ultimately choose one field over the other, and knowing my choice would be Peds I decided to save a year.

Since the OP is an MD/PhD I'd like to address that too. Peds is a fantastic field for the physician researcher. Many programs are starting to put emphasis on recruiting MD/PhD graduates, and a number of children's hospitals are adding considerable research facilities. All Peds subspecialty fellowships have research built in, as opposed to IM in which some do and some don't (although they usually have the option). In many cases, Peds attendings at academic centers have 8-12wks of clinical service a year, with the rest to focus on research or other activities. (Cardiology is a notable exception, where a balance between research and clinical activity is achieved at only a few top notch hospitals.) Finally, the numbers are in your favor: about 25 MD/PhDs per year go in to Peds out of 2,200+ total PGY1 spots.

 

[KidDr]

As for independence, I don't see any difference between the two.

Everyone's given a lot of good advise so far. The only thing I don't quite agree with is this. I have plenty of friends in IM, and I do think there's a difference in "independence" between IM and peds, on many levels. Especially when you're at a big tertiary children's hospital, where a big percentage of the kids are followed by multiple specialists and the parents really don't want to see you (the resident)--they want to see their specialist. I realize this can happen at big academic adult medical centers too, but it's my sense that 1) it isn't as frequent, and 2) it isn't as pronounced.

Also, it can be harder to learn pediatric procedures, both because there's less of them to do (think of all the procedures done fairly regularly in IM that are rare in peds--pericentesis, thoracentesis, ABGs, etc), and because parents are sometimes leery to let inexperienced residents "learn" on their kids. That's not to say it's impossible to get procedures in peds--you just have to be more proactive, and rotate through the PICU and ED.

Overall, I think the peds residency programs that are based primarily out of large tertiary pediatric hospitals offer residents the least amount of independence, while those based out of county hospitals will offer the most. The same can obviously be said about IM programs, but there's still a difference...anyone with me here?? 🙂

 

[thos]

Take my opinion for what it is, that of someone who hasn't yet done residency. I see your point about procedures and specialists, but it seems it would be true of an attending gen ped also, i.e., the parents want to talk to the specialists and not as many procedures to do. In that sense, the training prepares you for your career the same way IM does. Also, in my experiences as an MS-III and MS-IV I spent time with both IM and Peds teams, and in both cases the interns and residents were completely in charge overnight (with available supervision) and had the same amount of input from attendings during the day. However, I am at a large medical center for both IM and Peds, and this may skew my perception.