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Deciding PICU vs. GI

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TBRaysgirl

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I am almost half way through my second year of pediatric residency and have always known that I want to pursue fellowship. I came in with a good amount of GI exposure from medical school where I saw a diverse range of GI pathology, transplant patients and overall very sick children. I loved the field and was pretty sure that I wanted to pursue GI fellowship. I never had much ICU experience but had a feeling I would like it, and needed to rule it out.

..Fast forward to now. I am currently doing residency at a mid-size program with a completely different GI population. A lot of gastroparesis, chronic abdominal pain, and very little transplant exposure other than those who are many years out and stable. Everyone, including myself, dreads seeing this population and unfortunately it has worn on me as well. To make matters worse, I realize I am less happy in general in an outpatient setting which makes up a large portion of the field.

I did PICU for the first time first rotation of second year and I loved the fast decision making, use of physiology and collaboration with multiple different teams. It is sad, but I feel that I have a tough personality which can handle it. I spoke with my attendings who agree I would be a good fit and have offered to mentor me, hook me up with research, etc. I was pretty confident about making the switch...until I attended the national GI conference and realized, again, there was a lot about GI I loved and that everyone was so happy. Now I am more conflicted than ever.

As far as my CV goes, I already presented at the GI conference and am working on publishing 1 case report (and another in the works). I am involved in an IBD transition study, though most of the work is being conducted by an adult GI fellow due to my schedule. My PICU attending has given me a lead on an ICU project which sounds exciting..but If I move forward, and end up doing GI, I do not want to make it seem like I am unfocused.

I know that nobody can make my decision for me, and ultimately I have to weight the pros and cons of each, but I was wondering if anyone else is in a similar decision or has been in the past. What did you ultimately decide and why? Otherwise, does anyone else have any insight? Thank you!
 

mvenus929

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Your role in the research is more important than what the research is in. If you start a proposal from scratch, including going through IRB, you will do better, even if the research is outside your field, than if you just do lab work, even in a project in your field. The purpose of fellowship is to train you to be a specialist, and that includes research in your specialty.

I can't offer you much beyond that... it sounds like you need to spend more time figuring out the day to day stuff, and realizing which you can't stand and which you can't live without.
 

BigRedBeta

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A few thoughts/questions/things to think about as you move forward

1) Do you like the sickest GI kids best or are there other GI patients you have a passion for? I enjoyed my pulm rotation, but the patients I liked best were the ones that ended up in the PICU. I wasn't super pumped by OP trach/vent management or "healthy" CF patients. The acute liver failures, subsequent transplants, and GI bleeds are going to be in the PICU...along with everyone else's sick patients.

2) Is it all OP clinic you're less than thrilled about or just the OP GI clinic you've been exposed to? Most PICU docs abhor clinic and so staying in the unit is a big draw. But if you like continuity of care and seeing kids grow, then you generally miss out on that in the PICU (not entirely though, but you rarely see kids repeatedly who are "healthy")

3) You mentioned transplant patients twice...maybe you should think about a doing a 4th year Transplant Hepatology fellowship after a GI fellowship.

4) Don't worry about the type of research. It really won't matter to PICU fellowships. The beauty of the PICU is that because we take care of everyone, you can push into research in any area. For GI fellowships, your prior research is likely entirely sufficient.
 
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michigangirl

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Everything BigRedBeta said, plus...

Needless to say, being torn between GI and PICU isn't a common scenario, so you won't find many people who had a similar choice to make. Absolutely don't worry about your choice of research making you look unfocused as others have said. It's most important to have a significant role and accomplished more within the area you're researching then to do several projects in different areas more superficially.

It sounds to me that you love taking care of sick and complex children. We get our share of GI pathology in the PICU, and since there aren't many folks who focus on GI in the PICU crowd from a research standpoint, you have ample opportunities to create a research niche in a GI area that pertains to critically ill children. In fact, if you came to interview at our fellowship program and articulated your interest in GI issues in the context of the PICU, that would set you apart from the crowd!

I don't know of any GI specialties that don't have outpatient responsibilities, so that's a factor. And even when GI is involved in our sickest patients, it's still in a consultation role-- my fellows get to have all the fun of dealing with the acuity unless the child needs an endoscopy.

Good luck!
 
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A few things to consider, IMO...

1. I think you will be happy either way - so at the very least remember this when you get frustrated about having difficulty deciding!

2. Think hard about where you see yourself in 10 years. Think about lifestyle differences between the two specialities. What types of lifestyle factors matter most to you? Also what non-clinical work (i.e. research, teaching, fellowship director, chief of dept, public health work, journalism) do you see yourself involved with and how would each speciality add to your ability to do these?
 

Stitch

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I would add that you need to think about the day to day stuff you'll be doing in each specialty. A lot of GI is abdominal pain, constiptation, cleanouts. A lot of GI patients are crazy and complete dumps from other services. Not something I could do. But as suggested above you could also do a 4th year and be dealing with liver failure and transplants. The endoscopy lab is also pretty cool.

You need to weigh those day to day activities against the PICU. Sometimes PICU is exciting, but lines and intubations become less so over time. My days as an ICU attending tend to focus on a few things. Bedside physiology, especially cardiorespiratory and ventilation management along with general vital sign manipulation. Shock. But a large part is spent communicating with surgeons, cardiac and otherwise. There's a lot of politics involved and you have to be able to play nice in the sandbox. You have to be willing to pick your battles and speak up for end of life care as well. If you do a lot of cardiac surgery, much of your time will be enacting the cardiac surgeons plan and you have to be okay with doing that instead of frustrated or bitter that you're not the solo captain of the ship (that surprises people sometimes).

What do you like reading about? What do you want to learn a whole lot more about? If you love reading about the liver and GI stuff, and the thought of doing things in the endoscopy suite gets you jazzed, then do that. For me, I loved learning about ventilators and the mechanical aspects of ECMO and the physiology of shock. Different strokes and such.

If you are interested in the general topic, you'll find research you're interested in to go with it.
 
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