Disappointed in Pediatric Intern Year

[adalo]

I am coming to the end of my intern year in pediatrics at a very reputable program, but am wracked with a sense of disappointment in my choice to pursue a career in pediatrics. I did well in medical school, with scores that would have left any field open to me, however, I chose pediatrics out of an interest in pediatric pathophysiology and a genuine love for caring for children. However, the reality of my life for the last year has been endless rounding, note writing, coordination of care, talking to upset parents and maybe all of 10 minor procedures. This is not what I went into medical school to do and I leave almost every long day feeling absolutely drained and feel like I have accomplished very little. Classic for burnout, but remember, with only 10 minor procedures in a year I have, by many objective metrics, done very little to concretely help my patients. The real problem is, I don't see it getting better anytime soon. Most of the senior residents in my program are very good people, but obviously worn down. The attendings seem to do just as much care coordination, very few procedures and when you look up their salaries, are making little more than the NPs. As a matter of fact, the NPs are actually better than most residents because the only thing we actually do is coordinate care and make minor decisions, something which a background in nursing prepares you to do better than medical school. The truth is, I just had no insight into how little "medicine" is involved in being a pediatric resident.

The real question now is, what should I do with myself now that pediatrics has lost its charm? I did enjoy NICU and PICU to a certain degree, but the endless rounding and care coordination still killed me. Also, procedures happen uncommonly in those fields. I have not done pediatric emergency medicine, so that is still a possibility. The reality is, I don't know if my soul can survive another two years of endless rounding and care coordination, let alone a lifetime. I am seriously entertaining a switch to emergency medicine at this time. I would also be interested to learn more about anesthesiology, but honestly I have had no exposure. I will have to finish at least a PGY2 year in pediatrics, so I have some time to decide on the matter. At any rate, I would love any input that you readers might have. I'd be especially interested to hear about the expericences of anyone else that has been in a similar situation.

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[22031 Alum]

Did you go into peds hoping to ultimately do a more procedural fellowship?? You lamented a lack of procedures 4 times in just that one post, which is more than I'd expect from someone who must have at one point made the "not surgery" decision.

 

[AStark]

Sounds like you're mostly demoralized with inpatient pediatrics. This isn't, of course, a major part of practice for most pediatricians, though it's fair to say that I've never thought of pediatrics as a procedurally-heavy specialty either. Had you considered interest in procedures before choosing pediatrics?

Most PGY1s do not get to do anything other than "minor" procedures. Are there any you feel like you're really missing out on?

 

[BobBarker]

Most pediatrics residents hate doing procedures. You could easily become the "procedures guy" and carve out a niche for yourself. I think you should start out your next year with every intention of making pedes workout as you will be so close to completing your residency at that point. There are combined pediatrics/anesthesia residencies. I think Baylor, Stanford, and some others. I would investigate these, call them, and try to transfer in. They are 5 years for Pedes and anesthesia. Then you do a one your pedi anesthesia fellowship and you will be the pedi minor procedure guy you want to be and a very sought after entity in any academic department.

 

[link2swim06]

Try peds EM. You will get better exposure to procedures (sewing up lacs, sedation, LPs). However, in general kiddos are not as sick as their adult counterparts. Therefore, unless you sub-specialize you are not going to be performing the same number of procedures.

You sound like you want to do surgery based on your first post.

 

[Mass Effect]

If you chose peds just to do procedures, you chose the wrong field. As mentioned above, try to do peds EM. Regular peds will likely include very few procedures. I also disagree with your notion that because you've done such few procedures you haven't helped your patients. This is absolutely not true in peds.

 

[Psyche Estrelle]

Just out of curiosity, you didn't do a million LPs and I+Ds in PGY1? I did my FM residency in a community hospital with a very poorly reputed peds program (it actually just got shut down last year) and they still got that experience. maybe you're just in the wrong place?

 

[hamstergang]

with only 10 minor procedures in a year I have, by many objective metrics, done very little to concretely help my patients.

So without procedures, we can't concretely help our patients? Seems like an odd sentiment to me. I'd imagine you've done a lot to help your patients, through coordinating care, educating parents, ordering the proper medications and treatments, etc.

 

[DeadCactus]

So without procedures, we can't concretely help our patients? Seems like an odd sentiment to me. I'd imagine you've done a lot to help your patients, through coordinating care, educating parents, ordering the proper medications and treatments, etc.

Everyone finds different aspects of patient care more rewarding than others. Figuring out what you like and maximizing it's role in your career is a key step in finding long-term satisfaction. You can't "reason" someone into changing what they like...

 

[hamstergang]

Everyone finds different aspects of patient care more rewarding than others. Figuring out what you like and maximizing it's role in your career is a key step in finding long-term satisfaction. You can't "reason" someone into changing what they like...

Liking something and recognizing the value in it are two different things. The OP may only like procedures, but that doesn't mean he/she can't get that others things help patients too.

 

[22031 Alum]

Liking something and recognizing the value in it are two different things. The OP may only like procedures, but that doesn't mean he/she can't get that others things help patients too.

Maybe OP could have phrased things better, but making him/her recognize the value of certain aspects of medicine isn't the point of this thread. So you are right, coordination of care is valuable. That doesn't change the fact that OP doesn't like doing it, and feels that they aren't helping patients the way they'd like to. I'm imagining they picked Peds planning to ultimately subspecialize, as I can't imagine going into the residency thinking it'd be procedure-heavy.

 

[DrPerrla]

I'm just confused as to why you chose peds when clearly you want to do a ton of procedures. Peds ≠ tons of procedures. I'm not trying to be condescending but honestly, how did you not know this going into the field? With that being said, I would just make the most out of the rest of your residency and perhaps like you mentioned, try out Peds EM or Peds Anesthesia and hopefully one of those will give you what you're looking for.

 

[calvnandhobbs68]

I am coming to the end of my intern year in pediatrics at a very reputable program, but am wracked with a sense of disappointment in my choice to pursue a career in pediatrics. I did well in medical school, with scores that would have left any field open to me, however, I chose pediatrics out of an interest in pediatric pathophysiology and a genuine love for caring for children. However, the reality of my life for the last year has been endless rounding, note writing, coordination of care, talking to upset parents and maybe all of 10 minor procedures. This is not what I went into medical school to do and I leave almost every long day feeling absolutely drained and feel like I have accomplished very little. Classic for burnout, but remember, with only 10 minor procedures in a year I have, by many objective metrics, done very little to concretely help my patients. The real problem is, I don't see it getting better anytime soon. Most of the senior residents in my program are very good people, but obviously worn down. The attendings seem to do just as much care coordination, very few procedures and when you look up their salaries, are making little more than the NPs. As a matter of fact, the NPs are actually better than most residents because the only thing we actually do is coordinate care and make minor decisions, something which a background in nursing prepares you to do better than medical school. The truth is, I just had no insight into how little "medicine" is involved in being a pediatric resident.

The real question now is, what should I do with myself now that pediatrics has lost its charm? I did enjoy NICU and PICU to a certain degree, but the endless rounding and care coordination still killed me. Also, procedures happen uncommonly in those fields. I have not done pediatric emergency medicine, so that is still a possibility. The reality is, I don't know if my soul can survive another two years of endless rounding and care coordination, let alone a lifetime. I am seriously entertaining a switch to emergency medicine at this time. I would also be interested to learn more about anesthesiology, but honestly I have had no exposure. I will have to finish at least a PGY2 year in pediatrics, so I have some time to decide on the matter. At any rate, I would love any input that you readers might have. I'd be especially interested to hear about the expericences of anyone else that has been in a similar situation.

I really don't get your post. You're lamenting your lack of procedures multiple times, but your last post on this site you were considering switching into psych??

You seem to really hate care coordination, since you mention it like a million times (also kinda weird cause care coordination in peds is about 100x better than in adults seeing as most kids have few chronic conditions and basically never have kids you can't "place" somewhere, unlike the homeless guy with HIV whose family won't take him back and no shelter wants him over on the medicine floor). Sounds like it's time to do EM or something else that lacks care coordination. Maybe switch to anesthesia? You'll get procedures, won't have to round and won't have to worry about care coordination again. You'll just have to start dealing with adults again (until you get to a peds fellowship if you ultimately do that) but it doesn't really sound like you're in love with the kids anyway....Anesthesia is also typically a very switchable specialty, although since you'll have to finish your PGY2 anyway, it might be worth it to just stick it out till the end and see if you want to do Peds EM or switch over, plus you'll get to be board certified in peds either way (will be the same amount of time since the EM fellowship is 3yrs anyway).

 

[adalo]

Thank you for your replies. Sorry I am so late to respond. I have been busy. I finished intern year and things felt better as I got more familiar with the system. Second year is now nearly over, and I must say I am essentially in the same place I was earlier. As far as why I picked pediatrics when I like procedures, well, I just don't think I realized how important to me until I stopped doing them. It's not like I want to be a surgeon, I just need to do something tactile and tangible to feel like a real MD. As far as care coordination goes, well, I just feel like that is 75% of what I do, which prevents me from learning real medicine. Yeah, I know it is important, but I don't want to do it that much. It just drains all the joy from the job. And I'm sure it's even worse in IM. Another issue is the money. I'm finding that people make about $120 in academics when they graduate (the pay is the same more or less whether or not you do fellowship). Maybe you can make more in NICU or PICU, questionable with cards. Private practice gen peds can make 120-160 starting out, but that is not for me. NPs where I do residency make 90-150 and social workers 70-95. A pretty raw deal for pediatricians (esp because we do the medicine and the SW!). Also, specialist jobs in peds (aside from NICU) are hard to come by as, honestly, most kids never need a specialist.

So, I'm in a tough spot and just don't feel like I'm learning what I want to learn. I need to think about applying to another training program, though I will of course finish my current program. It's looking like I will branch out from pediatrics as I just don't feel like a pediatrician deep down. EM is not quite for me, I've looked into this extensively and it just doesn't fit my personality. Gas, well I am not sure, but I'm exploring the field. Sports medicine might fit the bill, so I am looking into that as well. I know I want to build more clinical skills, so I am not interested in leaving clinical medicine at this time. I would appreciate any more advice about other options you all may have.

I hope med students thinking about pediatrics take note of some of the problems in the field I listed above. I would only recommend doing a peds residency if you know you could be OK doing general pediatrics. If you are like me and start peds thinking you are going to specialize, then find those specialties not a good fit, then you have a problem. Also, there are a terrifying number of people who complete a fellowship (esp like genetics, nephro, heme/onc) that end up doing gen peds because they can't find a job after fellowship. Yeah, you may think it's worth it to take care of sick kids with interesting disease, but in reality these diseases are rare and society doesn't need to invest heavily in their care compared to other diseases so research also often lags years to decades behind adult research (also due to ethical problems with running trials on kids). That being said, gen peds can make a big impact on individual lives and thus improve society. So, peds can be great, you just have to realize that job/research options may be limited in the specialties.

 

[aks2016]

Research Options limited in peds?!!! one children hospital in the Midwest alone received 180 millions of NIH funding last year. I'm sure places like CHOP or Boston spend even more on research. In general most of the big free standing Children's Hospital have some really strong and incredible research opportunities from basic all the way to clinical and translational. If you think about it almost all of the disease processes start in early childhood.

 

[shoal]

OP, thanks for updating your post. its ver unforunate you went into a field that isnt a good fit for you. I cannot imagine getting paid 120-140k while NPs and sw make nearly as much. pediatricians are just too squishy and nice and would work for free. on a more serious note, i think your plan sounds good, finishing your residency most likely makes sense and will give you some options. Now you gotta figure out what you want to do, and make sure you get your feet wet, so you do not repeat your mistakes. who knows even, as an attending perhaps the coordination of care will be signifcantly less.

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[rokshana]

OP, thanks for updating your post. its ver unforunate you went into a field that isnt a good fit for you. I cannot imagine getting paid 120-140k while NPs and sw make nearly as much. pediatricians are just too squishy and nice and would work for free. on a more serious note, i think your plan sounds good, finishing your residency most likely makes sense and will give you some options. Now you gotta figure out what you want to do, and make sure you get your feet wet, so you do not repeat your mistakes. who knows even, as an attending perhaps the coordination of care will be signifcantly less.

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not sure where the OP is looking, but there are opportunities in peds that pay better than that..peds hospitalists are becoming more popular (following in lines with IM hospitalist) and while they may not pay as well, they are not 120k...and subspecialties like NICU and CC are paying in the 200k + range...go to the middle of nowhere and its over 300k.

 

[Raryn]

Thank you for your replies. Sorry I am so late to respond. I have been busy. I finished intern year and things felt better as I got more familiar with the system. Second year is now nearly over, and I must say I am essentially in the same place I was earlier. As far as why I picked pediatrics when I like procedures, well, I just don't think I realized how important to me until I stopped doing them. It's not like I want to be a surgeon, I just need to do something tactile and tangible to feel like a real MD. As far as care coordination goes, well, I just feel like that is 75% of what I do, which prevents me from learning real medicine. Yeah, I know it is important, but I don't want to do it that much. It just drains all the joy from the job. And I'm sure it's even worse in IM. Another issue is the money. I'm finding that people make about $120 in academics when they graduate (the pay is the same more or less whether or not you do fellowship). Maybe you can make more in NICU or PICU, questionable with cards. Private practice gen peds can make 120-160 starting out, but that is not for me. NPs where I do residency make 90-150 and social workers 70-95. A pretty raw deal for pediatricians (esp because we do the medicine and the SW!). Also, specialist jobs in peds (aside from NICU) are hard to come by as, honestly, most kids never need a specialist.

So, I'm in a tough spot and just don't feel like I'm learning what I want to learn. I need to think about applying to another training program, though I will of course finish my current program. It's looking like I will branch out from pediatrics as I just don't feel like a pediatrician deep down. EM is not quite for me, I've looked into this extensively and it just doesn't fit my personality. Gas, well I am not sure, but I'm exploring the field. Sports medicine might fit the bill, so I am looking into that as well. I know I want to build more clinical skills, so I am not interested in leaving clinical medicine at this time. I would appreciate any more advice about other options you all may have.

I hope med students thinking about pediatrics take note of some of the problems in the field I listed above. I would only recommend doing a peds residency if you know you could be OK doing general pediatrics. If you are like me and start peds thinking you are going to specialize, then find those specialties not a good fit, then you have a problem. Also, there are a terrifying number of people who complete a fellowship (esp like genetics, nephro, heme/onc) that end up doing gen peds because they can't find a job after fellowship. Yeah, you may think it's worth it to take care of sick kids with interesting disease, but in reality these diseases are rare and society doesn't need to invest heavily in their care compared to other diseases so research also often lags years to decades behind adult research (also due to ethical problems with running trials on kids). That being said, gen peds can make a big impact on individual lives and thus improve society. So, peds can be great, you just have to realize that job/research options may be limited in the specialties.

Look, I did (am finishing) an internal medicine residency and did a crapton of procedures over the last 3 years. By halfway through my third year when I stopped logging them, between lines, intubations, lumbar punctures, and thora/para/arthrocentesis I had done >120 procedures. It's certainly nowhere near surgical numbers, but I feel comfortable doing them, and my program encourages us to be aggressive in getting our numbers. I'm probably on the upper range of normal for my program, but many people over the years who graduated were in the same general ballpark. I've kept in touch with a number of those graduates who went on to do general IM, whether outpatient, hospitalist, or a mix. Do you know how many are still doing procedures? Graduates of a fairly procedure heavy IM residency, who were aggressive with getting more than the required #? I know of one hospitalist who still does the occasional line and the primary care guys still do the occasional joint injection. That's it.

I can't extrapolate all the way from IM to peds, but the two fields are pretty similar. The peds residents I know do plenty of procedures in residency, though the mix is certainly different than the ones I did. And from what I can tell talking to the few I know, not too many of them do any after they graduate. It's just not part of the modern practice of general peds/IM in most areas that have the resources available where it doesn't have to be. In rural areas it's a bit different, but that's modern society.

I'll give you the same advice I'd give a colleague in IM: You want to do procedures, do a fellowship in PICU, NICU, GI, or Cardiology. Hell, I know what you said above, but a peds EM fellowship is basically a ticket to day-to-day small procedures. In addition, at least for adults, heme/onc does their own bone marrows and the occasional intrathecal chemo (depending on the program), endocrine does neck ultrasounds and FNA biopsies, rheum does joint ultrasounds/injections, ID does the occasional lumbar puncture, so if you really just want the occasional stab at something, you can consider those as well.

 

[adalo]

Thank you for your kind replies. Yes, there is a lot of money in peds research, but it is certainly not going far in paying junior faculty salaries. Yes, we can make more in peds, esp CC and NICU, but these fields are something you really have to be called to, I don't think anyone could do those jobs unless you truly wanted to devote your life to the field. Also, the frequent passing of children and babies can be a big bummer (though certainly morbidity is less than the MICU). Peds hospitalist might be a good gig, but they are getting burned out in <5 years in the academic settings I have worked in. Maybe it's better outside of academics, but I can't really say.

So yes, I need to come up with a plan and test the waters before I dive in! It's not that I'm one of those horribly depressed and burned out people, I'm doing reasonably well in residency. I just need to find a job that is a better fit.

 

[bonsaipalmtree]

Another pediatric intern here, stopping by to say that I feel your pain. Initially, pediatrics inspired me, but now, I feel like a note-writing automaton. I never lusted after procedures, but always thought I'd at least become competent at them, and never imagined that they'd take a backseat every day to answering pages and writing notes (only to have them heavily edited by my attending!). The long days of care coordination and the complete lack of autonomy have left me feeling a lot like you, drained and unproductive, a machine cog rather than a doctor- and it doesn't seem to get a lot better as an attending. When you spent your entire residency doing care coordination, how are you supposed to do an LP as an attending, drain an abscess, or even just place an NG? Best to just call IR, call surgery, call the nurse- because that's what residency taught you to do, when you had pages to answer and notes to write.

 

[BigRedBeta]

@adalo sorry to hear about your experiences. It's unfortunate, and clearly you didn't find a program that fit your needs...perhaps because you didn't realize that certain things were important to you until the die was cast and you were already matched. There are programs out there that would have been closer to what you were hoping for. The dirty truth that no one talks about in residency (almost any field) is that the bigger the name, the less resident education means - good procedures get booted to fellows, they have the resources for silly things like suture teams or one NP that does all the splinting of fractures in the ED, leaving the MD's in training to try to develop a cursory knowledge on the margins.

These same reputable programs don't like to talk about life in private practice and what to expect once you leave the ivory tower. You see only unhappy hospitalists, burned out likely because they are glorified residents, still stuck in the system that doesn't let them do anything more than write notes and coordinate care. Everything else is taken of care of - 98% of LP's get done in the ED, IR is available for PICC lines, and newborns are whisked away to the NICU before anyone else knows they've arrived, ready for the first year Neo fellow to place umbilical lines...the thing is, if you get into the community, those resources don't exist and so you, as the expert in children, have to do those things. I'm a PICU attending and did some locum tenens work recently in a couple of locations far from the big cities and full service children's hospitals. While on these assignments I got asked to do all kinds of things that you seem to be hoping for (or I did the procedural sedation so the hospitalists could do them). But no one tells you what life is like in the exurb community hospital or out in small cities and towns that still have sick kids that need to go to the hospital (none of the towns I was in were smaller than 125k - not huge, but not blink and you'll miss it either), because they either a) don't know or b) are so condescending that they can't fathom anyone actually living or working in these places.

Further, job opportunities are out there for pediatric subspecialists, and anyone who tells you their having trouble getting a job, is saying they can't find a job that fits their own criteria. If you've spent med school/residency/ fellowship going NYC->LA->Chicago, then yeah, you're probably not going to consider the job in Little Rock, AR, or Hershey, PA even though they have really great children's hospitals and you'll walk into a loaded patient panel and appointments lined up 4-5 months in advance. But there are lots of opportunities (same reasoning behind all of those general pediatricians out in CA whining about their 80k salaries with no performance bonuses...they made a decision about the peripherals and chose a job that satisfied everything but their career goals)


As a PICU attending, I don't disagree that NICU and PICU require a certain attitude, and while a love of procedures is a common trait, it's probably not enough to go into fellowship by itself, Heme/onc is the same way, if not even more so. There are procedures to be had in those fields, but I don't know if they necessarily fulfill the idea of doing something tangibly good for your patient though. An LP, central line, or bone marrow biopsy aren't the same as a surgeon cutting to cure.


So where do you go from here? Well, for your own happiness, I think you need to use the last year of residency to fight for as many procedures as possible. Anything and everything. Talk with your PD and see if you can create a procedures elective where you follow the PICC team for a week (or spend time in IR), a week in ortho clinic doing splints, and time with anyone else who has robbed you of the procedures you want. Next you need to figure out if you're doing more training or not, either a peds fellowship or some sort of second residency. If this is the route you choose, be very upfront about what you're looking for, ask to see procedure logs of the fellows so you know the volume to expect. Avoid places where IR is encroaching or that have the specialized services. Find the locations that expect fellows to do their own procedures. If more training is not the right choice, then hospitalist positions are your best bet, and you need to be ultraselective in what you're looking for from the job itself while simultaneously being open to a lot of locations you might not otherwise consider.

Feel free to PM me if you have any other questions about what life is like on the outside of academics