Dual board in PICU and pediatric cardiology

[newprep]

I am a pediatric critical care fellow who want to work in cardiac ICU after my training. I am more interested in getting second fellowship in pediatric cardiology, rather than pursuing 1 year CVICU fellowship. Can anybody highlight me pro/cons of pursuing either route; like competency/job market? Also how do I figure out which program waives one year of research to obtain fellowship in 2 years as that part is not clear in program website? What kind of program should I be looking for cards fellowship [large vs small]

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[BigRedBeta]

It's my understanding that all of them should waive that 3rd year. That's direct from the ABP, but I suppose there could be some programs that will ask you for 3 years.

The CVICU route is of course shorter and gets you to the CVICU faster. The job market for CVICU is very hot right now with nearly every PICU I ran across looking to add someone with specialized cardiac expertise. The 4th year is at this point, generally considered evidence of that, but some of the really big centers will have a preference for dual boarded candidates - the degree of that preference will likely depend on how many of the staff are dual boarded themselves.

Dual board route of course makes you board certified in both. You can read your own echos, you have a greater understanding of outpatient management, likely have a more nuanced view of the hemodynamics in lesions due to the Cath Lab experience, and a better skillset in heart failure and transplant management. If you really enjoy clinic (which I'm guessing as a critical care fellow you don't) then dual boarding allows to do that as well in some places.

Dual board gives you more options at the expense of the extra year.

 

[MonkeyRalph]

Not all programs are able to accommodate a two-year fellow, so you will need to contact each program director individually and ask if they're in a position to consider a two-year applicant. When I applied from cardiology to picu, about 80-90% of PICU programs would consider a two-year applicant. I'm inclined to think that it would be slightly less the other way around (just because of the way that many cardiology training programs are structured). The only way to know is to ask. Just send an email with your CV to the PDs and program coordinators at the places you're considering and see if they're willing to consider it. If so, then the application process is the same (go through the match).

As for pro's/con's, I think BigRedBeta is right; it gives you more options at the end of your training. At this point, many programs (though not all) will hire folks with the 1y CVICU training, however in the future, it may be more difficult to end up at the exact program of your choice if you don't have dual certification. Also, almost anyone who's hiring these days will look at two otherwise equal candidates and will choose to hire the one with dual certification over the 1y training without any hesitation. Good luck. It's a tough road, but it's worth it!

 

[michigangirl]

Everything they said. If you can swing the 2 year cardiology fellowship (only way to know is to ask all of your programs of interest), then that's the best long-term investment with the most flexibility.

 

[BigRedBeta]

Good point about the ability to accommodate a 2 year fellow. I hadn't thought of that, but it's very true.

I'm not sure I agree with the assertion that a dual boarded candidate will be hired automatically over someone with a 4th year of training. Lot of factors at play come into hiring decisions. Turf wars over the CVICU definitely complicate things and open up inter-division politics. Lots of different permutations based upon the department of Pediatrics, the units, and what the individual applicants want. I can definitely set up different scenarios in which a Division Head in Critical Care would prefer to unilaterally hire someone with only a 4th year of training rather than open a can of worms by involving the Division Head in Cardiology. But I don't think that should deter you from going through a cardiology fellowship if that sounds appealing to you.

 

[Omar Little]

Hey,

Apologies for the newbie questions, but how does one go about doing a combined cardiology/critical care fellowship? Do you apply for the cardiology match? critical care match? both (aren't they at different times)?

More importantly, how do applicants know so early that they are interested in something so specialized? Would it be a good idea to try and do a cardiac ICU rotation in 4th year of med school (can't imagine you'd get much autonomy, but could probably learn lots) - or just wait until residency and figure it out? Its so difficult, I'm reading about all these amazing directions a career can go, but feel like I have so little experience to choose at this point. I can barely formulate a rank list!

thanks.

 

[newprep]

I know people choose doing combined fellowship and applying during residency, but I am not sure I would have been able to choose dual fellowship during med school, or for the matter even during residency. With weeks or month long rotation in ICU as med student or resident, I don't know I would have understood dynamics among different team [CV surgery, cards, PICU], and hence scope of practice of dual boarded person.
I am more inclined now to apply for a second fellowship in cardiology during my first year of PICU fellowship, as I see the field more clearly from a fellow's perspective while working in ICU for last several months.

 

[Giic]

Double-boarding is a good longterm investment, if you can stomach being in the clinic. Some of us (actually most of us) who went into PICU did so because we absolutely DETEST the clinic environment. Cant explain why. We just function better when we are juggling multiple patients at a time, and those patients are really sick.
Double-boarding makes it easier to find jobs, and no one doubts whether or not you can read your own echos. I know a lot of PICU+CVICU people who *do* read and perform echoes, but that's not immediately obvious to most people who meet you, or to people reading your resume.


Regarding how to go about this... Since you've already done PICU, then I would just email different cardiology programs and let them know your situation. See who is willing to allow you to come in for 2 years. Most double-boarded people do cards first, then PICU. And I tend to feel like PICU programs are more flexible with allowing someone to come in for just 2 years. [I also tend to feel like cardiology folks who do PICU for 2 years still think like and will always think like plain cardiologists - but that's a story for another day].

If there was a way to do 2 years of CVICU training after PICU.... aaah, now THAT would be perfect. You could learn all the echo and cath you want without ever stepping foot in a clinic.

 

[MonkeyRalph]

Double-boarding is a good longterm investment, if you can stomach being in the clinic. Some of us (actually most of us) who went into PICU did so because we absolutely DETEST the clinic environment. Cant explain why. We just function better when we are juggling multiple patients at a time, and those patients are really sick.
....
If there was a way to do 2 years of CVICU training after PICU.... aaah, now THAT would be perfect. You could learn all the echo and cath you want without ever stepping foot in a clinic.

Not to open a can of worms... (I'm not even gonna touch that "plain cardiologists" comment)....
I agree that double-boarding is a better longterm investment and that a great deal of cardiac intensivists HATE the clinic environment. But I think cardiac intensivists who've never followed congenital heart patients in an outpatient setting sometimes don't offer as balanced a perspective for their CVICU patients who are convalescing. Yes, all intensivists should be able to acutely resuscitate or prevent deterioration in critically ill patients, but cardiac intensivists should also sometimes be able to offer their patients the perspective of how are these ICU decisions going to affect their life once they go home. Just my opinion. (Disclaimer: I actually hate clinic myself, but I see the value in it for those training to be cardiac intensivists).

 

[Giic]

Not to open a can of worms... (I'm not even gonna touch that "plain cardiologists" comment)....
I agree that double-boarding is a better longterm investment and that a great deal of cardiac intensivists HATE the clinic environment. But I think cardiac intensivists who've never followed congenital heart patients in an outpatient setting sometimes don't offer as balanced a perspective for their CVICU patients who are convalescing. Yes, all intensivists should be able to acutely resuscitate or prevent deterioration in critically ill patients, but cardiac intensivists should also sometimes be able to offer their patients the perspective of how are these ICU decisions going to affect their life once they go home. Just my opinion. (Disclaimer: I actually hate clinic myself, but I see the value in it for those training to be cardiac intensivists).

You're probably right... I have heard cardiac surgeons say that they like to discuss patients (longterm goals), and rub minds with cardiac intensivists who are cardiologists, because of their perspective on the outpatient stuff. No argument there.

Regarding the "plain cardiologists" comment -- I have worked with many double-boarded cardiac intensivists (3-year cardiology) who don't seem to know (or care!) about anything beyond what's basic in the neuro system, vent management, renal physiology, electrolytes, hematology, etc. I wasn't saying it to be rude, just my honest observation. It really used to make me wonder. And my conclusion was that they had gone through 2 years of PICU fellowship just "going thru the motions" with only one goal in mind - which was to eventually take care of cardiac kids. Your goal affects the way you learn, and how much attention you pay to certain things. No one ever did 2 years of PICU after 3 years cardiology - because they wanted to end up taking care of general PICU kids. None of them would want to (or be able to) care for autoimmune diseases or trauma, or even septic shock which is considered bread-and-butter in the PICU. So it's a bit of a false premise in a way. Actually some of them do part-time cardiology clinic, when not on service.

 

[Bitsy]

You're probably right... I have heard cardiac surgeons say that they like to discuss patients (longterm goals), and rub minds with cardiac intensivists who are cardiologists, because of their perspective on the outpatient stuff. No argument there.

Regarding the "plain cardiologists" comment -- I have worked with many double-boarded cardiac intensivists (3-year cardiology) who don't seem to know (or care!) about anything beyond what's basic in the neuro system, vent management, renal physiology, electrolytes, hematology, etc. I wasn't saying it to be rude, just my honest observation. It really used to make me wonder. And my conclusion was that they had gone through 2 years of PICU fellowship just "going thru the motions" with only one goal in mind - which was to eventually take care of cardiac kids. Your goal affects the way you learn, and how much attention you pay to certain things. No one ever did 2 years of PICU after 3 years cardiology - because they wanted to end up taking care of general PICU kids. None of them would want to (or be able to) care for autoimmune diseases or trauma, or even septic shock which is considered bread-and-butter in the PICU. So it's a bit of a false premise in a way. Actually some of them do part-time cardiology clinic, when not on service.

If double-boarded cardiac intensivists didn't care about learning beyond the basics of other organ systems, they wouldn't have done 2 years of pediatric critical care IMHO. They could have done just 1 year (4th year in cardiac ICU) with less focus on improving knowledge in other organ systems. I would also counter that no one doing 2 years of PICU after 3 years of cardiology is looking to take any short-cuts (3 years peds residency + 3 years peds cardiology + 2 years critical care = 8 years).

 

[Giic]

If double-boarded cardiac intensivists didn't care about learning beyond the basics of other organ systems, they wouldn't have done 2 years of pediatric critical care IMHO. They could have done just 1 year (4th year in cardiac ICU) with less focus on improving knowledge in other organ systems. I would also counter that no one doing 2 years of PICU after 3 years of cardiology is looking to take any short-cuts (3 years peds residency + 3 years peds cardiology + 2 years critical care = 8 years).

Not sure I understand you last sentence? About short cuts? What are you referring to? If the point is that they've put in so many years, and therefore they would give it their all - my response would be "that's what you would think"... Interest determines more than dedication or willingness to work hard. And I've just found that that interest in general PICU is lacking. A 2nd year straight PICU fellow is usually a lot more engaged/interested/knowledgable in trauma and complex modes of mech ventilation and ICP patients - than a 2nd year PICU fellow who did Cardiology before. Because the latter knows that this PICU fellowship is only a right of passage that gets them to the cardiac ICU. And i also disagree that they would have just done one year PICU if they were not interested. Nope. Not true. One year is not enough for most people to learn the basics (bare bones minimum) especially getting comfortable with procedures.
I still believe that my comments hold true- at least with a lot of them I've worked with.

 

[Stitch]

You're probably right... I have heard cardiac surgeons say that they like to discuss patients (longterm goals), and rub minds with cardiac intensivists who are cardiologists, because of their perspective on the outpatient stuff. No argument there.

Regarding the "plain cardiologists" comment -- I have worked with many double-boarded cardiac intensivists (3-year cardiology) who don't seem to know (or care!) about anything beyond what's basic in the neuro system, vent management, renal physiology, electrolytes, hematology, etc. I wasn't saying it to be rude, just my honest observation. It really used to make me wonder. And my conclusion was that they had gone through 2 years of PICU fellowship just "going thru the motions" with only one goal in mind - which was to eventually take care of cardiac kids. Your goal affects the way you learn, and how much attention you pay to certain things. No one ever did 2 years of PICU after 3 years cardiology - because they wanted to end up taking care of general PICU kids. None of them would want to (or be able to) care for autoimmune diseases or trauma, or even septic shock which is considered bread-and-butter in the PICU. So it's a bit of a false premise in a way. Actually some of them do part-time cardiology clinic, when not on service.

Totally agree. I've worked with a LOT of dual boarded individuals. They are incredibly smart, dedicated and do a fantastic job of caring for post operative cardiac patients. They are more respected by the surgeons and truly understand the anatomy as well as the physiology of what's going on. But in general they don't look at the whole picture of multi organ failure/involvement because they are so focused on the heart. So sepsis, lung protective ventilation for ARDS (use of modalities like APRV), even renal failure gets pushed aside because it's not the heart. A large part of this is due to the fact that the cardiac surgeon is really the one in charge and driving care. There are some great surgeons out there, but they often really have no idea about how children are different than adults or how to manage other issues besides cardiac failure. And don't even get me started on end of life discussions (or lack thereof).

 

[Giic]

Totally agree. I've worked with a LOT of dual boarded individuals. They are incredibly smart, dedicated and do a fantastic job of caring for post operative cardiac patients. They are more respected by the surgeons and truly understand the anatomy as well as the physiology of what's going on. But in general they don't look at the whole picture of multi organ failure/involvement because they are so focused on the heart. So sepsis, lung protective ventilation for ARDS (use of modalities like APRV), even renal failure gets pushed aside because it's not the heart. A large part of this is due to the fact that the cardiac surgeon is really the one in charge and driving care. There are some great surgeons out there, but they often really have no idea about how children are different than adults or how to manage other issues besides cardiac failure. And don't even get me started on end of life discussions (or lack thereof).

Amen to that (especially the part about end of life discussions).

 

[newprep]

Thank you guys for all info for last few months. I am preparing my application stuff for cardiology fellowship this year. do you guys have idea on what type of programs should I be looking for. I intend to work in major academic center with CVICU, with may be some general ICU calls.
- should I only look for programs which has pediatric transplants and VADs etc; or is it okay without that
- how should I find which programs have strong pulmonary hypertension/heart failure component
- do anybody know good programs I should look for which support dual boarded fellow [ Or any programs better to avoid]

 

[SurfingDoctor]

- should I only look for programs which has pediatric transplants and VADs etc; or is it okay without that

I suppose you look for what you want to get out of it. Transplant and extracorporeal support (VAD, ECMO) are going to be offered at most major academic centers. It is certainly something to be familiar with, but it is a small number of the total CVICU patients. Additionally, I will say that devices and device technology change over time. Now, I don't practice in the CVICU much, if at all anymore, but VADs and device technology are under constant revision and updates. The basics are the same, pumping of a certain stroke volume at a certain rate, anticoagulation, etc, but the nuances of VADs change so much. I remember as a fellow seeing a patient with a Syncardia and one with a Novalung, never seen either one since. However, again the basic concepts: pump, anti-coagulation, battery are about the same. Anyway, to answer your question yes, you should go to a place that has an active transplant program (maybe 15 to 20/year)

- how should I find which programs have strong pulmonary hypertension/heart failure component

What specifically are you referring to? If you are going to a program with transplant/VADs, they will have a heart failure program. You can't manage end-stage pediatric heart failure without a VAD/Transplant program. Pulmonary hypertension is also treated at most major pediatric academic centers. Now if you are talking about irreversible pulmonary hypertension leading to heart failure, then you are talking about a program that offers lung or heart/lung transplant. These centers are few. I'll be honest, I did training at a "large" pediatric lung transplant center (8-10/year) and the academic center I'm at doesn't do pediatric lung transplant currently. It is pretty rare to see heart/lung transplants and in general from my limited experience (n of 2) they don't do well (nor lung transplant for that matter, unless they are older patients with CF and a good nutritional status). I don't think going to a center with heart/lung transplants will make you a better CVICU intensivist.

- do anybody know good programs I should look for which support dual boarded fellow [ Or any programs better to avoid]

I think you would have to email PDs. I know that we've had cardiology fellows that have interviewed for 2 year PICU spots, so I assume the opposite is true, but I don't think it is well advertised. I would ask and make sure you get a definitive answer because having completed a 3 year fellowship already, doing another 3 years (as opposed to 2, or even 1 year as a CVICU-only fellow) is a waste of your time.

 

[WheezyBaby]

Just going to tack onto this thread rather than start a new one.

I'm a med/peds resident primarily interested in PICU. I love the pathophysiology, care for acutely ill children, variety of pathology, sense of ownership of patients and the unit, opportunities for teaching, the psychosocial dynamic with parents, etc - but I don't think I can see myself doing solely PICU because I also value continuity of care / longterm patient relationships as well as variety (I don't particularly like clinic... But I like the variety that occasional clinic offers). An idea I've tosses around is combined picu/cards and adult congenital heart. I don't sync wonderfully with what, in my experience, has been the typical cardiologist mentality of deferring care to other physicians for noncardiac problems, but otherwise I enjoy cardiac physiology, particularly congenital defects and the various repairs, and obviously cards + congenital heart would open up plenty of opportunity for longterm outpatient care of those kids. With that said, my only PICU experience has been general PICU and not CVICU, but I think I see myself more of a general PICU person - I feel I'd prefer the variety in pathology and avoiding the dynamic with CT surgery that, at least from my limited exposure, would not be my favorite. Would a cards/picu combined fellowship be silly to consider if I don't see myself in the CVICU (though I'm certainly open to it if/when I got exposure and enjoyed it)? And would the addition of the adult congenital heart fellowship be a possibility?

 

[SurfingDoctor]

Would a cards/picu combined fellowship be silly to consider if I don't see myself in the CVICU (though I'm certainly open to it if/when I got exposure and enjoyed it)?

Well, I can't imagine what you would get out of dual training in Cardiology and PICU if you have no intention of doing CVICU. The only dual trained physicians I know that have those credentials work exclusively (or near exclusively) in the CVICU

And would the addition of the adult congenital heart fellowship be a possibility?

First, adult congenital fellowships are only offered to cardiology fellows. Second, I can't imagine you splitting time between PICU and adult congenital clinic. I personally have never seen it. You essentially would have to have 2 bosses and 2 separate roles, which since you don't want to do CVICU, will have no overlap. Maybe if you did CVICU and had some adult congenital time, but being on service 24/7 usually overwhelms most physicians. I can only see headaches for you. Now, there are some centers that are starting post-ICU follow up clinics. I don't think it has really trickled down to pediatrics as much, but it may as children who go home from the ICU don't always come out the same as they went in and need specialized post-ICU care. Most PICU doctors I know would shutter at the idea of doing clinic, but that maybe a way to get your clinic fix. See http://www.ncbi.nlm.nih.gov/pubmed/22152275

 

[newprep]

wondering, while applying for second fellowship do I need a recommendation letter from my previous residency program director [along with my current fellowship program director which I ve requested]. Any thoughts on it?

Also, while inquiring different programs about taking 2 year fellow; I find different programs have different perceptions on it [straight NO to will accommodate, to ?? excited]

 

[SurfingDoctor]

wondering, while applying for second fellowship do I need a recommendation letter from my previous residency program director [along with my current fellowship program director which I ve requested]. Any thoughts on it?

Also, while inquiring different programs about taking 2 year fellow; I find different programs have different perceptions on it [straight NO to will accommodate, to ?? excited]

I would say no to the first question. The point of the PD LOR is for someone who can evaluate your clinical performance in total. Your fellowship PD should be able to do that and would have a more up to date assessment of your clinical acumen than your residency PD.

Yes, there are different levels of interest from PDs about 2 year fellows. At least from my understanding based on divisional faculty meetings, it has more to do with creating imbalance in fellowship spots more than anything else. For instance, if a fellowship typically takes 4/year and a 2 year fellow joins, they graduate during the second year, leaving 1 class with 3 fellows and having to recruit 5 fellows to fill the gap. This creates headaches for everyone in the program. I assume the excited ones have some cycle issues and the timing is right for a 2 year fellow versus the unexcited programs which the timing is off and they are not so interested creating an off cycle schedule.

 

[MonkeyRalph]

wondering, while applying for second fellowship do I need a recommendation letter from my previous residency program director [along with my current fellowship program director which I ve requested]. Any thoughts on it?

Also, while inquiring different programs about taking 2 year fellow; I find different programs have different perceptions on it [straight NO to will accommodate, to ?? excited]

I agree that you SHOULD only need one PD letter (from your fellowship PD), but some programs did ask for both the residency and fellowship PD letters, so I would just clarify this with whatever programs you're applying to (and ideally ask your residency PD now if they can update your letter so that it's available to you should you need it).

I do agree that there are many staffing/program-cycle issues that play into whether a program is willing to train 2-year fellows, but I would also say that some programs have a strong track-record of training dual-board eligible fellows and are usually willing and able to accommodate such applicants into the schedule as long as they're not down a fellow for some other reason. (These programs are typically the ones that have more flexibility in their schedules, which is great from a fellows' standpoint). You should definitely ask programs if they have a track record of training 2-year fellows, because it's common enough now that the bigger programs should have some experience with it and it is probably better to be at a place where you're not the guinea pig (depending on other factors). For instance, my PICU program has enrolled a dual-board eligible person every year for the past three years and at least 15-20% of our current applicants are also cardiology-trained.