Fellowship Advice

[Stone Cold]

Hi,

I'm a PGY-2 (IMG) and needed some fellowship advice. After going through the rotations, I've finally shortlisted to PICU, NICU and Cards in order of preference. During my recent cards rotation, the attending who also happens to be the head of Pediatric Cardiology department suggested me to go for a double fellowship i.e., either PICU or NICU and than pursue a cards fellowship later on which essentially is double board certified and will be highly sought after by hospitals and PPs' across the US. Since I'd already have a fellowship in PICU or NICU, most cards programs might allow me to complete a cards fellowship in 2 years.

While I'm comfortable for longer training periods since I have no med school debt, could anyone advice me on the viability of taking this route and if double fellowship is worth it in the end since this is not the traditional 3yrs PICU + 1yr CVICU route but 3yrs PICU/NICU + 2-3yrs Peds Cards.

One reason I put cards towards the end in my order of preference is I'm not entirely comfortable with longer clinic hours and prefer inpatient setup which is why I'd go with PICU or NICU if I were to do just one fellowship

Thanks

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[doopdidoop]

i have limited experience myself, but what I do know is that the job market for PICU right now is quite tough, yet pediatric CICU doctors remain in high demand, especially those that are dual boarded. that being said, I don't think it's quite true that MOST cardiology programs would be able to accommodate a 2 year fellow - you'd have to find a program that is large enough to absorb the loss of a fellow for a year. the biggest academic centers will always want the dual boarded CICU physician over the PICU physician who did one extra year, which is preferred over someone "just" PICU trained. however, there are still mixed units and smaller programs out there that are less stringent about having someone dual boarded. from what I've heard, NICU trained peds CICU people have a hard time finding a job in a dedicated pediatric CICU without doing a cardiology fellowship - NICU is very different than PICU. the other thing to consider is that by doing CICU via double boarding you are end up limiting yourself to academic centers - think of where pediatric cardiac surgery is performed.

the more important thing is to decide what you actually want to do for a career. the day to day patient population of a peds CICU physician is very different than a PICU physician on a non-cardiac service, and NICU is totally different from the other two. usually, people who take the double board route are sure they want to take care of the sickest pediatric congenital heart disease population (and usually no one else - there are exceptions to this) and be able to draw on both of their training experiences to care for these kids - I've had some friends pursue this pathway but both did cardiology first.

all this being said there is a lot more to factor into a decision like this than just money - not that money is not important. but to me, it sounds like you need to decide what kind of career you want first, and then go from there.

 

[Stone Cold]

i have limited experience myself, but what I do know is that the job market for PICU right now is quite tough, yet pediatric CICU doctors remain in high demand, especially those that are dual boarded. that being said, I don't think it's quite true that MOST cardiology programs would be able to accommodate a 2 year fellow - you'd have to find a program that is large enough to absorb the loss of a fellow for a year. the biggest academic centers will always want the dual boarded CICU physician over the PICU physician who did one extra year, which is preferred over someone "just" PICU trained. however, there are still mixed units and smaller programs out there that are less stringent about having someone dual boarded. from what I've heard, NICU trained peds CICU people have a hard time finding a job in a dedicated pediatric CICU without doing a cardiology fellowship - NICU is very different than PICU. the other thing to consider is that by doing CICU via double boarding you are end up limiting yourself to academic centers - think of where pediatric cardiac surgery is performed.

the more important thing is to decide what you actually want to do for a career. the day to day patient population of a peds CICU physician is very different than a PICU physician on a non-cardiac service, and NICU is totally different from the other two. usually, people who take the double board route are sure they want to take care of the sickest pediatric congenital heart disease population (and usually no one else - there are exceptions to this) and be able to draw on both of their training experiences to care for these kids - I've had some friends pursue this pathway but both did cardiology first.

all this being said there is a lot more to factor into a decision like this than just money - not that money is not important. but to me, it sounds like you need to decide what kind of career you want first, and then go from there.

Thanks for that wonderful insight. The problem with solely relying on CICU is I'd geographically limited since there aren't a ton of pediatric cardiac surgery centers out there. My program doesn't have one but one of my away rotations in a top-5 hospitals is what got me interested in CICU. One reason I didn't wanna go for cardiology first is being an IMG, it's relatively hard to match into a good program and secondly if I don't want to pursue a second fellowship, I'm not comfortable with the outpatient/clinic duty baggage that comes with being a cardiologist. As of now, I'd still go for PICU and decide if it's worth double boarded but just wanted to get an insight from someone apart from the people i worked with.

I'm not too concerned about the money given Peds folks are anyway paid the lowest. Tack on maybe $100k more with any of these sub-specialties over gen peds and given that CICUs are located in the largest cities and major academic centers, we're bound to get paid on the lower end of the spectrum. Could you tell me more about your friends you mentioned about, the route they've taken, current setups they're working at and how different is their career from regular picu/nicu folks

 

[PTPoeny]

If you double train your job will either be entirely or mostly in a CICU rather than a standard PICU. I know one person who also does a small amount of clinic and some time reading imaging studies. Everyone else I know with double training works in the ICU. The difference from straight PICU is that you can work in units that are closed to straight PICU folks. And even in the centers with CICUs that hire PICU people the extra training will make you more highly recruited.

Double boards is definitely preferred to just the single extra year everywhere I interviewed and I graduated straight PICU last year. If you definitely want to do the combined training you should do cards first. There are more ICU physical "muscle memory" skills that you don't want to lose during a cardiology fellowship. I know people who have done PICU first then cards and they all did a lot of ICU moonlighting to keep their skills up and some even spread out their cards fellowship to be able to keep up their ICU skills.

 

[doopdidoop]

Thanks for that wonderful insight. The problem with solely relying on CICU is I'd geographically limited since there aren't a ton of pediatric cardiac surgery centers out there. My program doesn't have one but one of my away rotations in a top-5 hospitals is what got me interested in CICU. One reason I didn't wanna go for cardiology first is being an IMG, it's relatively hard to match into a good program and secondly if I don't want to pursue a second fellowship, I'm not comfortable with the outpatient/clinic duty baggage that comes with being a cardiologist. As of now, I'd still go for PICU and decide if it's worth double boarded but just wanted to get an insight from someone apart from the people i worked with.

I'm not too concerned about the money given Peds folks are anyway paid the lowest. Tack on maybe $100k more with any of these sub-specialties over gen peds and given that CICUs are located in the largest cities and major academic centers, we're bound to get paid on the lower end of the spectrum. Could you tell me more about your friends you mentioned about, the route they've taken, current setups they're working at and how different is their career from regular picu/nicu folks

yup, definitely you would be restricting yourself - not only geographically, but to specific centers geographically. if you are double boarded, most division directors will not hire you to do solely PICU; they will want you to devote most, if not 100% of your practice in the CICU. certainly, you could apply for just PICU jobs, but the division director may wonder if you lack focus if you just did extra training and decided not to use it. understandable that you would want to do cardiology second, but like the above poster mentioned, there are drawbacks to doing it in that order. 2 of my friends did cardiology first, then PICU and are both practicing in large, academic centers with 100% clinical time in the CICU; one friend did PICU first and cardiology second but really felt that it was better to do it the other way around - this person is also practicing in a large academic center with 100% of her clinical time in a CICU. none of them do any regular PICU time. i'm currently in a mixed unit that leans more heavily towards cardiac. some of the attendings have extra cardiac training and they do more time on the cardiac side vs the med/surg, but all attendings here cover both sides to some degree. this is very uncommon from what i have seen in my current job search, and there is some internal push to separate the units. again, your decision really should be based on what kind of medicine you want to practice and then do your training accordingly. there is a real chance by double boarding you will never care for PICU patients again - if you're okay with that and prefer CICU, then go for it. i can't really comment on NICU because while NICU, CICU, and PICU get lumped together, i really feel NICU is an outlier - the medicine is totally different.

 

[SurfingDoctor]

Hi,

I'm a PGY-2 (IMG) and needed some fellowship advice. After going through the rotations, I've finally shortlisted to PICU, NICU and Cards in order of preference. During my recent cards rotation, the attending who also happens to be the head of Pediatric Cardiology department suggested me to go for a double fellowship i.e., either PICU or NICU and than pursue a cards fellowship later on which essentially is double board certified and will be highly sought after by hospitals and PPs' across the US. Since I'd already have a fellowship in PICU or NICU, most cards programs might allow me to complete a cards fellowship in 2 years.

While I'm comfortable for longer training periods since I have no med school debt, could anyone advice me on the viability of taking this route and if double fellowship is worth it in the end since this is not the traditional 3yrs PICU + 1yr CVICU route but 3yrs PICU/NICU + 2-3yrs Peds Cards.

One reason I put cards towards the end in my order of preference is I'm not entirely comfortable with longer clinic hours and prefer inpatient setup which is why I'd go with PICU or NICU if I were to do just one fellowship

Thanks

Doing NICU and Cardiology is a very unusual pathway. I've literally never seen it, but I suppose it could happen. I can't imagine what that job would look like.

 

[PTPoeny]

Doing NICU and Cardiology is a very unusual pathway. I've literally never seen it, but I suppose it could happen. I can't imagine what that job would look like.

I know of one cardiac NICU, basically CICU but only with the critical CHD that needs surgery within a few days of birth. I imagine they would hire someone dial trained ‍♀️

 

[SurfingDoctor]

I know of one cardiac NICU, basically CICU but only with the critical CHD that needs surgery within a few days of birth. I imagine they would hire someone dial trained ‍♀

I personally wouldn't pursue dual fellowship training with the hopes of getting a job at one particular place. If anything, most people need to develop their career path and plans so when they finally graduate, they can cast the widest net possible for jobs, not the smallest.

NICU is a large net, Cards is a large, but not as large net. NICU-Cards... that's a small net, but I guess to each their own. Maybe there would be a bigger market for it someday, it would be a roll of the dice though.

 

[MonkeyRalph]

I am dual-boarded in PICU and Cardiology and am very familiar with the job market and workforce in the US. I agree with most of what has been said so far.

The CVICU job market is still open with several programs recruiting each year, especially compared with the academic PICU market, which has been tougher and tougher each year lately. Having said that, the CVICU market is likely to be much more saturated by the time the OP is done with training, so it's tough to project that far ahead.

It's much easier to do cardiology as the first fellowship (3yrs) and PICU as the second fellowship (2yrs) than vice versa. Cardiology is a very clinically diverse fellowship with multiple different rotations (inpatient, ICU, cath, echo, EP, heart failure, adult congenital, exercise physio, fetal cardiology, MRI, pulmonary hypertension, prevention, etc), most of which you have to master in 2 years in addition to getting your skills as a cardiac intensivist honed during that time as well. This makes it hard for many programs to fit in a 2 year trainee without notable disruptions to their programs, so I would say the minority of cardiology fellowships are willing to entertain such an applicant. PICU, on the other hand, is a bit less heterogeneous (i.e. you're in the PICU, or you're in the CICU, or you're on research/elective) and it's usually a bit easier to fit a 2-year fellow into the rotation without massive disruptions (in most, but not all programs).

I know several dual-trained NICU-Cardiology folks across the country (I have personally trained with or worked with at least 7 of them), but almost none of them do CICU as primary cardiac intensivists, but serve more as a neonatal consultant role or a primary NICU role (in all but one center, to my knowledge).

It's a tough decision to make at this point, so I'd recommend deciding first if you want to be a PICU doc, a NICU doc, or a cardiologist (all of which are completely different). The CICU stuff can be decided later, though there are easier and more difficult ways to get there depending on the choices you make today.

 

[PTPoeny]

I personally wouldn't pursue dual fellowship training with the hopes of getting a job at one particular place. If anything, most people need to develop their career path and plans so when they finally graduate, they can cast the widest net possible for jobs, not the smallest.

NICU is a large net, Cards is a large, but not as large net. NICU-Cards... that's a small net, but I guess to each their own. Maybe there would be a bigger market for it someday, it would be a roll of the dice though.

Oh, I completely agree. I just wanted to put it out there that it is a possibility as someone mentioned they couldn't imagine any career path with both fellowship.

 

[DeadCactus]

As a tangent, any insight into why the PICU market so tough right now?

 

[doopdidoop]

As a tangent, any insight into why the PICU market so tough right now?

it's been a tough market in academics for a while now and the pandemic has really hit hospitals financially. i'm trying to not panic haha

 

[MonkeyRalph]

I think it's just the ebbs and flows of academic subspecialties. This happens every 5-10 years in every specialty where certain fields have a high saturation of younger physicians who are unlikely to retire soon and whenever there is financial uncertainty, even folks who are ready to retire may defer it for a few years for better financial security, which leads to less availability of jobs. I think even 6-8 years ago, PICU fellowship was much less competitive and many spots went unfilled each year, but the last 3-5 years has been much more competitive with many more trainees in the pipeline, which ultimately leads to more applicants for less jobs.

 

[SurfingDoctor]

Specific to PICU, there is a limited job market. As opposed to other subspecialties, PICUs (and CVICUs) are dependent on cities and hospitals. In the NICU or hospitalist (or most every other subspecialty), every community or community hospital needs that resource and aren't as constrained. But most community hospitals don't want (or can't have) PICU patients, and thus, the market is invariably lower.

So you have too many graduates, who have the same clinical skills, competing for a finite number of PICU jobs. It is something not COVID specific and something I foresee getting worse with time. About 1/2 of PICU are academic and the other 1/2 are private, but they both are confined by the same needs (actually... a certificate of need determined by Medicaid). Thus, if you don't bring something unique to the practice (private or academic), your chances are reduced.

We have talked within our group limiting the number of applicants per year to deal with this issue (similar to Pediatric Surgery which is actually very strict about the number of slots per year) but we haven't come to a consensus. As far as I know, last year was the first year in the history of PICU fellowship where the number of applicants was higher than the number of available slots. Anyway...