I am 100% sure I want to do Pediatrics... I think.

[stevo2365]

Now I know this topic has most probably been beat down more than I can imagine on this forum, as I have read most of them on this topic, but I'm still not too much clearer on what I should do.

Let me start by saying I love medicine, I don't mean IM medicine, or Peds medicine per say. I just love medicine in general, whether it be a case of bronchiolitis, Williams Syndrome, HTN, FSGN, or CHF, it all appeals to me, especially the crazy random/tough cases. However, ever since before even medical school, I've loved the concept of pediatrics. Working with children, the more lighthearted environment of the hospitals, and really impacting a child's life. I love that. And now as a 3rd year student who's already finished their IM rotation and is in the midst of their peds rotation, I am at a crossroads. For this reason: I love Pediatrics, I have a knack with the kiddos and love their pathology, but I am being told the overall lifestyle in terms of opportunities is limiting.

Let me be as specific as possible and see if I can get advice based on that. I grew up in a small town in Florida on the beach. I have always seen myself going back there. As a general pediatrician, I know that would be no problem, but that isn't really what I see myself doing. I see myself subspecializing in nephrology, cardiology, or heme/onc. Now I know nephro and heme/onc are 98% of the time tied to a large academic center in a big city, so that makes those tough for me to go after, but cardiology I've seen can be in private practice and live in a smaller city (if that's true please please can someone confirm that, and tell me what that job looks like?). So that's one thing. And on a semi related note, I am currently rotating at a stand alone children's hospital in a big city, and seeing some AMAZING pathology so I don't know if this is a realistic view of what I would be seeing normally.

Also, I'm being told the hours worked vs the money made (which I'm not that guy who cares about money, I just would like to give my kids opportunities one day as loan free as I could) is not the best. Any argument against this would be great too.

And last but not least, I just want to know if there are opportunities to be successful. Will I graduate as a pediatric ________ (whatever I choose) and have patients. Will I be constantly moving from hospital to hospital bc they can't afford their pediatric wing, or will I be able to amass a good group of patients whom I can reliably care for and treat.

Any answer to any of these questions or simple advice would be great. Thanks!

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[SurfingDoctor]

I will tell you, it is very hard to predict what the job market will be or look like 10-15 years down the road. Specific to my own field, intensive care jobs 10 years ago were a dime a dozen. If you had the required training and a pulse, you could pick wherever you wanted to go. Nowadays, there are still plenty of jobs, but the options are more limited (maybe not the specific practice type or the specific locale you wanted). Also 10 years ago, you had to practice more or less in an academic center. Nowadays, while academic centers still make up the majority of jobs, there are private groups and locum positions that cover community ICUs or hospitals as well as larger facilities in places I've never heard of.

To give a flavor, you can go to Pedjobs and search for general pediatricians or subspecialist and see what is around (this is not an exhaustive list FYI):
http://jobs.pedjobs.org/jobseekers/index.cfm

As far as will you have patients, unless people some procreating for some reason, yes. A new pediatric patient is born every second and unfortunately for them, some of them will have diseases that require subspecialists. That will never change. No one typically moves because they don't have enough patients. They move because of family concerns, they are fed-up with their employers, they got a better job offer somewhere else, etc. I've never heard anyone have to pack up and leave because they ran out of patients (or didn't have enough). Now, if you only wanted to take care of pediatric patients with FSGS or long QTc syndrome, then yeah, you probably couldn't practice wherever, but there are always going to be children with murmurs or children with hypertension who need to be checked out or followed by a cardiologist or nephrologist, respectively. Granted, this is just my perspective since I don't practice in those specific subspecialties, but in general, you should pick a path that interests you so that you can still find it interesting and fun to practice in 30 years, not just because a job might be here or there.

 

[WheezyBaby]

Now I know this topic has most probably been beat down more than I can imagine on this forum, as I have read most of them on this topic, but I'm still not too much clearer on what I should do.

Let me start by saying I love medicine, I don't mean IM medicine, or Peds medicine per say. I just love medicine in general, whether it be a case of bronchiolitis, Williams Syndrome, HTN, FSGN, or CHF, it all appeals to me, especially the crazy random/tough cases. However, ever since before even medical school, I've loved the concept of pediatrics. Working with children, the more lighthearted environment of the hospitals, and really impacting a child's life. I love that. And now as a 3rd year student who's already finished their IM rotation and is in the midst of their peds rotation, I am at a crossroads. For this reason: I love Pediatrics, I have a knack with the kiddos and love their pathology, but I am being told the overall lifestyle in terms of opportunities is limiting.

Let me be as specific as possible and see if I can get advice based on that. I grew up in a small town in Florida on the beach. I have always seen myself going back there. As a general pediatrician, I know that would be no problem, but that isn't really what I see myself doing. I see myself subspecializing in nephrology, cardiology, or heme/onc. Now I know nephro and heme/onc are 98% of the time tied to a large academic center in a big city, so that makes those tough for me to go after, but cardiology I've seen can be in private practice and live in a smaller city (if that's true please please can someone confirm that, and tell me what that job looks like?). So that's one thing. And on a semi related note, I am currently rotating at a stand alone children's hospital in a big city, and seeing some AMAZING pathology so I don't know if this is a realistic view of what I would be seeing normally.

I could be wrong but I can't imagine a small town (depending on how you define that) is going to have enough congenital heart kids, arrhythmias, and "benign referrals" (eg innocent murmur referrals) to keep a peds cards guy in business working full time. You could potentially split time between gen peds and peds cards I suppose

Also, I'm being told the hours worked vs the money made (which I'm not that guy who cares about money, I just would like to give my kids opportunities one day as loan free as I could) is not the best. Any argument against this would be great too.

There's no argument against this. Sorry. Almost every field in medicine does better than peds, and many peds subspecialists take a pay cut from gen peds. That's either acceptable or not to you

 

[doc05]

you have some very valid concerns. also keep in mind that your idea of "private practice" in any specialty is becoming less and less likely. I'm not in peds, but as far as I can tell, with low physician reimbursements and significant potential for in-hospital care, the peds specialties will be mostly in an employed, hospital-owned practice model.

as SurfingDoctor notes, it's very difficult to predict a job market 10-15 years in advance. Again, peds isn't my field, but keep in mind that tons of practicing physicians are very very close to retirement age, so that will probably work out in your favor.

as SurfingDoctor says "No one typically moves because they don't have enough patients..." -- this is not true. In areas of high physician saturation, it's a real possibility, because taking referrals away from the established docs in town isn't easy. But it really depends on where you end up practicing.

 

[BigRedBeta]

Peds Critical Care Attending here, I'll send you a PM in the next few days.

 

[sliceofbread136]

Am at a very similar crossroads... I think I'm doing med peds

 

[WheezyBaby]

Am at a very similar crossroads... I think I'm doing med peds

I'm doing med peds, and while I have different career plans, OP's overall sentiments are similar to mine. The only reason I didn't mention it is I believe cards is moving toward encouraging adult congenital heart fellowship as opposed to double boarding adult and peds cards. Not that med peds people can't do the adult congenital fellowship and not that the training still wouldn't be beneficial. I'm not a cards guy though. Bigredbeta may be able to provide some additional insight there

 

[SurfingDoctor]

In areas of high physician saturation, it's a real possibility, because taking referrals away from the established docs in town isn't easy. But it really depends on where you end up practicing.

This maybe true, but getting into practice in a physician saturated market is different than someone established leaving a physician saturated market. It would somewhat foolish to venture out on one's own into a saturated market without the guarantee of joining an established practice, group, hospital, etc. Maybe we interpreted the question differently, but for someone who is practicing in a location, lack of patients is generally not the problem. Lack of reimbursement to keep the practice open on the other hand...

 

[stevo2365]

Thanks for all the replies and advice everyone. A lot of good points got brought up. As I talk to more and more pediatricians personally, they tell me generally the same thing, similar to what is above. That I can work in an area I want, establishing a practice will be possible, but tough, and that lastly, if I'm going to be the "bread winner" in the house it's going to be tough.

But I always ask as my last question, "If you could go back and do it all over again, would you pick adult medicine then?" And the answer has ALWAYS been "No way! I love peds! I would just make sure to specialize." And that's after they've spent the last 30 minutes telling me how tough the peds life is. -__- haha

And look forward to hearing from you BigRedBeta!

 

[stevo2365]

Oh, and on another side note, I've been greatly considering med/peds as well, and the reason I am weary of it is most doctors I speak to, none of which are med/peds, say more or less it's a waste. I believe they say it in the sense that about 75-80% end up practicing one field or the other and it is most feasible to just pick that one straight from the get go, save a year of residency, and have an extra year of training in that designated category. For me, I love the idea of an all encompassing field, but if it really is true it is very rare that both are actually practiced, I believe then that it is best to pick one. Anyone have any other advice or takes on that? I'd love to hear it's the better choice. Haha

 

[IlDestriero]

There are smaller children's hospitals out there. Maybe one of them would be right for you. There's plenty of pathology outside of the handful of major pediatric hospitals in the big cities.


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Il Destriero

 

[MudPhudHopeful]

Oh, and on another side note, I've been greatly considering med/peds as well, and the reason I am weary of it is most doctors I speak to, none of which are med/peds, say more or less it's a waste. I believe they say it in the sense that about 75-80% end up practicing one field or the other and it is most feasible to just pick that one straight from the get go, save a year of residency, and have an extra year of training in that designated category. For me, I love the idea of an all encompassing field, but if it really is true it is very rare that both are actually practiced, I believe then that it is best to pick one. Anyone have any other advice or takes on that? I'd love to hear it's the better choice. Haha

Steve, it's not true that most choose to exclusively practice one or the other. Most provide care to patients of all ages, although the breakdown between adults and children is non necessarily evenly distributed. See: http://www.ncbi.nlm.nih.gov/pubmed/16123468

 

[stevo2365]

Steve, it's not true that most choose to exclusively practice one or the other. Most provide care to patients of all ages, although the breakdown between adults and children is non necessarily evenly distributed. See: http://www.ncbi.nlm.nih.gov/pubmed/16123468

Thanks for the link, but after reading the abstract, the gist was "Conclusions Internal medicine-pediatrics physicians are more likely to spend a majority of their clincal care on adults and to perceive that they stay more current in the care of adults than of children. Potential reasons for this disparity may include training issues, greater reimbursement for the care of adults, perceptions of the impact on the medical market of the demographic shifts to older adults, and employment opportunities following training."

So although I'm sure a lot of the responders see a few pediatric patients throughout the year, I don't know if an extra year of residency is worth spending "a majority of clinical care on adults.." The worst part is I actually want to do med-peds, I'm just being the devils advocate to try and get the opposing argument to convince me otherwise. So please keep the facts coming.

 

[SurfingDoctor]

Oh, and on another side note, I've been greatly considering med/peds as well, and the reason I am weary of it is most doctors I speak to, none of which are med/peds, say more or less it's a waste. I believe they say it in the sense that about 75-80% end up practicing one field or the other and it is most feasible to just pick that one straight from the get go, save a year of residency, and have an extra year of training in that designated category. For me, I love the idea of an all encompassing field, but if it really is true it is very rare that both are actually practiced, I believe then that it is best to pick one. Anyone have any other advice or takes on that? I'd love to hear it's the better choice. Haha

I was not Med/Peds but have had a number of friends and colleagues who initially went that route. Again, not speaking from personal experience but observational experience, but Med/Peds people who stay in Med/Peds only really do primary care. To do Med/Peds and then subspecialize is generally speaking, not beneficial to you in any way. For the people who subspecialize who had Med/Peds training, they invariably give up either the IM or Peds certification because it is cost prohibitive and unnecessary to remain board certified in a specialty you don't practice. There are some new niches being developed in sub-specialties that link pediatrics and adults, such as adult congenital programs that was previously mentioned, but these are few and far between and a limited market for future jobs. While there probably is more need for transitional care (eg the children with chronic or congenital disease who is now living into adulthood) the lack of synergy between pediatric and adult hospitals, healthcare systems and insurance had made this a large hurdle. Maybe by the time you graduate residency, in +4 years, there may be a more established role, but it is hard to predict that future and this role has certainly not become more robust in the 10 years or so I've been practicing. Thus, at this juncture, it would be helpful for you to decide if you want to work primary care (or maybe community hospitalist) and take care of all patient populations (then go Med/Peds) or subspecialize (then pick one or the other).

 

[SurfingDoctor]

FYI, this is from the National Med-Peds Resident Association (https://medpeds.org/residents/fellowship-guide/#advantages) with specific regards to subspecialty training. I would preface this by saying that combined fellowships are hard to find, but this could in general apply to Med-Peds residency as well as combined fellowships. I tried to highlight the important parts:

Advantages of Combined Fellowships
To begin, a caveat: the following is based on opinion only, not evidence-based data. However, both the pediatric and internal medicine boards strongly encourage subspecialists in both fields to be on par with categorical sub-specialists if you plan on providing care in both age groups.

We will talk about academic careers first. Some who take this route feel like it helped push their careers in academia along a little faster and gave them certain advantages. Most people who do combined fellowships and enter into academic careers proceed directly into the Assistant Professor level and bypass “Instructor” status. This has some disadvantages, though: it puts the clock in motion for you to advance to Associate Professor with tenure almost immediately. With the “Instructor” label you have some time to get research, clinical practice, or teaching established before you have to get into the grind of “producing” towards your next promotion (usually 5-7 years out). Also doing a combined fellowship allows you to have credentials in both departments, which can be helpful to you in that it provides a wider base for funding for your career as well as providing access to the other department’s strengths.

Doing a combined fellowship continues what you have already done during residency training (practicing as an internist and a pediatrician in two departments). This dual appointment provides you with an array of teaching and research opportunities, as well as clinical avenues, to pursue. Usually you will have to pick and choose what areas you want to focus on — the choices will be staggering, but allow you to be diverse as well as do things that you really want to do. Doing a combined fellowship allows you to participate in multiple national organizations, again providing opportunity for you to advance your career. Frequently, national organizations are looking for someone who can fill a special niche, and a person who is board certified in three or four areas frequently can provide needed diversity to a committee or group.

For those interested in private practice, a combined fellowship provides the tools to expertly practice both disciplines with confidence. Combined specialists have gone to large metropolitan areas and easily put out their shingle as a dual certified subspecialist. Hospital credentialing and insurance credentialing are much easier with the “board certified” behind your name. For example, it is more difficult to get privileges to see pediatric pulmonary patients if you are only board certified in adult pulmonary medicine, especially in a larger metropolitan area. For smaller communities, combined fellowship may not provide as large an advantage. Also, being quadruple boarded may increase your standing in the medical community and may allow increased number of referrals (especially initially on arrival to a community) if you are viewed as an expert in both adult and pediatric diseases. Over time, this probably becomes less important and success depends more on how well you provide service for your colleagues.

Disadvantages of Combined Fellowships
Time and money. The more time you spend in fellowship training, the less money you are making in “the real world”. It is doubtful that a combined specialist will make more money than a categorical specialist. In general, an adult specialist will make more money than a pediatric specialist. No data exists on how much a combined specialist makes compared to a categorical specialist, but you can infer that they generally do not make more than a categorical adult specialist. This can vary, though, as some combined specialists have worked out agreements to supplement their incomes by providing a service that otherwise would not be available to a hospital or community. For example, it may be worthwhile for a hospital or multispecialty group to supplement a combined pulmonologist (who would be the only board certified pediatric pulmonologist in the area) in order to attract pediatric asthma or pediatric complex lung disease patients to that hospital or practice.

During the fellowship years, student loans are still growing and moonlighting becomes a priority supplement income. Also, many fellows are starting or expanding families so income becomes more important. From a monetary viewpoint, it does not make sense to stay in fellowship for 2 or more years longer when essentially you can make the same amount of money if you just complete a categorical fellowship.

Once you become dual subspecialty certified you will have a large amount of dues to pay to all of the professional organizations in which you will want to remain a member. Plus, you may have to pay for multiple subspecialty journals. This brings up the point of staying current in knowledge in all of these areas, which can be very difficult to do. Think about where you are right now, trying to keep up with general internal medicine and general pediatrics. Now, add to that keeping current in two sub-specialties as well.

Finally, for people in academic medicine you have responsibilities in two departments. In a sense you have two full-time jobs with differing demands, priorities, and supervisors. For academic success, you will probably need to align yourself with one primary department (either internal medicine or pediatrics), although you may have responsibilities (clinical, research, teaching, administrative, etc) in both departments.

 

[mvenus929]

Thanks for all the replies and advice everyone. A lot of good points got brought up. As I talk to more and more pediatricians personally, they tell me generally the same thing, similar to what is above. That I can work in an area I want, establishing a practice will be possible, but tough, and that lastly, if I'm going to be the "bread winner" in the house it's going to be tough.

But I always ask as my last question, "If you could go back and do it all over again, would you pick adult medicine then?" And the answer has ALWAYS been "No way! I love peds! I would just make sure to specialize." And that's after they've spent the last 30 minutes telling me how tough the peds life is. -__- haha!

Most Peds people can't imagine taking care of adults, which is why we chose Peds. It is hard to justify going into Peds otherwise, and for that reason, the people who,do it really love it.

 

[WheezyBaby]

The NMPRA website has a bunch of wonderful info. Highly recommend reading it thoroughly if you're considering med peds. Bottom lines. Its possible (and potentially very reasonable) to see both kids and adults. How easy this is depends on your area of practice, practice setting, and your geographic flexibility. If you want to practice med peds primary care, are willing to live anywhere, and want to be in private practice, you can see essentially whatever distribution of peds and adults you want. If you want to practice as an academic combined adult and peds heme/onc, you're going to be limited to areas with big children's hospitals, have to find an academic center with multiple departments looking and interested in hiring you, etc. Somewhere in the middle range of difficulty would be something like combined hospitalist or combined allergist working primarily as an outpatient. I know several individuals practicing combined hospitalist or primary care. I also know several individuals in the process of getting combined fellowship training. Individuals actually practicing combined subspecialties are much less common, but they exist. Regardless of their ultimate destination (solo peds, solo adult, or combined med peds), the vast majority of individuals who did med peds don't regret their decision