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Making the switch to Peds

Discussion in 'Pediatrics' started by pedhopeful, Apr 12, 2018.

  1. pedhopeful

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    Hello All, I have a question that I see has been posted a few times before but not in the past 3-4 years it seems.

    Can I make the switch from a non-Peds residency to Peds?

    About me:
    Currently in a rising PGY-2 in a 5 year EM/IM program- Had aspirations to do EM shifts and hospitalist weeks but now find myself completely turned off by this career path. I was between current residency and Peds in medical school but obviously went the route I did.

    I am in good standing with my current program and have already spoken with my PD about the possibility of re-entering the match for Peds and would have their support.

    I am scared though that I 1. won't match or 2. won't be competitive for very many programs.
    Does anyone have insight on how much re-matching hurts your application? Would I be turned down by all major university sites and big name peds programs? I would likely want to do PICU or Cardiology if possible.

    Some other things to consider: big step1/2 discrepancy low 210s=step 1 and mid 270s=step 2
    I honored most of third year but high passed peds but the comments are glowing for my eval.
    I didn't do a peds sub-i but did do 2 other core rotations exclusively at a peds hospital. I have tons of extracurriculars during medical school revolving around kids: tutoring, clinic volunteer, etc.

    Give it to me straight, do I have any hope? I am just so happy when working with kids and my peds em shifts are the only shifts I find myself enjoying. I feel like the ship has sailed on me being able to match peds but if I have any shot I want to take it.
     
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  3. Oso

    Oso
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    I'll let others comment on the feasibility of switching residencies (as I know nothing about this). But if you're ok with EM, you could always do a peds EM fellowship after finishing residency and work in a dedicated peds ED -> work exclusively with kids.
     
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  4. pedhopeful

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    Thank you for the reply. I have considered this and it appealing in that I would get to work with kids but I think I'd rather have a longitudinal relationship with my patients. The lack of this is one of my biggest regrets with doing EM.
     
  5. physicsnerd42

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    We have a Peds intern who was a gen surg intern last year at another institution. A gen surg intern from my institution also matched to Peds elsewhere last year. If you really want to switch, apply broadly. Also talk to the Peds PD at your institution to see their thoughts.


    Sent from my iPhone using SDN mobile app
     
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  6. pedhopeful

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    I would definitely be applying broadly. Did these residents have much say in where they ended up?
     
  7. GonnaBeADoc2222

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    You should really think long and hard about the lifestyle and financial implications of this. You are PGY2 now - if you apply for this upcoming cycle, you will still complete your EM/IM PGY3 year before switching to Peds. Then it's 3 years of peds residency followed by 3 years of fellowship.

    I can see how Peds Cardiology would satisfy your desire for continuity, but PICU isn't about continuity. It's about stabilizing and getting them to the floor. Very procedurally heavy. Your "continuity patients" are typically "rocks."

    Not only would you be throwing away the three years you already spent on EM/IM, but you would essentially be committing financial suicide by making this switch. You will also work waaaaayy more hours in any peds field than in EM. The hourly compensation in EM is higher than most other specialties.

    You say you like your PEM shifts. Why not try to do PEM? Don't believe the lies that you have to do a fellowship either. I have a colleague who is EM boarded who works almost exclusively in an (academic center) peds ED.

    Residency sucks. Stick with it, you'll be an attending soon enough and it gets soooo much better.
     
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  8. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    Seen it happen, though not commonly. And nothing you said hurts your chances. You matched to EM/IM, there's no reason for you not to Match to Pediatrics. Obviously, you will get asked about why you initially chose the residency you did and why you are now trying to switch, so just be prepared answer it truthfully. But overall, I don't think it would be a problem.

    Also as mentioned above, there are EM people who later go to do PEM. Typically do you have to do a fellowship to work at an academic center, though I bet there are position at private children's hospital that don't care if you are Pediatric trained or not. You have to being willing to find a fellowship program that either supports or is willing to take EM people, but it isn't that uncommon from what I recall. Given that you'd have 2 years left of your current residency and pediatric residency is 3 years, your time commitment would be about the same either way.
     
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  9. mvenus929

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    Can you make the switch? Yes. But you'll have to start over--there's next to nothing you can get to count as 'credit' from an EM/IM program. Your best chances will be at your home institution.

    You don't have to go to a big name program to get into a PICU or cardiology fellowship, though it makes it easier because you have access to the subspecialty and research opportunities. If you've already spoken with your PD, go talk to the PD at your peds program and discuss how they would look at your application.
     
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  10. pedhopeful

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    Thank you for your reply. To clarify I am coming in to my second year this June when the new interns start.
    Your point about the pay difference is well understood and I appreciate you raising the issue. I know that my compensation would be much more appealing in EM but I am just questioning every reason I had for going in to EM and finding that it was a big mistake. I loved the EM rotations but that was because I was shielded from the unpleasantness of it all and just directed to do procedures and fun stuff.
    Being around pediatric patients just makes me feel extremely happy and I think that if I could pull ~200k that I would live a great and happy life.
     
  11. pedhopeful

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    I think my next step is definitely to talk to the Peds PD. A lateral transfer would be very appealing. Thank you for your input, I really appreciate it.

    I am still trying to work up the courage so if anyone has other input I would love to hear it!
     
  12. Marie0123

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    For the PD at my program, Peds is her second residency/career. She was in EM and was an attending for a bit, but ended up going back to do a Peds residency and is now PD at one of the top programs. She loves 'second career' applicants (former nurses, even finance people, etc.).

    At least at our program, switching wouldn't hurt you at all. Just make sure you are up front with your program and if you decide to apply to outside programs, you'll want to emphasize your reason for switching in your personal statement (and likely your LoR from your current PD). Best of luck!!
     
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  13. MEN2C

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    This is bad advice. I am sure you can find an exception, and people were grandfathered in, but I very highly doubt there are going to be many opportunities for a young physician to work at a standalone children's hospital without being PEM certified (by either pathway, whether EM-->PEM, or Peds-->PEM). My institution wouldn't even consider the person without PEM fellowship training, and neither would most others unless you are some kind of research superstar. And even then, there would be plenty of consternation.

    If I am wrong, show me the profiles on websites of new hires working at children's hospital who are not PEM BE/BC. Of course, some of the older guys may have been working forever or have been grandfathered in, but that doesn't help a young physician trying to find a job.
     
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  14. xffan624

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    I know a two attendings that moonlight at the Peds EM I work at without a PEM fellowship. They're relatively new hires (ie young people). I'm not at a standalone, but I do work at an academic medical center.
     
  15. GoSpursGo

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    One of my coresidents was able to work on the less acute side of the peds ED at our large academic stand-alone children's hospital straight out of a peds residency. I suspect someone boarded in EM would do fine finding a spot.

    Of course that doesn't really help with the OP's question, and it sounds like they want some continuity. Honestly, with a 270s score on step 2 I suspect you would do fine in the match, you're going from a more competitive to less competitive specialty. People switch residencies all the time for legitimate reasons, and while it's terrifying to take the leap and actually reapply, chances are you'll land OK. Apply broadly but only to locations that you would actually be willing to leave your current residency for. As others have said, getting in "in" with the program at your home institution would be the easiest and safest way of going about this.
     
  16. MEN2C

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    Spot where? In the main side of a standalone children's hospital? I would be surprised.
     
  17. GoSpursGo

    GoSpursGo Allons-y!
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    You didn't specify main side. I don't pretend to be an expert on the hiring practices at every standalone children's hospital, but I was offering my n=1 experience. In any case, again, it's kind of a moot point if that's not what the OP wants to do.
     
  18. pedhopeful

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    Yeah you hit it on the head with calling it terrifying to take the leap. Honestly it has stressed me out beyond belief and I just wish I could be on the other side and in a pediatric residency. At this point though I know that a career with the path I’m on would be miserable.
     
  19. BigRedBeta

    BigRedBeta Why am I in a handbasket?
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    What do you have to lose at this point?
    I will have you note, it's April, it's after Match Day, people are rushing to make schedules for next year. Given the timing, if a lateral move is possible, each passing day diminishes the chance you could transition July 1 (which may be completely impossible anyway). You need to get in front of the Peds PD as soon as possible to map out what your options are. But out of courtesy to your current program, you need to determine if you're sticking around so they can make adjustments to their coverage schedule as well.
     
  20. GonnaBeADoc2222

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    This is only my opinion, but PEM fellowship gives you academic street cred only. Clinically, there is no emergent Pedi presentation a competent (adult) EM boarded attending cannot handle just as well (and often times better, and faster) than a PEM trained person (especially when it comes to airway management, vascular access and trauma).

    OP, if you truly envision yourself as miserable in EM, then you should switch. I just think your switch from EM/IM to Peds is a big one - what motivated yourself to do EM/IM to begin with? I just think there's so much flexibility in EM to tailor your practice to what you want, and avoid throwing away valuable years you've already spent in training. You can do a pain fellowship and have longitudinal relationships with patients that way (and do lots of procedures). Tox can also get you that in a way. If you want more Peds, and the ivory tower scoffs at you, you can work in community hospitals that have a separate Peds ED and preferentially sign up for more Peds shifts (I spent some of my training at a place like this). If you want even more Peds, you can moonlight at a Pedi urgent care.

    Aren't there a couple Peds/EM combined programs out there? Have you looked into those?

    In the end, you have to decide what will make you happy. If your perceived potential increase in on the job happiness outweighs the potentially drastic decrease in pay and increase in work hours, then go for it.
     
  21. BigRedBeta

    BigRedBeta Why am I in a handbasket?
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    I guess keyword being "competent". Available literature would suggest that most EM programs do not provide enough pediatric training in residency at least in relative proportion to the number of pediatric patients typically seen in a community ED.

    As a PICU attending, I see adult EM management of pediatric patients go awry not infrequently. I can count on two fingers the number of times I've had an adult EM person place a central line in a pediatric patient, I frequently see poor decision making in airway management (jumping to intubation without other interventions first, using uncuffed ETT, inappropriate ETT size selection, questionable RSI medication choices in patients with genetic conditions), flat out refusal to do LP's when clinically indicated, among other things. My least favorite thing that happens is the ABG in the seizure patient leading to intubation - and then they can't tell me if they actually got the patient to stop seizing before paralysis. Second least favorite is the awful DKA management (insulin boluses, bicarb) though the insulin boluses aren't always their fault and get triggered in triage protocols.

    Trauma management is usually just fine and issues are not the fault of the ED staff usually, moreso limitations of the surgical services with pediatric patients.

    This is not to say that PEM procedural skills are necessarily exceptional - a conclusion supported in the literature - but the decision making process is generally better.
     
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  22. GonnaBeADoc2222

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    Admittedly getting a bit off the original topic, but to address your points:

    1) Central line: almost no reason to place a pediatric central line in the ED. Vasopressors can be started peripherally. Same practice for adults. I've placed 2 central lines in adults in the last 10 months. Central access has real risks and almost everything can be accomplished using ultrasound guided peripheral lines.

    2) Jumping to intubation: This reflects overall poor care and I'd argue not specific to pedi management. We have the same non invasive tools at our disposal in adult medicine that should be used prior to intubation. I will say that there are often intangibles that are overlooked by the accepting ICU team when judging the EDs indication for intubation (mental status, appearance, work of breathing. etc)

    3) Equipment selection / RSI meds: don't have an excuse for this one

    4) LPs: If a patient is being sent down a low risk sepsis pathway and the eventual goal is to d/c, then sure you need the LP in the ED. LP in the ED otherwise is a huge luxury of time which we often don't have when there are 6 patients waiting to be seen in 20 in the waiting room.. The EDs job is to stabilize and disposition. The rest of the workup can be accomplished by the accepting team.

    5) Seizure, DKA, etc: Baffling and no explanation for this. Some people need to open a book.

    I will also say that anecdotally, I've seen EM attendings handle stressful situations with more of a coolness than PEM attendings.
     
  23. NurWollen

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    Is less-than-ideal procedural training something that could be partially remedied if PEM fellows spent more of their training in the PICU?

    Sent from my SM-G930V using SDN mobile
     
  24. GonnaBeADoc2222

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    Anecdotally, yes. My wife is a PICU doc at a major center. She is intubating / central lining / art lining almost every day. The PICU comes down to the ED to manage the sick kids.

    My other criticism of they way PEM was done where I trained (not sure if this is generalizable elsewhere) is that the fellows received almost no training in how to actually manage flow of the ED. They would typically only be involved in the "interesting" cases or those requiring a procedural sedation. They never directed the entire department. Managing flow is probably the hardest to learn and most valuable skill you need in the ED.
     
  25. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    Typically, the PICU does not respond or do procedures in the ER.

    And no, there are not enough procedures for PEM fellows to gain competencency in the PICU for procedures. Not without sacrificing PICU fellows procedura training.
     
    #24 SurfingDoctor, Apr 28, 2018
    Last edited: Apr 28, 2018
  26. BigRedBeta

    BigRedBeta Why am I in a handbasket?
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    In my PICU fellowship, ICU fellows probably came to 40% of ED intubations, and of those we responded to, more than 1/2 we ended up being the ones who did the intubation after the PEM fellow tried and failed. For us, there were enough lines in a general sense to go around that the PEM fellows could have gotten the 10-20 that would have conveyed some competence. However the issue was timing and when people were available and also how sick the patients were. The kids who are crashing, PICU attendings wanted the senior PICU fellow doing so that it got done, not the one to be teaching on. If PEM fellows were to spend more time in the OR, then they'd at least get more airway experience, and could potentially add in some line experience.

    In the two PEM fellowships I've seen up close, third year fellows had at least a 1/3 of their shifts where they were the only attending in the ED to provide at least some of the experience @GonnaBeADoc2222 mentions. Not sure though if that's actual "instruction" or more trial by fire.
     
  27. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    Can't say I've seen that at any institution I've been to. If the ER failed intubations, they called Anesthesia. Same goes for if the PICU failed intubations. I don't have a big enough "n" though, only 3.

    Also, procedures in general are becoming less frequent with more non-invasive interventions and more conservative management. I don't know the data for that, just what the PD says at our institution based on fellow procedure logs. I suppose if the PICU fellows gave up enough of their own CVLs, a PEM rotating could get the experience and understand the technique, but that can be dangerous. About 2 years ago, we had a run (n = 3, again) of PEM people putting femoral CVLs in children under 1 in the ER where they were put into the femoral artery. 2 of those patients required BKAs. Needless to say the practice stopped. There was just enough knowledge to be dangerous.
     
  28. GonnaBeADoc2222

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    When I was a resident, I was always amused that almost every airway I heard about in the Peds ED was inevitably described as "tricky."

    I'm glad they're getting that independent experience, however why keep these people in fellowship for a 3rd year if they're just being an independent "attending" anyway? I too have heard of this model where the senior fellow is acting as the "attending" and the real attending is home sleeping. That is BS. The attending should be in house supervising the senior fellow and providing real time feedback about their ED leadership skills. Somehow they are selling this swill that the senior fellow is getting some "great" experience while they're making 70k instead of 200k or higher - which is what they deserve.

    Holy hell that's insane!
     
  29. mvenus929

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    We didn't call PICU if there were failed intubations (though I can't say I've ever seen a failed intubation in the ED... couple we had to reintubate, but it wasn't failed, just had the wrong size tube for the airway). ENT and anesthesia tend to be our back-up people. But, I had a patient as a resident who came in in realllly bad DKA, and we could not for the life of us get access other than an I/O. Since he was headed for the PICU anyway, the attending and resident (we don't have PICU fellows) came down and placed a femoral line. FWIW.

    Also, our third year fellows do shifts as attendings, but never by themselves--they are always the cross-coverage attending, or working in fast track. We actually had our second year fellows doing those shifts as well, but that practice will stop after this year due to various concerns that have been raised.
     
  30. GonnaBeADoc2222

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    Are they getting paid the attending rate for these shifts? Because they should be.
     
  31. BigRedBeta

    BigRedBeta Why am I in a handbasket?
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    Perhaps it was more accurate to say we showed up to assess need for intubation if we were available for the borderline cases. Then we typically stuck around until the tube was in. Personally over the 3 years, probably went to 10-12 such cases, ended up doing 5 tubes, since I was there. Typically fellow looked twice, and then the ED attending would say "let's just have the ICU fellow do it".

    And we didn't have a nurse led PICC team, so any PICC needed to go to IR, which of course was only open during Banker's hours and if they had available space. That kept the CVL volume in the PICU. The fellows who were 3rd years when I was a first year actually had one year where the attendings were still taking call from home, which they said meant they did a lot more lines. Once the attendings moved in-house, there was more "guidance" on which kids could get by without a CVL (or truthfully, more CYA in being able to say, "I discussed it with the overnight attending and they were okay without a central line").


    The can of worms that is the ABP mandated 3rd year is a much bigger set of issues than just clinical expertise. There will come a day when at least some fellowships lose that 3rd year, if only so they can actually recruit people to ID or Adolescent fellowships
     
    #30 BigRedBeta, Apr 29, 2018
    Last edited: Apr 29, 2018
  32. SurfingDoctor

    SurfingDoctor "Hooray, I'm useful"
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    I agree, that our PICC team in fellowship was... lackluster. But that was 7+ years ago. It's not to say we don't put in CVL... but they need for emergent CVL has subsided. That has been my experience in a more "modern" era.
     
  33. mercaptovizadeh

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    Op should do A/I fellowship out of EM/IM. This way he gets his peds and continuity of care without needing to do peds residency + an additional fellowship (which may not give him that continuity he seeks).
     

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