Med Student Deciding

[Cookie Queen]

Hello
I'm an MSII and trying to look at specialities. I'm pretty sure I don't want to work with adults, and I love the critical care/hands-on fields. I want to feel like I really did some good each day, but I'd also like to have a life outside of work as well. I've been looking at neonatology (front runner), PICU, peds ED, pediatric surgery, anesthesia, etc.

Thoughts? Suggestions?

Thanks!!

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[J-Rad]

Well, I'm biased being a fellow in a high-accuity pediatric subspecialty (cardiology), so I think these fields are the bee's knees. A general pattern that I've noticed (not absolute though) is that budding neonatogists don't care for the PICU and budding intensivists don't like the frog pond, I mean NICU (obviously they all missed the boat, and didn't realize that cardiology is the ideal field, of course). Like almost all of the above pediatric subspecialties, peds EM seems to be a love-it-or-hate it field. Great for its shift work, intervals of high pucker-tone cases (liked by some, not all), and lack of outpatient drudgerie (calling in refills, well child checks, etc.); not liked for its rotating shifts and for the sheer volume of non-emergency or urgency crap that rolls in (seriously-you brought your kid to the ER for a runny nose?). Personally I loved my peds ED rotations and sometimes fantasize about doing a second fellowship in it(though likely never will). Of these three, peds ED probably offers the best lifestyle, if you tolerate rotating shifts, but different jobs in any of the fields will have more or less intense lifestyle demands. Peds surgery is a subpecialty of surgery, not pediatrics. So you need to be able to tolerate doing a general surgery residency (and likely a research year) and be a stellar enough resident to land an ultracompetitive fellowship. And your lifestyle is going to suck. I am not aware of any pediatric surgeons (actively practicing in the specialty) whom I think has an enviable lifestyle. If you are a superstar med stud, then consider ENT if you want to be a surgeon, lots of pediatric patients for the general ENT and peds ENTs do really cool stuff at times. And a way better lifestyle than peds surgery. Peds anasthesia might be a good fit as long as you want to be an anesthesiologist (as much as I appreciate these colleagues, it's not a field I ever found to be particularly interesting). Pediatric cardiac anesthesia would be very cool if you ask me. But this is way out of my knowledge base. Michigangirl would be a great one to weigh in as she just finished the peds anesthesia/PICU post-peds residency program (a program that does not exist in that form anymore from what I gather from her writings).
Oh, and did I mention that cardiology really is the best field

 

[oldbearprofessor]

Hello
I'm an MSII and trying to look at specialities. I'm pretty sure I don't want to work with adults, and I love the critical care/hands-on fields. I want to feel like I really did some good each day, but I'd also like to have a life outside of work as well. I've been looking at neonatology (front runner), PICU, peds ED, pediatric surgery, anesthesia, etc.

Thoughts? Suggestions?

Thanks!!

First decide if you want to be a pediatrician, then you can decide if you want a fellowship and which one. Neo and PICU have a lot of similarities with each other in terms of training and lifestyle. Both will involve lots of nights, both in training and later. Neither will keep you from having a life outside of work. Pedi EM as noted has more ready access than neo or PICU to shift work, but I'm unconvinced the life style is any better.

As you move forward think about a couple of things. First, do you want to do research and if so, what types of questions do you want to ask and help answer? Second, are you concerned about "giving up" older kids as patients. Most of us in pediatrics were thrilled to "give up" adults as patients (more or less, ignoring adult CHD, etc). But many would find it hard to just take care of newborns. Finally, do you wish to be involved throughout your career in advocacy for children and if so, are you more interested in things like accident prevention or breastfeeding advocacy?

Again, for now, don't overthink it. Decide first on pediatrics and then go from there as you finish med school and do your internship.

 

[BigRedBeta]

J-Rad's right on (as usual) with the exception of cardiology being where it's at (clinic!?! no thanks).

I think that as a 2nd year student, the absolute most important thing is to continue to have an open mind and be extremely self aware. You're going to have a ton of new experiences and you may find something that completely surprises you. I was pretty set on peds, but I never expected to love the day to day managment of multiple issues that's so common on inpatient adult medicine. That complexity was something I needed. Further, for a long time I underestimated my coping ability to deal with really sick patients that could die - until seeing how it affected the residents and my fellow students and realized I seemed to handle it better than most. I also thought that I liked the idea of specializing in just one organ, until I saw how much I enjoyed the variety of my general surgery rotation. Even my time on GYN surgery was better than my time on GYN Onc.

I think the other extremely vital aspect to keep in mind is to focus on the medicine - don't let one awesome attending sway your judgement. I saw quite a few of my friends get fixated on how much they loved working with one particular attending even though they didn't seem to really enjoy what that attending did. There was one friend that loved her family medicine clinic experience but couldn't stand internal medicine or peds clinic...and it caused her to really, really consider family practice until she did a rotation with someone else as a 4th year and realized that the medicine portion didn't change, but the preceptor made a huge difference. For me, my first week in the PICU as a fourth year had an awesome attending, and I had to really fight to focus on the medicine, but as I did, I noticed how well PICU fit what I had previously identified as being enjoyable - day to day management, more complexity, a wide variety of pathology/organ systems - as well as avoiding many of the things I didn't like such as clinic, dealing with social issues about going home, etc.

So, continue to take stock throughout your third year, notice the days you come home in a good mood, the days that just seemed to fly by, and the days that stick in your mind months later. And by the same token, take note of the days that were just the opposite. Try to figure out what the root cause was, and you'll find your answer.

 

[J-Rad]

There is a great deal of wisdom in the above two posts. OP, pay close heed to what was said in them.

 

[michigangirl]

Yes, all of the above wise posters have given you phenomenal advice-- it is great to think about these things early, know what you want from a lifestyle standpoint, and go into third year excited to figure it all out. JRad was right on about all of the specialties mentioned in his/her post.

From a lifestyle standpoint, I can tell you pediatric surgery is stressful and difficult. The pediatric fellows at our institution are exhausted. The training is long and extremely rigorous. That being said, if you do your surgery rotation and come home happy each day and excited, then it might be a good choice for you. But the algorithm for you right now is very broad-- you might start a surgery residency and love doing adults. Many surgeons work in the community and do general surgery on adults and children down to a certain age, so the opportunities are limitless.

Since everyone else did such a good job describing other specialities, a word about mine-- PICU and pediatric anesthesia. Like OBP stated, I am doing PICU because I love taking care of critically ill children and wouldn't "give up" taking care of older kids to be a neonatologist. There are many different types of PICUs-- private, academic, regional referral centers, community-- so the acuity and numbers and schedules vary from place to place. for me, academic picu is the right fit. But as others stated, you need to know you love pediatrics first, then branch out to everything else.

Anesthesia is great if you're interested in shift work and taking care of a large variety of patients (adult and/or peds)-- it's like your own mini ICU in the OR. The physiology is fascinating, you are an airway expert, and you can deal with any acute situation-- if you're interested, I encourage you to do an anesthesia rotation during your third year if possible.

good luck!

 

[redwings54]

It seems like there is a pretty good representation of the various peds subspecialities in this thread. Is there any way you guys can describe your lifestyles in terms of schedules, hours, time away from family? I am a current MS3 planning my fourth year of med school. I have spent some time with peds cards people and peds nephro but absolutely loved my time in the adult ICU. I like the intensity of PICU, but was told that the lifestyle was worse than that of a trauma surgeon (this was from a trauma surgeon however who was trying to convince me to go into surgery). I am also weary of necessarily being near a large hospital if I am to practice PICU medicine. I like the idea of peds cards taking care of very sick kiddos and treating them throughout their lives. It seems that you can tone down your practice over time too choosing to become more office based if you desire. But I am weary to limit myself to one organ system seeing how much I loved ICU medicine.

I have spoken with J-Rad a little about this in the past, but I am really contemplating peds cards vs PICU now and looking at residency programs that have these fellowships or at least have recently placed people into these fellowships. So no rush to respond needed since I am a MS3, but just more some inquisitive questions and something to consider in a future residency program. Looking forward to hearing some responses though. Thanks.

 

[michigangirl]

Aw, PICU life. Where do I begin? I love the PICU for the reasons you described-- get to deal with every organ system, sick kids, its exciting, and you make a difference when it's a life or death situation. But those can also be downsides. A lot of PICU lifestyle depends on the setting you choose. There are six beds PICUs in rural areas, and there are 40-60 bed PICUs in large cities. I will speak to staying in Academics (i.e. a place like Hopkins or Boston Childrens).

Academics is a paycut. But its also a great lifestyle. For example if you are a straight PICU doc you might be expected to do 14 weeks/year of service time. This varies greatly institution to institution. Those weeks are usually hard, grueling weeks. But that means you have 4 weeks of vacation and then 34 weeks of "non-clinical" time. Time for teaching, research, administrative stuff. Not so bad. There is an expectation that you will contribute to the institution greatly during those 34 weeks. But they are yours to decide how you do that. Means you make your own schedule those weeks.

Private practice pays better. But you often work harder-- more time in the PICU, not as much expectation to do academic/research work. Your time at work is time in the unit. More call. But I'll let someone actually in the private sector answer to this.

So in a nutshell- the trauma surgeon is wrong. The stuff we do in the picu is emotionally draining. But you get enough of a break from it in academics that it's completely doable. I love the flexibility (for me that means doing anesthesia and research). If you pick the right picu you can take care of post-op cardiacs too. Good luck.

 

[Stitch]

So in a nutshell- the trauma surgeon is wrong. The stuff we do in the picu is emotionally draining. But you get enough of a break from it in academics that it's completely doable. I love the flexibility (for me that means doing anesthesia and research). If you pick the right picu you can take care of post-op cardiacs too. Good luck.

Totally agree. There are a lot of different options depending on what you're looking for. It also seems that there's more of a push towards 'shift' type work. You cover days or nights for a week rather than doing 24 or 36 hours on. Michigangirl, can you comment on how far spread that is?

Either way, I can't imagine a tougher life style than a trauma surgeon, except maybe a busy OB practice.

 

[michigangirl]

definitely a shift toward shift work no pun intended. 8-14 or 16 hour shifts.

 

[premed101]

...

Academics is a paycut. But its also a great lifestyle. For example if you are a straight PICU doc you might be expected to do 14 weeks/year of service time. This varies greatly institution to institution. Those weeks are usually hard, grueling weeks. But that means you have 4 weeks of vacation and then 34 weeks of "non-clinical" time. Time for teaching, research, administrative stuff. Not so bad. There is an expectation that you will contribute to the institution greatly during those 34 weeks. But they are yours to decide how you do that. Means you make your own schedule those weeks.
.... If you pick the right picu you can take care of post-op cardiacs too. Good luck.

I realize these hours worked are different depending on the institution, but that seems like a very calm lifestyle. Do all academic jobs (even different ped sub-specialties) work similarly? Thanks!

 

[BigRedBeta]

Well...not quite the same for other peds subspecialists - there's that whole "clinic" thing to deal with. At my institution, the sort of setup that's been described is limited to the docs in the PI, the Cardiac intensivists (we have several cardiologists who either did combined PICU/Cards or who have merely chosen to limit their clinical duties to just the ICU with no outpatient cardiology clinic), and most of the Neonatologists (we have some Neos who run a followup outpatient clinic for NICU grads.

If you're a pulmonologist, neurologist, endocrinologist or nephrologist, etc, most of your clinical duties will be in the outpatient clinic. There will certainly be weeks covering inpatient services, but even the weeks you're not on service you'll still see patients. Exactly how many days of clinic you have a week will depend on what you negotiate. And for most of these specialists, weeks that they're seeing the inpatient side does not cancel their clinic spots - so it's more work on top of the standard week.

 

[tarheel86]

Bump for michigangirl if she is still around. I am resident really considering PICU and I think the anesthesia/PICU combination could be awesome and I had a couple of questions.

1. Do you know where you can get this training? I think Hopkins and CHOP have/had programs like this.

2. Upon finishing the program are you able to do both PICU and anesthesia as an attending? Meaning, could you be on PICU for 20 weeks of the year and in your "admin" time of the year actually work OR cases.

3. Do you have an recommendations on becoming a competive applicant for what I imagine would be hard spots to get?

Thanks

 

[8t7x]

Bump for michigangirl if she is still around. I am resident really considering PICU and I think the anesthesia/PICU combination could be awesome and I had a couple of questions.

1. Do you know where you can get this training? I think Hopkins and CHOP have/had programs like this.

2. Upon finishing the program are you able to do both PICU and anesthesia as an attending? Meaning, could you be on PICU for 20 weeks of the year and in your "admin" time of the year actually work OR cases.

3. Do you have an recommendations on becoming a competive applicant for what I imagine would be hard spots to get?

Thanks

i'm interested in this as well. thanks!

 

[michigangirl]

Bump for michigangirl if she is still around. I am resident really considering PICU and I think the anesthesia/PICU combination could be awesome and I had a couple of questions.

1. Do you know where you can get this training? I think Hopkins and CHOP have/had programs like this.

2. Upon finishing the program are you able to do both PICU and anesthesia as an attending? Meaning, could you be on PICU for 20 weeks of the year and in your "admin" time of the year actually work OR cases.

3. Do you have an recommendations on becoming a competive applicant for what I imagine would be hard spots to get?

Thanks

Might be a bit of a cross post since I half answered this on the NICU/PICU forum, but here goes---

1. As I mentioned-- no more combined fellowship. Can't do ACGME residency and fellowship at the same time, so this program has been ended. The only way to do PICU and anesthesia is to a. do the combined pediatrics-anesthesia residency (five years) and then do a three year picu fellowship followed by a year of peds anesthesia if you choose= 9 years OR b. do peds residency, then anesthesia residency (6 years) + picu fellowship +- peds anesthesia fellowship. All of this depends on if you want to do PICU and then take care of adults AND sick children in the OR vs. do PICU and take care of only adults in the OR. Most jobs in large tertiary centers require a peds anesthesia fellowship to anesthetize children over the age of 2.

As you get the picture-- it's a long road, and a lot of work to stay good at everything. I have stopped taking care of adults because I feel I need to focus as much as I can given I'm doing anesthesia and PICU, so honing in on peds physiology only enables me to feel like I'm always providing a high standard of care and know what the latest is in the field(s) I'm practicing.

The typical "combined" picu-peds anesthesia attending does a certain number of weeks in the PICU and fulfills the rest of their clinical commitment in the OR i.e. 1-3 days/week, call, admin, teaching, research. And I have the flexibility to leave academics and do Private practice anesthesia one day if I so please, part time in a surgicenter doing kids' tonsils and adenoids. I like knowing I have that option-- but I wouldn't give up taking care of sick kids at this point in my career for anything.

Being a competitive applicant for a pediatrics-anesthesia residency requires a lot of foresight into your intended career path as a third year! medical student, which I think is a bit difficult for most. But if you KNOW its what you want to do, you must do well in your anesthesia rotation as a med stud, peds rotation and really show the interviewers and programs that you have a scope for this long road.

I also must point out: if your ultimate goal is to be a pediatric intensivist and pediatric anesthesiologist-- this involves FOUR sets of board exams (actually five):

1. Pediatric Boards
2. Anesthesiology Boards
a. Written boards on computer
b. 1 hour oral board exam in some random city
3. PICU boards
4. And now, Pediatric Anesthesiology Boards (as of February 2012)
Not being all doom and gloom, just presenting what would be ahead as times are changing.
It's a much straighter and shorter path to be an adult intensivist-- as you can do just one residency of four years and a one year fellowship if you go the anesthesiology route. But obviously, some of us are gluttons for punishment (hello me!)
Good luck!