MICU vs PICU

[AztecTurtle]

Kind of a niche question but curious if anyone can weigh in on choosing between PICU vs MICU. Ideally would love to hear from someone who did one of the combined residency routes and chose between the two (or did both) but also interested in the perceived pros/cons from intensivists in either setting.

Considering going the intensivist route. Enjoy taking care of pediatric patients and like how PICUs typically admit across all spectrums of disease (where the adult world seems to have subdivided into cardiac, surgical, neuro, etc). The adult side is tempting though for the generally higher acuity, availability of high acuity community jobs, lower reliance on consultants, and more procedures both in quantity and breadth. Higher pay on the adult side is a perk but not a major issue in my situation.

I'm curious what pushed people one direction vs the other if they ever considered both and what makes them happy or dissatisfied with their choice.

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[psychbender]

I mean the big divide is do you want to take care of adults, or kids for your career?

There are mixed units in the community where general adult intensivists will take care of all-comers. While my current shop has semi-specialized units, we still see a mixed bag. My home is the CVICU, but post-cardiac surgery patients will usually only make up a third to maybe a half (if they were busy, or had too many complications recently) of my patients any given week. The remainder will be mostly general medical ICU type patients, with maybe a smattering of post-surgical patients. The only adult critically ill population that doesn't come to my unit is Neuro.

 

[GotToGetThatGPAUp]

I mean the big divide is do you want to take care of adults, or kids for your career?

There are mixed units in the community where general adult intensivists will take care of all-comers. While my current shop has semi-specialized units, we still see a mixed bag. My home is the CVICU, but post-cardiac surgery patients will usually only make up a third to maybe a half (if they were busy, or had too many complications recently) of my patients any given week. The remainder will be mostly general medical ICU type patients, with maybe a smattering of post-surgical patients. The only adult critically ill population that doesn't come to my unit is Neuro.

Not sure if you'd have this answer, but how different is the complexity between PICU and MICU? What I really enjoy about the ICU is the complex management, vents, the occasional on-your-feet emergency/resus, procedures, etc. However I also really enjoy working with kids, and love the culture at children's hospitals - so deciding between Peds and IM right now is getting difficult especially since I can't get a PICU experience before ERAS.

 

[gro2001]

I didn't do a combined residency, but I did an EM residency and rotate in both. Also, as a neurointensivist I sometimes end up getting involved in some peds neurocrit stuff in the PICU and obviously lots of interaction with MICU.

Other than the obvious difference of taking care of adults vs kids there are a few other major themes that I've seen hold up across institutions:

1) PICU is more general than MICU. Sure, in the community there is often one combined ICU for everything, or at least everything adult, but many hospitals at least split MICU/SICU. Also MICU/SICU/CCU is pretty common. And it's not unusual at all to have many more subspecialized units. On the peds side it's mostly all PICU. Pediatric cardiac ICUs are becoming more common, but mostly its just PICU for all things medical/surgical/cardiac/neuro/transplant/trauma etc. That's not necessarily good or bad, just something to be aware of.

2) PICU is more consultant dependent that MICU. Partly because of point 1 but also just because that's the culture in pediatrics, consulting physicians play a way oversized role than they do in the MICU (or any other adult ICU). There is nothing wrong or shameful about consulting as much as you need to, but the minimum amount of consultant involvement on the peds side is significantly higher. In my opinion, this is a negative. Apart from the intensivist ego being a little bruised, I feel it often leads to decision paralysis even on issues that should be solidly in the scope of practice of a pediatric intensivist.

3) PICU is much more academic and centralized. Lots of hospitals have a MICU or a general ICU you could work, from high powered academic lung transplant centers to tiny no-doc-overnight rural/smaller community hospitals. PICUs by and large tend to be centralized at the mothership of a health network, and disproportionately at academic centers. That's either a negative or a neutral, depending on what kind of place you want to live and work (though of course that can be hard to know before you even start a career in medicine).

 

[chessknt]

You need to figure out if you want to be a pediatrician or an internist first then figure out subspecialization later. The only subspecs from those fields that crosses over is ID and allergy/immunology.

I'm sure some here will attest to the challenges of picu because you get kids that shouldn't be alive and have minimal to no hope of ever living a productive life again who end up having endless resources poured in to them because they have no ability to advocate for themselves. The same thing happens in adults as well to be fair but the extent seems like it is not as extreme.

The more normal patients on each side are still going to be derived and rooted in that primary specialty which is why picking that one correctly is important.

 

[stillers]

Kind of a niche question but curious if anyone can weigh in on choosing between PICU vs MICU. Ideally would love to hear from someone who did one of the combined residency routes and chose between the two (or did both) but also interested in the perceived pros/cons from intensivists in either setting.

Considering going the intensivist route. Enjoy taking care of pediatric patients and like how PICUs typically admit across all spectrums of disease (where the adult world seems to have subdivided into cardiac, surgical, neuro, etc). The adult side is tempting though for the generally higher acuity, availability of high acuity community jobs, lower reliance on consultants, and more procedures both in quantity and breadth. Higher pay on the adult side is a perk but not a major issue in my situation.

I'm curious what pushed people one direction vs the other if they ever considered both and what makes them happy or dissatisfied with their choice.

I was a Med-Peds resident for 2 years and spent some time on both sides as trainee. Currently an adult Pulm-CCM doc.
The culture in peds is very different than adult medicine - lots of half-holding, second guessing, and all decisions and procedures go through the attending and consulting services. There is little autonomy for trainees compared to the adult side.

As someone else mentioned, a lot of care in the PICU is driven by consulting services, especially surgical services. In the MICU the ICU team is really running the show. MICU care is generally more complex than the PICU.

The PICU is less depressing than the MICU in my opinion. Kids are much more likely to heal up and leave the ICU. That's why I did pulm-crit - I didn't what the MICU to be my only job; I also like seeing reasonably healthy people in clinic and doing consults. If you do PICU, you're locked into the ICU forever. With adult Pulm-Crit, you have tons of other options.

I quit meds-Peds after 2 yrs because I realized I only wanted to do adult medicine. Had absolutely no regrets and it was one of the best professional decisions I made.

 

[stillers]

You're welcome.

I think in general even IM residents have less autonomy and are doing less procedures than 10-15 yrs ago. But my experience has been that if trainees are motivated, they can seek out procedures and do plenty before fellowship at most programs (central/art lines, thoras). I wouldn't let procedures be the determining factor in where you do your residency. We have some fellows who come in and have done minimal procedures...within a few months they are up to speed. Nobody comes into fellowship having done a bunch of intubations or chest tubes.