NICU should not be a required rotation for peds

[tacoman2493]

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I know the NICU guys are going to throw a lot of hate in my direction, but IMHO NICU is not necessary to be a good pediatrician. General peds dont manage RDS, they dont intubate 28 week premies, they dont insert UAC/UVCs, they dont do chest tubes. All those procedures you do in NICU will be lost forever unless you decide to do a NICU fellowship.

Its absurd that the ACGME requires not only 1 NICU rotation, but 3. WTF are they thinking?

I dont like the heavy procedure focus of NICU, I dont like throwing the whole playbook at a 24 weeker.

NICU rotation should be optional, not required.

 

[TexasRose]

I know the NICU guys are going to throw a lot of hate in my direction, but IMHO NICU is not necessary to be a good pediatrician. General peds dont manage RDS, they dont intubate 28 week premies, they dont insert UAC/UVCs, they dont do chest tubes. All those procedures you do in NICU will be lost forever unless you decide to do a NICU fellowship.

Its absurd that the ACGME requires not only 1 NICU rotation, but 3. WTF are they thinking?

I dont like the heavy procedure focus of NICU, I dont like throwing the whole playbook at a 24 weeker.

NICU rotation should be optional, not required.

By that reasoning, general pedis don't need training in Heme-onc (you'll never give chemo), inpatient nephrology (never do dialysis), etc.

General peds docs cover level I and II NICU's, so they should be very comfortable with treating these patients and with recognizing the need for a higher level of care.

Also pretty sure that a Pediatric residency means training in caring for all kinds of pedi patients from birth through adolescence.

Sorry you aren't enjoying your NICU rotation.

 

[tacoman2493]

By that reasoning, general pedis don't need training in Heme-onc (you'll never give chemo), inpatient nephrology (never do dialysis), etc.

General peds docs cover level I and II NICU's, so they should be very comfortable with treating these patients and with recognizing the need for a higher level of care.

Also pretty sure that a Pediatric residency means training in caring for all kinds of pedi patients from birth through adolescence.

Sorry you aren't enjoying your NICU rotation.

Yes but a general peds clinic sees heme/onc kids. A general peds clinic sees cards kids. A general peds clinic sees GI kids. Ditto for wards patients.

However, a general peds clinic will NEVER see a NICU kid. A general ward team will NEVER see a NICU kid. They see NICU grads, but thats worlds different than covering the cards/GI/pulm/hemeonc kids that you run into constantly.

Knowing and understanding the post-NICU sequelae such as NEC or BPD does NOT justify a NICU rotation.

 

[oldbearprofessor]

I know the NICU guys are going to throw a lot of hate in my direction, but IMHO NICU is not necessary to be a good pediatrician.

Hate? Nah, you're perfectly entitled to your perspective and to vent here without being hated on!🙂 You're even welcome to lobby the ACGME to decrease (or get rid of) mandatory NICU/PICU months that you don't think serve your needs. I don't necessarily disagree that 3 months of NICU (keep in mind this is Level 2 plus 3 combined in the requirements) and 2 month of PICU may be excessive for someone who is absolutely certain to never work in a small town or similar setting where they WILL be the only person resuscitating 28 weekers that happen to be born there. This will not disappear either. There are lots of these and other babies born who unexpectedly need the full range of resuscitation and stabilization skills you are being trained to provide in settings where there is no neonatologist available.

Also, keep in mind that if you decide to ever apply for hospital privileges, you will need to demonstrate that you were trained and demonstrated competency in anything you are given privileges to do. It's often expected in small hospitals that pediatricians will be available to cover neonatal emergencies. If the ACGME agrees with you and markedly decreases or removes neonatology from training of pediatricians, this would be an issue I think.

Really sorry you don't like the NICU, but try to find things in the rotation that you can learn that will help you. Learning about neonatal nutrition and breast feeding for example, especially in a level 2 setting, is knowledge you can take into practice.

In any case, I think a discussion of how much intensive care (NICU and PICU) should be mandated for residents is good one for this forum and is better than unending threads only about interviews!

 

[Cardsfan]

Ah the joys of the NICU. I agree that taking care of mirco-premies may not seem relevant to someone hoping to go into general peds, but many aspects of NICU can help down the road. As a subspecialist you will be consulted by the NICU and as a general peds md you will see newborns in the nursery and/or in your office. There are non-premies in the NICU - I know this can sometimes come as a shocker depending on what NICU you're rotating through. Full terms have their host of problems as well and all pediatricians should be trained to recognize these and know initial management/work-up. Hang in there....😉

 

[J-Rad]

I'd gather from this and your other post that your currently on a less than fun NICU rotation...
I too hate the species Homo Rodentius. Call them NICU Baby, R.U.S. (Rodent of Unusual Size), Poikilotherm...but whatever you call them, they are vile, hateful little creatures whether they are rat-sized preemies, or toad sized full termers...(I have a great idea where you can put that residual: it's all one tube, and beside the little tyke probably needs a cleanout anyway).

BUT: The ability to stabilize a critically ill neonate, full or pre-term is essential to the skill set of a pediatrician. As others have said, many general pediatricians will be called on to resuscitate/stabilize a newborn. Full term products of uncomplicated pregnancies get delivered everywhere, not just in level 3 NICUs (frankly the full termers are more scary to me) While anyone (in any specialty) can tailor some of the things they don't like out of their practice, residency is designed to give you the exposure and ability to build on the full armamentarium of the generalist. Dear lord if I could get rid of anything it would be the requirement for developmental peds. If you took just about everything I hate about pediatrics and put it into one specialty, Devo would be it. But my job before subspecialty training was to learn to be the best general pediatrician and that encompassed the gamut of pediatrics. I would be a suboptimal pediatrician if I didn't suffer through a few things. And in my program I suffered through 4 months of NICU rotations, another month's worth of NICU in off-service call, and two months of normal newborn (in which while on call you helped out with any NICU admissions). Residency is a finite period of time and so is NICU. Try to grin and bear it.

 

[edmadison]

I'll build on what most of the prior posters have said. I'll also restate that the residency requirements are to ensure that all BC pediatricians can meet a minimum standard of practice which includes being a peditrician working somewhere other than a tertiary hospital. Consider this:

One of my colleagues was working as a general pediatrician in southern Missouri. They had "drive by" 24 week twins during a blizzard. No transport was available for 36-48 hours. For those two days, he was those kiddos neonatologist and his hospital their Level III NICU.

That's why you do the rotations. NPs can do 90% of the general pediatricians job. One of the things that makes the physician special is all that sub-specialty knowlege.

I may not be a neo, but I know with OBP or one of his buddies on the phone, I have the skills to give those little guys a fighting chance until I can get them on the road.

Ed

 

[socmob]

I too hate the species Homo Rodentius. Call them NICU Baby, R.U.S. (Rodent of Unusual Size), Poikilotherm...but whatever you call them, they are vile, hateful little creatures whether they are rat-sized preemies, or toad sized full termers...(I have a great idea where you can put that residual: it's all one tube, and beside the little tyke probably needs a cleanout anyway).

Enjoying this conversation so far, but THIS was priceless!

 

[DarthNeurology]

I know the NICU guys are going to throw a lot of hate in my direction, but IMHO NICU is not necessary to be a good pediatrician. General peds dont manage RDS, they dont intubate 28 week premies, they dont insert UAC/UVCs, they dont do chest tubes. All those procedures you do in NICU will be lost forever unless you decide to do a NICU fellowship.

Its absurd that the ACGME requires not only 1 NICU rotation, but 3. WTF are they thinking?

I dont like the heavy procedure focus of NICU, I dont like throwing the whole playbook at a 24 weeker.

NICU rotation should be optional, not required.

I would disagree with this and other posts as well. I think that electives in intensive care settings be it in the NICU or the PICU are critical because they:

1. Demonstrate to the resident the severe spectrum of pediatric pathology, i.e. after seeing tiny premies on vents in the NICU compared to health babies you just sort of get a feel of what is normal and what is not.

2. Perhaps most importantly if you are never going to go into neonatology, or even be in the position of covering the NICU, the process of learning to take care of several very sick babies in an intensive setting is important to your intellectual growth as a physician. Simply learning about neonatal pathology AND becoming competent for dealing with neonatology will make you a better general pediatrician. I.e. clinical skills ARE transferable and practicing them in different settings will make you a better general pediatrician.

3. Having a firm understanding of neonatology is important for many subspecialties of pediatrics, i.e. neonatologist may consult pediatric neurologists, pediatric cardiologists ALL of whom help to take care of babies in the NICU and you don't have the basics of the NICU down pat then, well, you won't do well in one of these specialties when asked to consult on say a baby with a congenital cardiac abnormality who turned blue and was given prostaglandins . . . So if you want to do any specialty in pediatrics then you have to know the NICU well.

4. I think as other have mentioned that as a general pediatrician taking care of babies in the NICU is part of the bag of tools that you are expected to know how to use, if you can't do it then you are limited. Plus, what if as a general pediatrician you see a child who has come out of the NICU, . . . if you don't know the NICU well then you can't interpret what happened to the child, why the child was put in the NICU or even answer questions that the mother had not asked the neonatologist. So I would argue that not only must you learn Neonatology well, but that as a general practicioner of pediatric it would behove you and your patients to say updated about advances in neonatology and to continue to read some about neonatology as advances in this field affect everything from politics to planning to have a child to advances that can be used in other areas of pediatrics.

Also, to the person who said that development pediatrics is not crucial to pediatric residency training I would say that you are very mistaken. I feel that is crucial to have a good foundation in development pediatrics for well-baby checkups as well as checkups with teenagers, it is such as specialized field that it has its own specialty and all pediatricians should have a solid foundation.

 

[DarthNeurology]

Learning about neonatal nutrition and breast feeding for example, especially in a level 2 setting, is knowledge you can take into practice.

Exactly, NICU beats neonatal nutrition into you like nothing else, something which is very useful as in peds clinic.

NICU is sort of the superbowel of pediatric physiology and pharmacology where you get to strut your stuff and see how good you really are. I guess that would make PICU the olympics of pediatrics, in the end different games but same level of excellence required.

 

[J-Rad]

DN: I think you may have misunderstood what I said. Developmental is merely my least favorite, but I believe it to be just as critical to pediatrics as neonatology, gen. peds or any other rotation. Thus comments subsequent to the comment you seem to have focused on.

 

[tantrum]

I work in a small city. No matter what they tell you, you will need NICU skills. Even if the policy states that they transfer premies or transfer moms who are in premature labor, there will be occasions (lots actually) where you will need to intubate and ventilate premies and stabilize them before transport. It also made me flexible with locations as I worked in different settings. Even some of the anesthesiologists in small cities are less confident as regards neonatal intubation.

 

[oompaloompa]

I can empathize with the OP's extreme dislike of the NICU, it's definitely my least favorite service. However, I would tend to echo most of what other's have said about it's utility.

My argument is rather "How much is too much?". IMHO 2-3 months is plenty to get the gist if you plan to be well rid of these patients(for the most part) in your career. I do object to certain places blatently using the residents for coverage purposes and calling it "education." Six months of NICU is not education, it's cruel and unusual punishment. At my med school, the NICU was about half of the pediatric population in the hospital. Given that 3-5% of pediatricians will go on to specialize in NICU, is this appropriate? I don't think so. Severely outdated systems (and people) also prevent this service from operating with some semblance of efficiency, which is far more infuriating than anything else. So you're telling me that you need someone with 3 degrees to add up this column of numbers and write it down on this other sheet? Each baby in fact requires 3 pages of redundant dietary orders? Really?

 

[blanche]

I can empathize with the OP's extreme dislike of the NICU, it's definitely my least favorite service. However, I would tend to echo most of what other's have said about it's utility.

My argument is rather "How much is too much?". IMHO 2-3 months is plenty to get the gist if you plan to be well rid of these patients(for the most part) in your career. I do object to certain places blatently using the residents for coverage purposes and calling it "education." Six months of NICU is not education, it's cruel and unusual punishment. At my med school, the NICU was about half of the pediatric population in the hospital. Given that 3-5% of pediatricians will go on to specialize in NICU, is this appropriate? I don't think so. Severely outdated systems (and people) also prevent this service from operating with some semblance of efficiency, which is far more infuriating than anything else. So you're telling me that you need someone with 3 degrees to add up this column of numbers and write it down on this other sheet? Each baby in fact requires 3 pages of redundant dietary orders? Really?

oompa--did you say 6 mos of nicu?!? wow...that takes the cake.

 

[edmadison]

oompa--did you say 6 mos of nicu?!? wow...that takes the cake.

I agree with oopma about the volume of NICU. At our program it worse. There was a constant fight with the NICU attendings about how much time we spent there. They were persistently arguing about how important NICU skills were. I agree that they were important, but did I really need to spend 1/6+ of my residency there? This is what we did:

2 months NICU as intern
1 month NICU as R2
1 month Intermediate Care Nursery as R3. This was just a way of calling a NICU rotation something else. We still were expected to supervise the interns in the NICU.

200 hours of exclusive NICU call as intern (counts as NICU rotation for RRC purposes)

2 months of nightfloat over R2 and R3, 75%+ was NICU time.

In addition to this, we did one month in the newborn nursery and one month in the well baby clinic.

Oh the fun!

Ed

 

[oldbearprofessor]

Here are the rules:

The intensive care experiences must provide the
opportunity for residents to deal with the special
needs of critically- ill patients and their families. The
intensive care experience must be for a minimum of
5 and a maximum of 6 months. This must include a
minimum of 3 and a maximum of 4 block months of
neonatal intensive care (Level II or III) and 2 block
months of pediatric intensive care. Night and
weekend responsibilities when the residents are
predominantly responsible for the NICU are
included in the allowable maximum intensive care
experience, with 200 hours being considered the
equivalent of 1 month. However, when a resident is
covering the entire inpatient service, including
neonatal intensive care or the delivery room, these
hours need not be included in the calculation of
time in intensive care. Hours covering the PICU are
not included in calculation of time in intensive care.

 

[J-Rad]

I believe the RRC allows military programs a waiver to have an extra month's worth of NICU (as above, my program had 2 NICU months intern year, one each year for PL2&3, and at least another month's worth in off-service NICU call) in case you're practicing on "your island" (a common refrain where I was; and a realistic possibility for many).

 

[edmadison]

I believe the RRC allows military programs a waiver to have an extra month's worth of NICU (as above, my program had 2 NICU months intern year, one each year for PL2&3, and at least another month's worth in off-service NICU call) in case you're practicing on "your island" (a common refrain where I was; and a realistic possibility for many).

This is true and the waivers have been granted. I call BS on it and would have loved to argue with the RRC about it. You've got Rural FP docs doing the same thing and they don't do 6 months in the NICU -- In fact, at my program they didn't do any NICU at all. This is all about using residents to staff the NICU so they don't have to hire NPs or have staff present.

Ed

 

[HurricaneKatt]

I'll build on what most of the prior posters have said. I'll also restate that the residency requirements are to ensure that all BC pediatricians can meet a minimum standard of practice which includes being a peditrician working somewhere other than a tertiary hospital. Consider this:

One of my colleagues was working as a general pediatrician in southern Missouri. They had "drive by" 24 week twins during a blizzard. No transport was available for 36-48 hours. For those two days, he was those kiddos neonatologist and his hospital their Level III NICU.

That's why you do the rotations. NPs can do 90% of the general pediatricians job. One of the things that makes the physician special is all that sub-specialty knowlege.

I may not be a neo, but I know with OBP or one of his buddies on the phone, I have the skills to give those little guys a fighting chance until I can get them on the road.

Ed

 

[Bernardo_11]

Well, I can't say it was one of my favorite rotations either (I still have PTSD episodes from it). But having been a general pediatrician out on Guam for a year prior to fellowship (where on rare occasions I had to manage level 3 NICU babies, attend high risk deliveries, and even do some PICU cases).... I am glad and grateful to have had all that ICU experience during residency.

Residency is basically a totipotent period of training. You can never be certain what type of specialty you'll enter, which region of the world you'll end up, or how much of something which you absolutely detest (I know I felt that way at times) actually becomes something of value when you're out in the real world somewhere.

Another thought is how much more can we cut NICU from residency? Will the person who plans on going into neonatology be really prepared with 1 month of level 3 NICU work? The more we remove ICU months from residency, the more we chop away at the totipotency of our training, which I find dangerous as it will only decrease the available options; Especially for those who have decided they love pediatrics, but still would like to explore its full gamut to know for sure which facet they like best.

And I say this as a DB Pediatrician, probably one of the least intense specialties out there... 😀

Nardo