Pediatric EM Route

[bluewelder]

I am a 3rd year student, and I am pretty sure I want to eventually do a fellowship in pediatric EM. My question is whether I should do my residency in EM or in Peds. As I see it now, there are pros and cons to both. If I do EM first, my total training time will be a year shorter, but I won't get as much experience with kids. If I do Peds first, I feel like I will be better trained to work on kids, but I will have to spend an extra year in fellowship. I also have a few other questions about Peds EM as there are no Peds EMPs at my current institution.

1. Is there any difference in the perception of potential employers with regard to the two routes? i.e. Is there any perceived difference in competence between the two?
2. How do the salaries compare between general EMPs and Peds EMPs? I have read conflicting reports on this. The Careers in Medicine site shows Peds docs making more, but the limited information on the forums here seems to suggest the opposite.
3. If I do EM first, and I work in a general ED, will I be expected to see adults? Would I just see most of the kids that come in and fill in the rest of the time with adults, or would I see only kids?
4. If I do Peds first, will I even be able to work in a general ED, or will I be restricted to children's hospitals?

Any advice offered on this subject would be greatly appreciated as I will begin planning my fourth year shortly, which means scheduling away rotations in the specialty in which I plan to do residency. Thanks!

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[Poetic Silence]

These are some interesting questions. I'd like to observe this discussion.

(I'm on my mobile, so, posting is the only way I can subscribe. Ignore this post.)

 

[SoCuteMD]

I am a 3rd year student, and I am pretty sure I want to eventually do a fellowship in pediatric EM. My question is whether I should do my residency in EM or in Peds. As I see it now, there are pros and cons to both. If I do EM first, my total training time will be a year shorter, but I won't get as much experience with kids. If I do Peds first, I feel like I will be better trained to work on kids, but I will have to spend an extra year in fellowship. I also have a few other questions about Peds EM as there are no Peds EMPs at my current institution.

1. Is there any difference in the perception of potential employers with regard to the two routes? i.e. Is there any perceived difference in competence between the two?
2. How do the salaries compare between general EMPs and Peds EMPs? I have read conflicting reports on this. The Careers in Medicine site shows Peds docs making more, but the limited information on the forums here seems to suggest the opposite.
3. If I do EM first, and I work in a general ED, will I be expected to see adults? Would I just see most of the kids that come in and fill in the rest of the time with adults, or would I see only kids?
4. If I do Peds first, will I even be able to work in a general ED, or will I be restricted to children's hospitals?

Any advice offered on this subject would be greatly appreciated as I will begin planning my fourth year shortly, which means scheduling away rotations in the specialty in which I plan to do residency. Thanks!

I am a 4th year resident in EM who seriously considered Pedi EM fellowship, but decided against it for myself. That being said, I love peds and pedi EM.

1. Is there any difference in the perception of potential employers with regard to the two routes? i.e. Is there any perceived difference in competence between the two?

I don't think there's any perceived difference in competence between the two, other than peds people are not as well (or at all!) suited to caring for adults.

2. How do the salaries compare between general EMPs and Peds EMPs? I have read conflicting reports on this. The Careers in Medicine site shows Peds docs making more, but the limited information on the forums here seems to suggest the opposite.

The adult EM faculty make more than the peds EM faculty where I am a resident. This doesn't seem to surprise the peds EM faculty. Anecdata, but it's all I have.

3. If I do EM first, and I work in a general ED, will I be expected to see adults? Would I just see most of the kids that come in and fill in the rest of the time with adults, or would I see only kids?
Depends how the structure is and what the peds volume is. However, most general EDs can not support round-the-clock pedi staffing with the pedi volume they have - so you would probably be expected to see adults.

4. If I do Peds first, will I even be able to work in a general ED, or will I be restricted to children's hospitals?

If you do pedi first you may be able to work in a general ED that has a high pedi volume. My residency's community site has a pedi section that is open from 3p-12a (usually staffed by a BC EM doc, occasionally by a moonlighting pediatrician). However, if you accepted a dedicated pedi EM position like that you would likely have a life of working the evening shift every day you worked, which might get old. EM -> pedi EM would give you more flexibility. The community site does not have a dedicated pedi EM physician, but I'm pretty sure they'd hire one if the opportunity arose. I should mention that this "community" ED has 60,000 visits, is in the biggest city in the state and the hospital itself has 400 beds and multiple residencies and fellowships (not just people who rotate from "the big house" for their community experience). If you do pedi ->pedi EM, you will have to work in a peds hospital or a larger hospital.

At the end of the day, most board certified pedi EM people did pedi, then pedi EM. For those who do EM and consider pedi EM, there is little payoff to doing another 2-3 years of fellowship and a very high cost. If I recall correctly, there may be somewhere around 100 total EM -> pedi EM folks (a credible source told me this, but I could be mixing up my numbers).

At the end of the day, you should do the RESIDENCY you want to do. Life happens, fellowship doesn't always happen and after 4 years of medical school and 3-4 years of postgraduate training you should be in a position where you could work and be happy for the rest of your (working) life. Fellowship should be the icing on the cake.

 

[deleted109597]

1. Is there any difference in the perception of potential employers with regard to the two routes? i.e. Is there any perceived difference in competence between the two?

Yes, Peds EM people who went peds=>Peds EM seem to not hold EM=>Peds EM in the same regard in my experience. So there may be people out there who won't like you, but I haven't seen it cause anyone to not get a job yet

2. How do the salaries compare between general EMPs and Peds EMPs? I have read conflicting reports on this. The Careers in Medicine site shows Peds docs making more, but the limited information on the forums here seems to suggest the opposite.

Pure Peds EM pays less than EM. CiM is wrong. There are places where the peds EM docs make the same as EM docs, but that's basically from averaging, and having the EM guys work there

3. If I do EM first, and I work in a general ED, will I be expected to see adults? Would I just see most of the kids that come in and fill in the rest of the time with adults, or would I see only kids?

You would only see kids. You wouldn't and shouldn't be credentialled to see things you aren't trained to do. Peds=>Peds EM doesn't train you to see adults.
Now, there are strange cases where adults walk into peds EDs and due to EMTALA, they have to be screened and may be having emergencies. You would be expected to figure out in a hurry what the problem is and transfer out. My pediatric site strongly resists me doing anything for the adults that come in, because the radiologists say they can't read the images, etc, etc.
4. If I do Peds first, will I even be able to work in a general ED, or will I be restricted to children's hospitals?

Any advice offered on this subject would be greatly appreciated as I will begin planning my fourth year shortly, which means scheduling away rotations in the specialty in which I plan to do residency. Thanks!

You will see more kids and have more training in kids if you go the peds route. You will have more ability to work due to number of jobs out there and will likely earn more if you do the EM=>Peds EM route.
That being said, I work in both a children's hospital and a regular hospital, and I never did a fellowship. They aren't necessarily required, but it's not the easiest thing to do it without the extra training.

 

[DeadCactus]

As someone also interested in Peds EM, it basically comes down to whether you want to see adults.

If you just want to see only kids and want to work in a major Children's Hospital, go Peds -> Peds EM. Otherwise I would say EM -> Peds EM or the (so far unmentioned) combined EM/Pediatrics residency route.

Pay is going to depend on the ratio of adults/peds you see more than what you were actually certified in with the obvious point to be made that a Peds+PEM folks can only see children and will thus tend to be on the lower side of salary.

There is constantly a murmuring of EM+PEM and EM/Peds trained folks being stigmatized by Peds+PEM folks, but I think the whole issue is overblown. Frankly the N for EM+PEM and EM/Peds folks is so small in comparison to Peds/PEM that I think the murmurs are more legend and opinion than anything factual. If it does exist, the impact if has seems to be completely unnoticeable especially outside of the mega children's hospitals.

Other thoughts:

The EM+PEM training is not necessarily shorter. Though you could limit yourself to only 3 year EM programs and 2 year PEM fellowships, there are 4 year EM residencies and some fellowships are 3 years even for EM graduates.

While an EM graduate will have less experience with children they'll have much more experience with procedures and critically ill patients.

An EM background leaves you with a much larger job market since you don't require a dedicated Pediatrics ED.

A PEM background leaves the door open for hospitalist or clinic work, though few people would take the (general) pay hit to spend their time in those settings instead of the ED.

 

[deleted109597]

the (so far unmentioned) combined EM/Pediatrics residency route.

EM/Peds =/= Peds EM.

 

[Socrates25]

If you are absolutely sure you only want to treat children, then I would go the peds --> peds EM route. Otherwise go the adult EM route because there are many, many more job opportunities and the pay is better.

This is a rough generalization, but I'd say that compared to adult EM, peds EM has more patients that are brought in for complaints that dont need workups. With a general peds background, you'll be able to triage/sort thru these patients more effectively than an adult EM --> peds EM fellowship person would.

 

[DeadCactus]

EM/Peds =/= Peds EM.

In terms of sitting for the pediatric emergency medicine board, sure. In terms of knowledge or employment opportunities, I've seen nothing to support that distinction...

 

[deleted109597]

There are plenty of places that only want fellowship trained doctors, mostly in academic centers. There are plenty more that don't.
But again, there are also plenty of places that don't need you to do the combined residency either.

And the Peds/Peds EM stigma is very present, especially in the fellowships run by Peds/Peds EM folks. They don't like the fact that ABEM lets you only do 2 years of fellowship, and I know a handful of people who had to do 3 year fellowships after EM residencies due to politics. Almost all of this is on the academic side, as the community pedi shops generally don't care, and most can't get fellowship trained people to come there anyway, outside of directors.

 

[DeadCactus]

There are plenty of places that only want fellowship trained doctors, mostly in academic centers. There are plenty more that don't.
But again, there are also plenty of places that don't need you to do the combined residency either.

And the Peds/Peds EM stigma is very present, especially in the fellowships run by Peds/Peds EM folks. They don't like the fact that ABEM lets you only do 2 years of fellowship, and I know a handful of people who had to do 3 year fellowships after EM residencies due to politics. Almost all of this is on the academic side, as the community pedi shops generally don't care, and most can't get fellowship trained people to come there anyway, outside of directors.

I would agree that Peds+PEM is the safest route for someone wanting to work at one of the giant academic pediatric hospitals because it opens the door for employment at whatever places in which stigma against the EM may exist.

There's a relatively recent paper in the Journal of Emergency Medicine looking at PEM fellowship faculty and trainees. The bulk of the faculty are Peds+PEM, about a third are Peds only, and about 5% were split evenly between EM/Peds and EM+PEM. With an even split between EM/Peds and EM+PEM, I have a hard time buying that EM/Peds is any worse than EM+PEM for an academic career. With a third being Peds only, I see more evidence for their not being enough trained people interested in those jobs to begin with. Seems that people from either of the EM track should be more concerned about not wanting those jobs than not qualifying for them.

Will a "fellowship-only" department hire a combined graduate? I'm unconvinced that anyone knows. There are so few out there and even fewer that want the job.

Either way, I don't think Peds+PEM, EM/Peds, or EM+PEM folks are struggling to find a job even if they want an academic position. They're all valid routes to pediatric EM with their own pros and cons. The best route will depend on the individual...

 

[FirefighterDoc]

I am a 4th year resident in EM who seriously considered Pedi EM fellowship, but decided against it for myself. That being said, I love peds and pedi EM.

1. Is there any difference in the perception of potential employers with regard to the two routes? i.e. Is there any perceived difference in competence between the two?

I don't think there's any perceived difference in competence between the two, other than peds people are not as well (or at all!) suited to caring for adults.

2. How do the salaries compare between general EMPs and Peds EMPs? I have read conflicting reports on this. The Careers in Medicine site shows Peds docs making more, but the limited information on the forums here seems to suggest the opposite.

The adult EM faculty make more than the peds EM faculty where I am a resident. This doesn't seem to surprise the peds EM faculty. Anecdata, but it's all I have.

3. If I do EM first, and I work in a general ED, will I be expected to see adults? Would I just see most of the kids that come in and fill in the rest of the time with adults, or would I see only kids?
Depends how the structure is and what the peds volume is. However, most general EDs can not support round-the-clock pedi staffing with the pedi volume they have - so you would probably be expected to see adults.

4. If I do Peds first, will I even be able to work in a general ED, or will I be restricted to children's hospitals?

If you do pedi first you may be able to work in a general ED that has a high pedi volume. My residency's community site has a pedi section that is open from 3p-12a (usually staffed by a BC EM doc, occasionally by a moonlighting pediatrician). However, if you accepted a dedicated pedi EM position like that you would likely have a life of working the evening shift every day you worked, which might get old. EM -> pedi EM would give you more flexibility. The community site does not have a dedicated pedi EM physician, but I'm pretty sure they'd hire one if the opportunity arose. I should mention that this "community" ED has 60,000 visits, is in the biggest city in the state and the hospital itself has 400 beds and multiple residencies and fellowships (not just people who rotate from "the big house" for their community experience). If you do pedi ->pedi EM, you will have to work in a peds hospital or a larger hospital.

At the end of the day, most board certified pedi EM people did pedi, then pedi EM. For those who do EM and consider pedi EM, there is little payoff to doing another 2-3 years of fellowship and a very high cost. If I recall correctly, there may be somewhere around 100 total EM -> pedi EM folks (a credible source told me this, but I could be mixing up my numbers).

At the end of the day, you should do the RESIDENCY you want to do. Life happens, fellowship doesn't always happen and after 4 years of medical school and 3-4 years of postgraduate training you should be in a position where you could work and be happy for the rest of your (working) life. Fellowship should be the icing on the cake.

In with some more anecdata.

I will be starting school in the fall, but i currently work in a pediatric ED. We're a nice size level II hospital with about 40-50 ED beds, 10 of which are peds specific. We staff our Peds ED with all fellows. All of our docs are peds->peds EM. That being said, they said they haven't seen much bias for the EM->PEM guys, just that there arent as many of them. I will say that when the adult ED gets swamped ( i.e. during flu season...) there is a lot of pressure from the adult docs and medical director for the PEM docs to see low acuity adults (lacs, simple fx's, etc....). This still seems to be a source of controversy. All that to say that even if you go the peds->PEM route, you still might see some adults. But again, n=1. PEM is a big interest of mine as well and i was thinking of going the EM->PEM route.

 

[dally1025]

An attending once told me that if you're interested in a particular subspecialty you should never do a residency you would not be happy doing sans fellowship. Things change, fellowships can be uber competitive (not the case for PEM but you never know what will happen in 5 years), etc so if for some reason you don't end up doing a fellowship you're not miserable. If you hate the thought of seeing another 60 year old lady with chest pain do peds -> EM. If the thought of possibly having to do well child checks for the rest of your life makes you want to gag do EM -> PEM.

 

[Apollyon]

In with some more anecdata.

I will be starting school in the fall, but i currently work in a pediatric ED. We're a nice size level II hospital with about 40-50 ED beds, 10 of which are peds specific. We staff our Peds ED with all fellows. All of our docs are peds->peds EM. That being said, they said they haven't seen much bias for the EM->PEM guys, just that there arent as many of them. I will say that when the adult ED gets swamped ( i.e. during flu season...) there is a lot of pressure from the adult docs and medical director for the PEM docs to see low acuity adults (lacs, simple fx's, etc....). This still seems to be a source of controversy. All that to say that even if you go the peds->PEM route, you still might see some adults. But again, n=1. PEM is a big interest of mine as well and i was thinking of going the EM->PEM route.

Are the peds only docs credentialed to see adults? I would be ABSOLUTELY surprised to find that a hospital's credentials committee would give privileges to someone who was neither trained nor experienced in a certain area.

 

[Poetic Silence]

Are the peds only docs credentialed to see adults? I would be ABSOLUTELY surprised to find that a hospital's credentials committee would give privileges to someone who was neither trained nor experienced in a certain area.

Hello again. I wasn't intending to involve myself in your discussion, but. . .

Plenty of pediatricians and pediatric specialists see adult patients. This is especially common in the military where pediatricians serve as general medical officers.

I also have observed how common it is for children with cancer and tumor diseases to keep their pediatric oncologist long after their 21st birthday.

Just my observations of a university hospital.

 

[Apollyon]

"Plenty" greatly overstates it. And the military is a separate thing - credentialing among hospitals and hospital systems is the huge, vastly overwhelming status quo. Sending a pediatrician to be a battalion surgeon is *****ic, but that is mil med for you (and, as a note, a GMO is someone that did internship, which are virtually always prelim or transitional years - not the first year of a 3 year program, and negligible prelim pediatric positions exist).

And my comment is directly about EM - again, the number of peds subspecialists that still see, or need to see (because they're not dead) peds patients that are no longer peds, and don't need an adult doc in a parallel subspecialty, are a quite small group.

I'm just sayin', is all.

 

[Socrates25]

I'm a pediatrician, and while it is true that its fairly common for peds subspecialists to see adult patients, that should NOT be happening in EM.

The reason peds subspecialists see adults is because there is not much overlap between the peds and adult subspecialty knowledge base in certain fields. Example: adult cardiologists dont know very much about the nuances of congenital heart disease, but they run circles around peds cardiologists in terms of coronary artery disease. Therefore, it makes sense for adults with congenital heart disease to be followed by a peds cardiologist, unless there's an adult cardiologist who is comfortable managing that. Often what occurs is that these patients have 2 cardiologists -- peds and adult to help manage their issues. Another example is peds heme/onc -- adult cancers are fairly different than pediatric cancers so its very common for peds heme/onc docs to follow patients into their mid 20s.

EM is different -- I would be shocked if a hospital would allow a peds EM person to manage adult patients. I know it happens in the military but thats only because the military can get away with it because of extraordinary malpractice protections that dont exist in the private sector. The civilian sector doesnt allow that nonsense.

 

[diphenyl]

What then would you propose be the age limit for peds trained EM guys? I've seen some say 0-18 and others say 0-21.

 

[KidDr]

I am a peds EM attending, did the peds--> PEM route. I will try to post more later, but for now, here are 3 quick thoughts:
1. Our department is made up of mostly peds-->PEM trained people, but we have a few general pediatricians, a few who were grandfathered in, and a couple EM-->PEM people. The general pediatricians are the only ones in the group who have different credentials (they can't do deep sedations or intubate and I think a few other things). Everyone else is the same, and maybe it's just the environment at my hospital (community with strong university ties), but in my experience, no one cares how you got your training (grandfathered in, peds-->PEM, or EM-->PEM). So this idea of EM-->PEM people being looked down on isn't a universal thing by any means.

2. Some days, I wish I had done EM-->PEM instead of peds-->PEM, even though I really don't like taking care of adults. The main reason is the procedural experience. The EM folks enter PEM fellowship with a huge advantage when it comes to procedural competence, and that advantage continues through fellowship and beyond. There just aren't as many procedures in peds. Yes, I got experience with intubations, LPs, IVs, simple lacs, a few CVLs and art lines, and a few other procedures in residency, but that is nothing compared to the EM guys who enter PEM fellowship already very competent in complex lac repairs, fracture reductions of all types, nerve blocks, hematoma blocks, chest tubes (I think I did 2 in residency total), various ophthalmology procedures, huge numbers of trauma and medical resuscitations, ultrasound, and so on. The EM people also already know how to move patients (not something I learned in peds residency). On the flip side, I obviously started PEM fellowship with a big advantage when it came to taking care of kids of all sizes (from 500 grams up to adult size) and everything that goes along with that. So it's all a tradeoff.

3. I strongly agree that you should pick your residency based on what you could see yourself doing a few years down the road. Don't assume that you'll do fellowship--a lot can change in a few years.