Pediatric residency - the ups/downs

[Dragonfly411]

Out of curiosity, what are the ups/downs of pediatric residency (specific to peds and not just residency, in general, like the hours)? I would also love to hear residency/patient stories that reinforced people's choice for this specialty or even experiences that transiently led them to consider switching to another residency.

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[wellchild]

Yikes. Asking an intern (in any specialty) what the ups and downs in the middle of January is a dangerous proposition, but I'll throw in my two cents, because I've thought about this quite a bit actually.

Aside from maybe more trivial wishes, like wanting the ability write 8-word progress notes like the surgery residents get to do, or be able to sit at a desk and drink coffee every morning like I did in radiology, the thing I've disliked the most about my pediatrics residency is by far the parents. The beauty of pediatrics is that the vast majority of our patients are clean slates, far from the DM/CHF/HTN/EtOHism patients that make up much of the internal medicine wards. And while I loved my experience at the VA in medical school (really, I promise), I love working with kids because generally if they're sick, it's no fault of their own. The rule falls apart, however, when a kid has ****ty parents, which take on many appearances. There's the obvious emotional toll in seeing abused children, but there's also the same types of frustrations I thought I'd find in IM--trying to get parents to make lifestyle decisions to keep their children healthy. While I expected to be essentially retired from the motivational interview in getting adults to stop smoking or stop eating fast food every meal (and thus feeding it to their families) or get more active, instead it's taken on a greater significance for me since I'm often trying to do those things to advocate for a patient who can't advocate for him/herself and yet is affected by all those same lifestyle habits. It's harder than I anticipated.

So parents were the singlemost thing that threatened to send me into surgery or IM, and yet I'd also say they can be one of the most enjoyable parts of my job. While the terrible parents are often the easiest ones to remember, the parent who would do anything for the health of his/her child is much more common. I love answering their questions and teaching parents eager to learn. I have even come to the point where I don't completely despise anti-vax parents because I at least understand that they are trying to do the best for their child's health, albeit in an uninformed manner. I love enthusiasm for health. I didn't see it in family or IM or surgery like I see it here.

So my answer is the same for both things. Other things that led me to peds over surgery (my other top choice) had a lot to do with lifestyle and the ability to subspecialize in pediatrics into procedure-heavy specialties that would scratch that itch yet not decrease the quality of my life as I had seen in many surgeons. Not to knock surgeons, god knows I love them when they're around, but like peds wasn't for them, surgery wasn't a lifestyle for me.

Hope this helps. I'll be interested to see what others write.

 

[oldbearprofessor]

Okay, I'm not a resident, but I've been one and periodically I bump into one in the halls.

In my view, the parents are a "draw". Some are great, some awful. Not all that much different than any other medical specialty. What brings the ups and downs of a pediatric residency the most (other than the parents...), are the kids themselves and how we relate to them, as people and as doctors. So, great moments are getting an IV or blood draw quickly, having a little kid draw you a picture of yourself, or seeing a tiny preterm go home in good shape.

Bad moments are missing the art line/blood draw/etc and seeing the baby/kid in pain, having to deal with really screaming kids while looking in their ears, etc.

Alternate answer to your question:

Best: Neonatology
Worst: Adolescent medicine

 

[dolly dagger]

I agree with wellchild--asking an intern in January what s/he thinks of internship is asking for trouble But I think this is a great question, and I'm curious to read people's responses as well.

I'm not sure if I went into Pediatrics for the same reason most people did--I really only applied in Peds because I really REALLY want to go into Peds Cardiology. I never considered Gen Peds or any other Peds subspecialty, and that's come to mean that I sometimes view my Peds residency as a "preliminary" residency that is the path to fellowship.

That being said, I don't enjoy the same aspect of Pediatrics that my co-residents seem to love the most: healthy children. I am bored to tears with clinic schedules full of well-child checks and the mild ailments of childhood, and I'm tired of admitting children for constipation and cellulitis. I see the joy that other residents get in seeing cute kids all day and reassuring the "worried well" parents, and I just don't share it--I feel like if I wanted to hang out with healthy children all day, I would've saved myself a lot of expense and exhaustion and become a kindergarten teacher.

After quite a bit of reflection, I realized that intellectual stimulation was one of the biggest reasons I went into medicine, and General Pediatrics has less pathology than General IM or General Surgery. There may be a lower percentage of sick kids than sick adults, but when kids get sick, they can get quite ill. The distinct pathophysiology their small airways/congenital malformations/growing bodies present are challenging and unique to Peds. But their generally excellent premorbid status (read: they are otherwise healthy children!) means they do tend to recover, which is really satisfying. It really is great to see kids get better and grow up, but my Gen Peds-minded co-residents and I part ways on the events leading up to that: they find joy in preventing a healthy kid from getting devastatingly ill from Hib or the measles, and I find joy in watching a kid with a VSD get back on the growth curve after repair.

So, overall, I'm happy with my decision to go into Peds because I truly believe a career in Pediatric Cardiology will be stimulating and fulfilling. But yeah, residency is definitely reaffirming that Gen Peds is not for me.

 

[BigRedBeta]

So not an intern here.

Thinking back over the past year and half, I honestly can't think of anything that made me question my desire to do peds.

Like Dolly, I'm someone who LOVES taking care of kids that are sicker than snot (though I'm a PICU person). There are plenty of my fellow residents who dislike being in the PICU or NICU, not only because they're difficult rotations, but because being there negatively affects the resident's mental health. There was one of my fellow residents who freely admitted that she cried everyday when she got home from the PICU. She's going to be a phenomenal general pediatrician though and she's never wavered from that being her career goal. Meanwhile, if I was forced to be a general pediatrician...I would probably quit in the first six months. Usually, clinic makes me want to claw my eyes out, though I do manage to enjoy my 1/2 day of continuity clinic each week (if only because it's just a 1/2 day and I only take on parents that I like).

The best part of residency is simple: the kids. Whether it's crayon stains on my white coat, the response I get from asking 4, 5, and 6 year olds if they brought their belly button with them, or watching the teenagers' attitude totally change when I ignore their parents to talk directly to them, almost every day going to work is a chance to play. The other thing that stands out to me is how much variety exists simply from my patients being very different dependent on their age. It keeps my day interesting and keeps me from getting bored.

Parents represent the entity that's hit or miss. The great parents are just another great part of my day, while the ones that don't care leave me dumbfounded. Teaching is a love of mine so getting the chance to educate parents so they're kids continue to do well is rewarding. And while the "worried well" parents on occasion can be frustrating (the fever started when? 45 minutes ago? Well...there's not much I can tell you), in the end, I know it's because they love their child.

The bad, of course is things like child abuse, and there have certainly been cases I've seen that have caused me to question human nature. I manage to deal with it because I know that what I'm doing can help these kids, even if it's very different than anything I went to medical school for.

The absolute worst thing...the nightmare social situations that arise, particularly for the kids with chronic medical conditions that might be dependent on medical technology. I'm lucky to be at a place with phenomenal social workers and discharge planners, who have saved me untold hours of frustration, but I'd be lying if I said that being able to avoid a large percentage of social nightmares was NOT a contributing factor towards my decision to specialize in Critical Care.

Beyond those things, I think that any resident in any field will tell you that the best parts of their day are when they get to demonstrate progress, even competence. A difficult diagnosis, mastering a new procedure, or making critical decisions. If those things happen while operating fairly independently, then all the better.

 

[umass rower]

The absolute worst thing...the nightmare social situations that arise, particularly for the kids with chronic medical conditions that might be dependent on medical technology. I'm lucky to be at a place with phenomenal social workers and discharge planners, who have saved me untold hours of frustration, but I'd be lying if I said that being able to avoid a large percentage of social nightmares was NOT a contributing factor towards my decision to specialize in Critical Care.

Funny, because I almost see this as an argument NOT to go into PICU, since that's where the CP/MR/trach/G-tube & fundo/non-interactive spastic quadriplegics seem to like to hang out. But hey, to each their own. With the legitimately interesting kids, I can definitely see the appeal.

I have to reiterate what others have said, though: kids are kids, and the way we work with them is just different from the way things work anywhere else. I know my medicine, but I have trouble being stern and straight-laced; anywhere else, that would be a failing to an extent, but in Peds it's an asset. This is where medicine and personality meet, and while it always matters that you give the right treatment for a problem, often the way you give it matters almost as much to the family or the patient.

The highs are the unexpectedly good outcomes or reactions that it seems only kids are capable of. Going from the brink of death to bouncing around the playroom in a matter of a day or two. Lying around after some crazy procedure, still showing their personality when an adult would be immobile and begging for more Dilaudid. Stoically going through a chemotherapy regimen they couldn't begin to comprehend, making the most gut-wrenchingly benign requests ("Can you play a game of Sorry with me tonight?" from a girl who recently got a bone marrow transplant).

The lows are twofold: one, when things go wrong or just turn out badly, it hurts. That goes almost without saying. The other part is that there are some aspects of Peds where you don't always really feel like a doctor at all. Well child visits that I find mind-numbingly routine, the "nothing" complaints that abound in the office, and general adolescent medicine in general (can't they just grow a frontal lobe already?).

 

[michigangirl]

I agree with most of what was said above, so I won't reiterate. but regarding chronic MRCP, spastic quad kids hanging out in the PICU and that being a down side to the PICU-- these kids only come to the PICU when sick. They have to go somewhere after discharge from the unit, whether it's home or to the floor. So yes, sometimes it seems like these chronic kids are in abundance in the PICU, but usually it's because they need us. And often these parental interactions are some of the most rewarding-- to see the love and dedication some of these parents have to their special needs children is truly awe inspiring.

Funny, because I almost see this as an argument NOT to go into PICU, since that's where the CP/MR/trach/G-tube & fundo/non-interactive spastic quadriplegics seem to like to hang out. But hey, to each their own. With the legitimately interesting kids, I can definitely see the appeal.

I have to reiterate what others have said, though: kids are kids, and the way we work with them is just different from the way things work anywhere else. I know my medicine, but I have trouble being stern and straight-laced; anywhere else, that would be a failing to an extent, but in Peds it's an asset. This is where medicine and personality meet, and while it always matters that you give the right treatment for a problem, often the way you give it matters almost as much to the family or the patient.

The highs are the unexpectedly good outcomes or reactions that it seems only kids are capable of. Going from the brink of death to bouncing around the playroom in a matter of a day or two. Lying around after some crazy procedure, still showing their personality when an adult would be immobile and begging for more Dilaudid. Stoically going through a chemotherapy regimen they couldn't begin to comprehend, making the most gut-wrenchingly benign requests ("Can you play a game of Sorry with me tonight?" from a girl who recently got a bone marrow transplant).

The lows are twofold: one, when things go wrong or just turn out badly, it hurts. That goes almost without saying. The other part is that there are some aspects of Peds where you don't always really feel like a doctor at all. Well child visits that I find mind-numbingly routine, the "nothing" complaints that abound in the office, and general adolescent medicine in general (can't they just grow a frontal lobe already?).

 

[umass rower]

I agree with most of what was said above, so I won't reiterate. but regarding chronic MRCP, spastic quad kids hanging out in the PICU and that being a down side to the PICU-- these kids only come to the PICU when sick. They have to go somewhere after discharge from the unit, whether it's home or to the floor. So yes, sometimes it seems like these chronic kids are in abundance in the PICU, but usually it's because they need us. And often these parental interactions are some of the most rewarding-- to see the love and dedication some of these parents have to their special needs children is truly awe inspiring.

But then again, there are also the ones whose parents are never seen, who come from and go back to their long-term care facility after we've dealt with their umpteenth pneumonia for the year. We have a few that are regulars here, and they make me a little depressed every time they roll in through the door.

 

[Stitch]

I agree with most of what was said above, so I won't reiterate. but regarding chronic MRCP, spastic quad kids hanging out in the PICU and that being a down side to the PICU-- these kids only come to the PICU when sick. They have to go somewhere after discharge from the unit, whether it's home or to the floor. So yes, sometimes it seems like these chronic kids are in abundance in the PICU, but usually it's because they need us. And often these parental interactions are some of the most rewarding-- to see the love and dedication some of these parents have to their special needs children is truly awe inspiring.

This depends on your hospital though. We (thankfully) have a unit where these kids can go while they await placement or if they aren't that sick, but many other hospitals I've been in don't have that. Their PICUs can easily get clogged with a fair number or non critically ill rocks that don't go anywhere for weeks, and it can be quite frustrating to take care of those kids. Basically they end up in the unit only because they have a vent, even if it's just at night and requires no changes or little maintenance.

But then again, there are also the ones whose parents are never seen, who come from and go back to their long-term care facility after we've dealt with their umpteenth pneumonia for the year. We have a few that are regulars here, and they make me a little depressed every time they roll in through the door.

Yeah, we have a lot of these, and it's sad. On some level I understand why the parents have checked out, but the feeling is that they are just waiting for the kid to die so they can be done with it. And of course these kids are hard to kill.

 

[BigRedBeta]

Funny, because I almost see this as an argument NOT to go into PICU, since that's where the CP/MR/trach/G-tube & fundo/non-interactive spastic quadriplegics seem to like to hang out. But hey, to each their own. With the legitimately interesting kids, I can definitely see the appeal.

Medically these kids are not a problem. They add to the overall milieu of the unit, and if they need to be there, I want to care for them. But once they're no longer PICU players, I'm done. They go to the floor, and they can hang out there for weeks - it's no longer on my radar (I realize that may sound harsh).

The discharge planning issues, the difficulties with putting them in state custody, or finding a general pediatrician near their hometown that will serve as a medical home, or whatever it is that is keeping them in the hospital are things that are extremely frustrating for me, and were I in an attending position that frequently dealt with discharging patients home, those would be things that counted as major negatives.

Basically, I'm saying I want to minimize the number of patients I have to discharge out of the hospital. At my hospital, the discharges from the PICU tend to be limited to the ingestions in which the kid is totally back to normal after 12 or 16 hours. Pretty much everything else will spend at least some time on the floor before being sent out.

 

[michigangirl]

But then again, there are also the ones whose parents are never seen, who come from and go back to their long-term care facility after we've dealt with their umpteenth pneumonia for the year. We have a few that are regulars here, and they make me a little depressed every time they roll in through the door.

Yes, it's depressing, but even more reason why these patients need US-- someone to advocate for them when noone else seems to care. It's not like they are brain dead or were ever at a point where it was reasonable to withdraw care (i.e. 1 year old with anancephaly who is just following her course to die in infancy but somehow she ended up intubated after an arrest and now the parents refuse to withdraw). Many of these chronic patients have some meaningful interaction with their environment.

 

[elr1983]

Agree with above. I really like the PICU for the complexity of the patients, interesting physiology, fast paced....but HATE the management of MRCP/ex premies/HIE with bad brains/bad lungs/bad gut who get a virus and hang out with us forever slowly weaning the vent, just so they can go home, have no meaningful interaction with their surroundings, and come back a few weeks/months later. That also reminds me of the other "down" of peds, the NICU....

The good stuff is seeing that really sick kid bounce back, whether from sepsis, cancer, asthma, etc....plus all the fun interactions with toddlers, holding the babies, even (sometimes) the (pleasant) adolescents.

 

[CrazyPeds527]

As a future intensivist, I agree with BigRed: I HATE the floor discharge nonsense.

I also agree w/ MichiganGirl - the ability to advocate for the chronic kids is something worthwhile that PICU docs seem to do really well. The ability to not see the patient as a GORK is something I believe we, as jaded residents, generally suck at. Ditto for the heme/onc kid that we as residents mostly take care of the inpatient sick/frequently admitted/dying, versus the more common outpatient leukemic who kids his 3 years of total chemo, is in remission, and never gets admitted to the hospital

Residents are jaded by our disconnect between the inpatient and outpatient world, and spend little to no time in nursing facilities, seeing the joy that some of these kids bring to their parents, despite their MR.

All in all - residency (intern year in particular) is a grind. it's easy to be beaten down if you dont have the time, energy or coherence to stop and see what's awesome about what we get to do.

Taking and helping to heal a nearly dead kid and being able to shake his hand a few days later - unmatched, in my mind - thats why i want to keep on doing this, it keeps me comin back