Pediatrics vs family medicine decision after peds hospitalist rotation

[Cyclist89]

I'm not sure whether I want to commit to only treating peds patients all the time, or do a peds-friendly FM outpatient practice. Began med school with an interest in peds due to personal experience. Moved up my Peds ER rotation to try it out, and hated most of it. Hated variable shift scheduling, lack of continuity, patients that were either stable kids with overworried parents complaining about not giving their kid antibiotics for a viral URI, or the flip side a completely crashing kid that was ridiculously sick. So thought Peds was out.

Began to focus on FM because I liked much of everything ok, didn't crave kids vs adults one way or the other. Was thinking I would do outpatient medicine and could focus on peds if I wanted.

Then comes my peds hospitalist rotation this month. This is the first time this year that I've found the medicine to be enjoyable and excitable. I love peds hospital medicine as content. Even the asthma exacerbations because the age groups really make a difference for coverage and care. We have also had some amazing pathology: biliary atresia, vague depression sx dx to be lupus in a 15 yo, Sturge-Weber syndrome, lots of Downs with RSV etc, dysmorphic newborns. I was always interested in peds path in second year and it was awesome seeing the variety during this service. I also got along very well with 5/6 of my attendings and liked that they were all laid back and down to earth. I found the parents to mostly be very engaged and ready to learn about their kid's condition. And it helped my earlier feelings of disliking that the patient's couldn't talk to me-because the parents are adults that you talk to as well.

So now I am confused. If it makes a difference, I enjoy kids, but I am not the super excited to play with kids every day, goof around a bit type person. I enjoy the job I am doing, but am not a doc who is a big kid at heart. I also don't terribly hate the adult diseases (DM, Lipids, HTN) and management, and feel like sometimes real difference can be made in outpatient adult care. However, keeping kids on outpatient FM would probably not have as much of the peds medicine I like, because anything interesting/chronic would be off to a peds doc even if I personally felt comfortable with the patient themselves. I don't know if I would enjoy outpatient general peds either.

I am excited because interest finally clicked on a rotation this year-however I don't know if that is enough for me to commit to only kids for the rest of my training. Anyone have any thoughts? Is there anything else you think I am overlooking for my speciality choice? Much appreciated.

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[Stitch]

Hard to say, but can definitely understand where you're coming from. Sicker kids should definitely be managed by pediatricians, and peds hospitalist medicine is becoming more and more common for inpatient peds. Many bigger hospitals are pushing out the private out patient pediatricians who used to come in and round on patients. People really like the breadth of pathology without having the stress of running resuscitations all the time. You'll also be interacting will a wide variety of sub specialists and can teach residents.

Some down sides to peds hospitalist exist though. First, the ABP has approved a separate, boarded subspecialty status for peds hospital medicine. I think this is ridiculous as most graduating residents are perfectly capable of taking care of in patient peds. The effect of forcing a board exam will eventually mean that you'll have to do a two year fellowship after your three year peds residency if you want to work. This will squeeze out newer peds hospitalists who haven't grandfathered in and limit job options immediately after residency (though there will still be plenty of jobs in the near future as there aren't enough hospitalists to go around). Secondly you won't get the continuity of care you mentioned. You are taking care of someone else's patient for a limited period of time. Some chronic kids who are frequent fliers at the hospital you will get to know, and there's an opportunity to aid these families as they navigate chronic illnesses and eventually end of life care, but much of that often falls into the PICU realm. Also, on some level peds hospital medicine can be a real dumping ground for patients that no one else wants to take care of. Surgical patients or other peds subspecialty patients often get put on the hospitalist service, and sometimes you can feel like you're a perpetual resident doing what someone else wants. That's just part of the job.

You don't have to be a 'kid at heart' or always want to play with your patients to be a pediatrician. You just have to care about the kid, the family and the general well being of children. If you like adult diseases and pathology you could also do med/peds, as this would allow you to double board and give you quite a few options after residency. You'd miss out on the OB/gyn stuff that FM gives you however.

 

[NurWollen]

Hard to say, but can definitely understand where you're coming from. Sicker kids should definitely be managed by pediatricians, and peds hospitalist medicine is becoming more and more common for inpatient peds. Many bigger hospitals are pushing out the private out patient pediatricians who used to come in and round on patients. People really like the breadth of pathology without having the stress of running resuscitations all the time. You'll also be interacting will a wide variety of sub specialists and can teach residents.

Some down sides to peds hospitalist exist though. First, the ABP has approved a separate, boarded subspecialty status for peds hospital medicine. I think this is ridiculous as most graduating residents are perfectly capable of taking care of in patient peds. The effect of forcing a board exam will eventually mean that you'll have to do a two year fellowship after your three year peds residency if you want to work. This will squeeze out newer peds hospitalists who haven't grandfathered in and limit job options immediately after residency (though there will still be plenty of jobs in the near future as there aren't enough hospitalists to go around). Secondly you won't get the continuity of care you mentioned. You are taking care of someone else's patient for a limited period of time. Some chronic kids who are frequent fliers at the hospital you will get to know, and there's an opportunity to aid these families as they navigate chronic illnesses and eventually end of life care, but much of that often falls into the PICU realm. Also, on some level peds hospital medicine can be a real dumping ground for patients that no one else wants to take care of. Surgical patients or other peds subspecialty patients often get put on the hospitalist service, and sometimes you can feel like you're a perpetual resident doing what someone else wants. That's just part of the job.

You don't have to be a 'kid at heart' or always want to play with your patients to be a pediatrician. You just have to care about the kid, the family and the general well being of children. If you like adult diseases and pathology you could also do med/peds, as this would allow you to double board and give you quite a few options after residency. You'd miss out on the OB/gyn stuff that FM gives you however.

How long do you suspect someone would have to have been practicing to be grandfathered in as a BC peds hospitalist? I read that it might be the better part of a decade before the process of creating a subspecialty board and accrediting fellowships is complete.

I understand that increasing the standard of care should be a constant goal in medicine, but it does seem odd that what a general pediatrician qualified to do now will require two years of extra training in the near future.

 

[oldbearprofessor]

http://www.aappublications.org/news/aapnewsmag/2016/02/25/Hospitalists022516.full.pdf

Hard to tell the time line on this. I think there will be a long period of time before having fellowship trained hospitalists becomes necessary for getting any job. But, eventually it will happen. I'm not troubled by it, this was inevitable once fellowship training began in earnest.

 

[Cyclist89]

Thanks very much for all your thoughts and time. Especially to Stitch for the very helpful pros/cons. Finished my rotation today and I definitely have some soul-searching to do.

 

[Step Up]

I enjoy kids, but I am not the super excited to play with kids every day, goof around a bit type person.

This is a common misconception, and I don't understand how medical students still think this after having experiences in pediatrics. Most pediatricians are NOT like this, especially pediatricians that commonly deal with SICK children (e.g. intensivists, PEM, neonatologists).

 

[Cyclist89]

None of my hospitalist preceptors were overly playful. Some of my ED ones were. I only brought it up because it seemed like a pretty common (at least med student) answer to why kids only: you get to play with kids. I was considering the more common personality traits people gave in different posts here for why they decided on pediatrics as a specialty.

 

[jonb12997]

This ties into the, oh you must love doing rotations in the NICU, you get to cuddle babies all day. If only!


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[BigRedBeta]

I think the first question is really, how much do you love OB? Crave is an interesting way to put your preferences, but I prefer "what can't you live without". If you *need* OB to be fulfilled professionally, then yes, FM is it. My guess is that this is not the case given you're considering straight peds. Med/Peds is a fantastic option that I think often goes overlooked at schools with really visible FM programs/clerkship. Undoubtedly, med/peds will make you a better at inpatient medicine than FM - more ICU months, more wards months, etc. It's also nice because it really doesn't close any pathways (other than OB) after residency. You'll get the chance to see the full spectrum of medicine from prematurity to geriatrics and then find your niche.

Choosing between peds and med/peds - again, what can't you live without? Again, craving one patient population is different than saying you'd feel a empty space in your career without a certain type of patient. I had friends who did med/peds because they LOVED kids, but the thought of not seeing adults ever again was a hard sell. You just have to know yourself.

As for the playfulness, there's a time and place. I'm by no means the cuddliest of pediatricians, but play can be an important tool to complete your exam and get the information you need or to prevent a meltdown (unless you like screaming 2 year olds).

 

[smq123]

As a family medicine physician who works in a Peds-Adult Medicine-OB multispecialty practice, one thing that I would tell you to be aware of is that if you are bent on looking for a peds-heavy outpatient FM practice, you could be limiting your job offers. A lot of FM practices are looking for someone who will see adult people - adult medicine, unfortunately, reimburses better. Plus, after the Affordable Care Act was passed, there was a HUGE influx of adult patients who suddenly had insurance and took advantage of it to get care, so there was a big demand for adult medicine physicians. Peds did not have this problem, as many of their patients had always had insurance of some sort (CHIP, Medicaid, etc.)

Furthermore, the challenge of being a family med doctor who sees peds is that you will always be expected to show that you do it just as well as a pediatrician - that you do not provide inferior level care. That is tough, because our training is a lot shorter than theirs.

Finally, it sounds like you really enjoyed inpatient peds, not outpatient peds. And as a family doctor, you're just not going to do any inpatient peds. So if that's something that you love, then it will be hard to give up.

 

[mvenus929]

I would recommend doing a rotation in an outpatient field that manages chronic patients. There are a number of clinics specifically designed for complex kids--one of my chiefs is moving away to a job in California working with complex kids, and I think Duke has a 1 year fellowship in additional training of the complex kids. Based on your initial post, I think this might be more interesting for you than bread and butter outpatient pediatrics and may help you figure out if you do only want to do peds, or if you want to take care of adults.

As someone else mentioned, it's not strictly IM vs FM vs Peds... Med/Peds is becoming more and more popular, and there are a number of combined fellowships so that you can literally take care of some kids their entire lives even as they age out of the pediatric system. I imagine the common fellowships for that are cardiology (congenital heart disease), pulmonology (CF), Genetics (which is technically a separate residency and might also be interesting to you), and Endocrine (type 1 diabetes, panhypopit, post-cancer endocrinopathies, etc), though I'm certain there are others.

 

[tantacles]

It sounds like Med-peds might be a good option for you. If you love adult diseases, particularly in the pediatric population, it's one of the best fields to go into. You also have to like treating adults, so your adult medicine rotation might inform you a bit about how you want to proceed.

With regard to the difference between family medicine and Med-peds, Med-peds folks tend to see sicker people in residency than do family medicine physicians because it's more inpatient focused, and you'll receive strong training on how to be both a good pediatric and adult hospitalist, now a popular pathway for Med-peds. You also gain the ability to sub specialize in myriad fields, something that family medicine won't really offer.

It's a hard decision, but see how medicine suits you and it might help inform your decision!


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