Peds ER vs. Adult ER after general peds residency

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diamonddoc

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Hi guys,
I'm a peds PGY1 and am interested in ER. I have two routes I can take: Do a peds ER fellowship (PGY 4-6) and limit myself to working in a peds ER with less pay than adult ER docs make. Or, I can do a general ER residency (PGY 4-6) and be able to cover adult ER's and feel very comfortable, with my peds background, covering peds ER's as well. Any benefits to either of these routes?

Also, should I do an ER fellowhip/residency is there any way to keep that long-term relationship you'd have in general peds, but doing ER? Any suggestions?

Thanks.

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The only real benefit to doing a Peds EM fellowship is that it's easier to get into than a second residency.

I have one of my colleagues who graduated from my residency after completing his pediatrics residency (and also doing an extra year as chief). As far as I know, he doesn't practice general pediatrics (never did aside from residency), but if you'd like I can give him your email address if you'd like to discuss it with him.
 
diamonddoc said:
Hi guys,
I'm a peds PGY1 and am interested in ER. I have two routes I can take: Do a peds ER fellowship (PGY 4-6) and limit myself to working in a peds ER with less pay than adult ER docs make. Or, I can do a general ER residency (PGY 4-6) and be able to cover adult ER's and feel very comfortable, with my peds background, covering peds ER's as well. Any benefits to either of these routes?

Also, should I do an ER fellowhip/residency is there any way to keep that long-term relationship you'd have in general peds, but doing ER? Any suggestions?

Thanks.

Most peds ER's don't even require the peds EM fellowship and have straight pediatricians on staff, although they are trending toward hiring board certified EM physicians.

I feel that the future trends will be the hiring of EM residency trained physicians that do a fellowship in pediatric EM, and not pediatricians that do a fellowship. If you were dually certified in peds & EM, that would give you a distinct advantage over all of these.

(My information comes from discussions on this topic with staff of my state children's hospital ER.)
 
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OSUdoc08 said:
Most peds ER's don't even require the peds EM fellowship and have straight pediatricians on staff, although they are trending toward hiring board certified EM physicians.

I feel that the future trends will be the hiring of EM residency trained physicians that do a fellowship in pediatric EM, and not pediatricians that do a fellowship. If you were dually certified in peds & EM, that would give you a distinct advantage over all of these.

(My information comes from discussions on this topic with staff of my state children's hospital ER.)


Actually, most Peds ED's have either fellowship trained pediatricians or grandfathered general pediatricians who have been practicing peds EM long enough that no fellowship has been required. Only the smaller peds ED have straight pediatricians on staff.

Most (90%) of peds EM fellowship grads are pediatricians as opposed to EM docs so the majority of future peds ED staff are going to be pediatricians, not EM docs.

If you do a EM residency without a fellowship, you cannot sit for the Peds EM boards. This pathway has been closed for several years now. You could work in a general ED and be very comfortable with peds patients but you would not be truly board certified in Peds EM. I don't know what kind of impact this would have on trying to find a job in a stand alone children's hospital ED.

In terms of competitiveness, only about 2/3rds of applicants to Peds EM fellowship actually get a spot. I don't know what the odds are for getting into a new residency with the new funding changes.
 
OSUdoc08 said:
I feel that the future trends will be the hiring of EM residency trained physicians that do a fellowship in pediatric EM, and not pediatricians that do a fellowship. If you were dually certified in peds & EM, that would give you a distinct advantage over all of these.

ponyboy is right. the general pediatricians working peds ED have been grandfathered in, and the trend now is toward EM fellowship trained pediatricians. sorta like ED's prefer ED docs instead of FP docs (if given the choice), peds ED's will prefer peds +EM fellowship, if for no other reason than to be true to the profession :cool: seriously though, a lot of peds ED is bread and butter peds residency stuff that we deal with daily for three years-- vs an EM residency that will have rotations in peds ED or the random peds cases that come into their traditional ED's. i know i'd prefer peds +peds EM fellowship than EM + peds EM fellowship for my kids, simply due to having more peds experience.

of course the dually residency trained physician does trump both, but why in the hell would a pediatrician want to see gomers??? :confused: defeats the purpose of going into peds, doesn't it? :)

--your friendly neighborhood trying to find a peds subspecialty caveman
 
Homunculus said:
the general pediatricians working peds ED have been grandfathered in, and the trend now is toward EM fellowship trained pediatricians. sorta like ED's prefer ED docs instead of FP docs (if given the choice), peds ED's will prefer peds +EM fellowship, if for no other reason than to be true to the profession :cool: seriously though, a lot of peds ED is bread and butter peds residency stuff that we deal with daily for three years-- vs an EM residency that will have rotations in peds ED or the random peds cases that come into their traditional ED's. i know i'd prefer peds +peds EM fellowship than EM + peds EM fellowship for my kids, simply due to having more peds experience.

We rotate side by side with our colleagues in the Peds ED, and one thing they CANNOT do is trauma - even the ones that want to founder, and, when an EM person is available, >9/10 just yield to them. You're right about a large part of peds ED being basic peds, as in Peds ED and Peds clinic - however, the EM RRC dictates 16% of total shifts be peds, and a total of 4 months of peds experience - from the ACGME:

Pediatric experience, defined as the care of patients less than 18 years of age, should be at least 16% of all resident emergency department encounters, or 4 months of fulltime-equivalent experience dedicated to the care of infants and children. The program can balance a deficit of patients by offering dedicated rotations in the care of infants and children. The formula for achieving this balance is a 1-month rotation equals 4% of patients. Although this experience should include the critical care of infants and children, at least 50% of the 4 months should be in an emergency setting.

Is it really that much of a difference, especially in a 3 year Peds EM fellowship, if a person's residency was peds or EM? I mean, as you say, a LOT of it is fundamental peds, which do not have a steep learning curve, as far as EM goes, and stuff like critical care and procedures are very similar in adults and kids (sutures, LP's, intubation), with the exception of having to math out doses (and which the Broselow tape bridges the gap). I rotated through the PICU with my Peds colleagues, and we all got the same nothing out of it (and certainly none of us learned how to indvidually manage a generally critically ill child, with the majority of patients being bone marrow, cardiothoracic, and post-op/SICU types - if you didn't have it going in, you didn't get it while you were there), and then we all rotate through the peds ED.

For a peds ED, having a peds EM fellowship trained provider - regardless of the residency - is, in my opinion, more than enough. 2 or 3 years, day in and day out, of working in the peds ED trumps one or the other residency. For the general ED, the EM RRC strives to ensure that a BC/BE EM doc can see any and all patients that come through the doors - from 23 weeks gestation to >100 years old, from mutilsystem failure/cardiac arrest to no complaint/wants a sandwich.

Interestingly, there is a proposition that was introduced to ABEM last year that said that, to teach EM residents, you had to be EM trained (or PEM) - which would ace out the general pediatricians working in the ED. No legs for that, so far, though.
 
Quick clarification from previous post:
If you do residencies in both EM and Peds, you cannot sit for Peds EM boards. Previously this was a pathway to Peds EM certification but it is now closed.

I think that anyone who is fellowship trained in Peds EM after a peds residency will be comparable to their counterpart who has finished an EM residency. Most fellowships are tailored to the residency from which you came so that peds grads get more trauma/ortho exposure while EM grads get more peds exposure. The reason why most fellowship grads are pediatricians is simply because not many EM grads apply to the fellowships.
 
Ponyboy, forgive me If I am wrong. However, I'm a third year med student and I spoke to an ER resident last week and I was told that ER residency + Peds Residency= The ability to be Triple boarded. Is there a site I can go to read up on this info myself.
 
drcrusher said:
Ponyboy, forgive me If I am wrong. However, I'm a third year med student and I spoke to an ER resident last week and I was told that ER residency + Peds Residency= The ability to be Triple boarded. Is there a site I can go to read up on this info myself.

One of our attendings did EM/Peds, and he also stated he's not eligible for Peds EM, so I feel that to be accurate.
 
I wouldn't count on the ability to do a double residency, as medicare is starting to make it tougher for programs to get funding for a resident who is doing his/her second residency.

The trend is definitely towards Peds EM boarded people (either peds + PEM fellowship or EM + PEM fellowship), as the EM RRC (residency review committee-- the educational standards-setting body) is going to start requiring that EM residents are only allowed to be precepted by PEM-trained people (through either of the above tracks) when working in a peds ED, which is going to put pressure on the places which employ non-grandfathered pediatricians in an academic environment.

drcrusher said:
Ponyboy, forgive me If I am wrong. However, I'm a third year med student and I spoke to an ER resident last week and I was told that ER residency + Peds Residency= The ability to be Triple boarded. Is there a site I can go to read up on this info myself.
 
Apollyon said:
I mean, as you say, a LOT of it is fundamental peds, which do not have a steep learning curve

ouch. sure, i guess if you are talking "fundamentals", but fundamentals in *any* specialty isn't that steep. especially ED fundamentals :p ;) :D


Apollyon said:
For a peds ED, having a peds EM fellowship trained provider - regardless of the residency - is, in my opinion, more than enough. 2 or 3 years, day in and day out, of working in the peds ED trumps one or the other residency.

i agree to a point, but i'm also biased. 100% (figuratively) of a peds residency is peds-based. 16% (figuratively) of EM is peds-based. that's gotta make *some* difference. you're right though-- three years of fellowship is probably plenty to be a competent peds ED doc. but if you consider that pediatricians will likely be doing the hiring for peds ED's, it can only be a good thing to also be a pediatrician when you're looking to get a job. :) the peds mafia runs deep . . . . :cool:

at any rate, i think we've answered the OP's question :thumbup:

i will add for the OP that there are at least a few peds-er trained docs i've run into that have clinic 2-3 days a week (at a group practice) and take two-three 12-hour shifts/week at a children's ED. not a bad gig at all.

--your friendly neighborhood searching for his future niche caveman
 
Homunculus said:
ouch. sure, i guess if you are talking "fundamentals", but fundamentals in *any* specialty isn't that steep. especially ED fundamentals :p ;) :D

From the (P)EM end - sick, not sick? Fever, workup or not? Admit, yes or no? Viral syndrome?

Peds proper has a lot, but a lot of that is zebras (like Pompe's disease - I've actually seen it, but that's only because we have a center here that recruits for gene therapy worldwide - not for that, what would I ever see? Cornelia de Lange? Lieutter-Siwe (did I spell that right?)?). Peds EM is a lot of clinic, and a lot of clinic is runny noses and fevers.

As a buddy said, "with kids, it's all or nothing, and it's usually nothing, but when it's something, it's everything". I am gratified that pediatricians learn their stuff (so they can continue what I start), but, even now, peds hospitalists are on the rise, and it's a lot easier for me to say, "6 weeks, fever? Slam dunk - admitted", even, essentially, before I've laid hands on pt. I do the workup, but know there's only one road to go down (unless the pt has an already diagnosed disease, but then they have a PMD/service already).

And, EM fundamentals? True, not steep, but the breadth, I tell you - the breadth!

Oh, and, you know, adults are just large children!
 
DD,

Have you gotten any good answers to your delimma? I am a 2nd year peds resident and for the last week have been considering the exact same thing - PEM fellowship vs EM residency after peds residency. Here are my questions/take on the situation.
1. Do I want to treat adult patients?
I did an EM month as a 4th yr med student and liked it. Esp, the trauma and procedures. It was late in my 4th year and right before the match, but even then I did ask myself if I was a peds person vs and EM person. I have spoken with several of my advisors and friends at my program, some PEM trained and actually 2 peds and EM trained - the general consensus if to find out if I want to treat adults, or even have the training and ability to do so, even if I work in a Peds ED. I am planning on doing another adult EM month soon to help me sort this out.
2. Is it even possible to do another residency, from a funding standpoint?
What I am finding out is that this is variable from place to place. I have emailed several EM PDs, one who said his program cannot take previously trained residents for funding reasons, another who said no problem and to apply. I think the best thing to do is just to write 'em and ask.
3. Will I be able to work in a Peds ED without doing a PEM fellowship?
From talking to several people at my home program, including the Peds ED Department direrctor and some PEM fellowship trained docs and older grandfathered-in PEM folks and just plain old pediatricians working as "second attendings" (see the less acute/non-trauma pts) in our dept; the answer seems to be YES. The Peds EM world is about 15-20yrs behind the adult EM world, in terms of politics and policy. Right now, adult EM is trying to get all the FP, surgeons, IM, etc folks out of the ED. But in smaller cities, there are not enough EM trained people to work everywhere. In peds ED, there are obviously less Peds EDs across the country. If you want to work in a prestigeous academic setting, doing the fellowship might help you out. But if you want to work in a regular Peds ED, it should not be a probelm - look at how many general pediatricians work/moonlight at community and academic Peds ED now. Surely having the additional EM residency in addition to a peds residency gives you a leg up over them. I cannot see in the next 20-30 years there being enough of a push to get even the general pediatricians out of the Peds ED. It is a matter of supply and demand. There are not enough fellowship spots or trained PEM people to take all the spots, again maybe the academic centers, but certainly not all the community jobs.
4. Let talk $$$
As we both know, being a general pediatrician pays crap. Not that we are doing this for money, but hey, the kiddies gotta eat. PEM folks seem to make more than gen peds folks. But the ability to also work in the adult EM world can potentially double your income. Even if I want to work 3/4 time in the Peds ER b/c that's what I love, there are alot more opportunities to pick up adult ED shift in rural towns than there are to pick up PEM or peds urgent care clinic shifts, and the money for big folks is much better per hour.
5. Experience level - PEM fellowship vs adult EM
This is a hard one for me. If I truely want to work exclusively in the PEM world, then the fellowship would be better - more time in the Peds ED = more direct patient care experience. But when I think about how much I like trauma, there is no doubt that adult EM gets more experience. At least at my hospital, if there is a cool trauma, code, whatever, most attendings in the Peds ED do not see alot of those things and are not comfrotable with the management (the newly trained PEM folks and a couple of the older PEM grandfathered-in people being the exception). IE, when a really sick kid comes in, they quickly stabalize, them defer to the trauma surg team, or the PICU team comes down to do the intubation or chest tube or CVL. I am told that with our new PEM program director, this will change, but who know? I guess, I am just worried that if I am practicing in the real world, no trauma team in house, community ED, I might not have seen or done enough.
6. Time use - fellowship vs another residency
I am OK with deffering the good life for another 3 years either way. And there are opportunities to moonlight eiter way. But the PEM cirriculum has 11 months of research. OK, not bad, pretty easy months, but I do not want to do research when I am finished. The EM residency has 21 months in the ED and the other months are all clinical. I feel that might be the better use of my time/training.
OK, now my wife would rather me do the fellowship - overall easier life, more time at home with her and my daughter, and we would not have to move yet again. So, we gotta talk that one out.
7. What else am I forgetting?
DD or any of you cool EM folks please feel free to chime in.
 
TeleoDeum said:
I cannot see in the next 20-30 years there being enough of a push to get even the general pediatricians out of the Peds ED. It is a matter of supply and demand. There are not enough fellowship spots or trained PEM people to take all the spots, again maybe the academic centers, but certainly not all the community jobs.

Today, not 20 or 30 years from now, there are people at ABEM that are pushing for this. I don't think it's moving too fast, though.
 
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