PEM to PICU

[AztecTurtle]

I'm currently a PEM attending a few years out considering trying to jump ship to PICU. The life style and financial sacrifice for 2-3 years of fellowship is obviously a big barrier but some days I think it would be worth it.

I went into PEM for the variety, acuity, and procedures. My favorite thing in medicine are the first few hours of stabilizing a patient when you're starting from scratch and not sure yet what is going on. I considered PICU but initially decided some of the negatives outweighed the positives: most patients already have a diagnosis, babysitting subspecialty patients, trapped for days/weeks with challenging family dynamics, rounding.

Over time, my perspective has shifted. A lot of PEM patients are transfers that come with a diagnosis too. A lot of PEM patients are just there to see their subspecialist with me contributing little to their care. The occasional challenging family dynamic seems countered by having more time to build a relationship with other families. Rounding and having time to actually think through a patient and their physiology now often seems more appealing than mostly heuristic decision making and primarily being concerned with efficiently getting out of a room and onto the next. Procedures seem relatively rare in both fields but definitely more common in the PICU. The schedule seems incrementally better than PEM in that there are generally no evening swing shifts and nights are blocked together. Generally, the relationship between PICU and other services seems more collegial than between those services and PEM.

I think in summary, the appeal of PICU is higher acuity with most patients having clear, objective pathology and a clear role for me to play in their care besides reassurance. My biggest concern is that the two specialties may prove to be similar enough where it's hard to justify the investment in time and income for an incremental gain in career satisfaction. It's not like I hate PEM or my job. What I find the most rewarding just seems to have changed over the past few years.

Mostly just posting as a sounding board and to organize my own thoughts but interested in any outside perspectives.

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[SurfingDoctor]

There’s a lot to unpack there.

First the procedure thing. The number is probably the same, the types are just different. There are generally more airways in the ED than the PICU. But vastly more CVLs, alines and chest tubes in the PICU. Either way though, no one should pick either field based on procedures in my opinion because as you mentioned, they aren’t super common.

Second, the acuity is variable and highly dependent on a number of system/institutional factors. Namely, are there step down units, and separate cardiac versus medical units. Even then, the acuity can be highly variable. Granted, as opposed to the ED, when there is high acuity, you manage it and don’t just stabilize it, but there is a lot of chronicity in the PICU population. Even rip roaring sepsis in its acuity is a disease of chronicity. Just so you don’t get the impression that it’s all high acuity or diseases that can be fixed. Sometimes it is, but there’s a lot of the time it’s not and merely fixing it enough till next time.

Third, the swing shift is institutional dependent and more typically than not. We have random scattered shifts, but you usually have daytime and postcall responsibilities. We also have 24+ hour shifts. Maybe what you saying would be more common in a PP model, but I’ve not seen it at the institutions I’ve been to. In fact, there’s still some places that do daytime service with night home call, meaning you are “on” for 7 days straight.

Fourth, the financial loss is considerable for someone who is already an attending and should not be taken lightly.

To be frank, this sounds more kinda like burnout and looking for a change. However, the grass is rarely greener. I’m not trying to dissuade you, but I think you need to have a very clear idea of how this will help you than can’t be fixed by addressing other things in your current job/situation.

Feel free to PM more if you want or continue the discussion in this forum. Either way.

 

[Natremia]

Sorry to semi hijack but:

I thought PEM was a ticket to daily procedures? Is my residency experience not the norm?

Is NICU or Cards (interventional, EP) the only two with pretty much guaranteed daily (or every other day) procedures?

 

[FrkyBgStok]

Have you looked at other jobs? I did residency at a community facility, doing PEM fellowship at an academic center, and the PEM life is drastically different in each. Here, there are fellows everywhere in every specialty so I feel like that middle man just calling consults to come take care of stuff. But I am actively involved in doing the stuff because I know I am going back to the place I did residency and we don't have plastics, ENT, ophtho, burn, and other specialties at our fingertips every hour of the day. This allows for more procedures and more mental stimulation, at least in my mind.

as surfing doctor mentioned, maybe you just need a change of scenery because going back for a drastically different job is a big deal that would be a huge pain if you aren't 100% sure. and like anything, procedures are hit or miss. I have days where I do something on every patient, and days when I don't do anything. but that is no different than PICU. In my own experience, NICU seemed to have the most procedures.

 

[PTPoeny]

I think that you would have to very carefully choose among PICU jobs to get one that you like more then where you are now. There are plenty of units with more chronically critical patients than acutely ill patients. And once they are there and settled there aren't many procedures as you wait weeks to months for them to get better. And there are all sorts of different schedules out there that may be better or worse. My schedule does not have any grouped night shifts, for instance.

Given all that, I also wonder if a different PEM job would be able to give you significantly more career satisfaction without the cost of a second fellowship.

 

[oldbearprofessor]

Sorry to semi hijack but:

I thought PEM was a ticket to daily procedures? Is my residency experience not the norm?

Is NICU or Cards (interventional, EP) the only two with pretty much guaranteed daily (or every other day) procedures?

Not to hijack this, but nowadays attending neonatologists do few procedures. Whether community or academic, others (trainees, NNPs, RTs) are doing most of the lines and even intubations (in the United States at least, this looks different in many other countries). We still do procedures as attendings, but it's not daily or close to it for most neos, even the younger ones. There are some places with more hands-on neos, but the trend is for less procedures by attendings.

 

[Natremia]

Not to hijack this, but nowadays attending neonatologists do few procedures. Whether community or academic, others (trainees, NNPs, RTs) are doing most of the lines and even intubations (in the United States at least, this looks different in many other countries). We still do procedures as attendings, but it's not daily or close to it for most neos, even the younger ones. There are some places with more hands-on neos, but the trend is for less procedures by attendings.

Well, couldn’t an attending choose to do such procedures if one wished? At the end of the day only one person is on the hook for the newborns outcome.

 

[oldbearprofessor]

Well, couldn’t an attending choose to do such procedures if one wished? At the end of the day only one person is on the hook for the newborns outcome.

It's not that simple. Unless said attending wishes to be present 24/7, do all of their own transports and not have much time to do anything else, modern neonatology requires that others be trained in procedures and gain adequate experience with them. There are a lot of folks that need training in most NICUs and, although undoubtedly an attending would have first dibs on them, it would be difficult to not give others adequate opportunity by taking daily procedures. Ultimately however, there really isn't that much excitement in doing ones 1000th UAC. I'm not sure that would be something I'd base a career decision on.

 

[Natremia]

It's not that simple. Unless said attending wishes to be present 24/7, do all of their own transports and not have much time to do anything else, modern neonatology requires that others be trained in procedures and gain adequate experience with them. There are a lot of folks that need training in most NICUs and, although undoubtedly an attending would have first dibs on them, it would be difficult to not give others adequate opportunity by taking daily procedures. Ultimately however, there really isn't that much excitement in doing ones 1000th UAC. I'm not sure that would be something I'd base a career decision on.

I value your input and seasoned response, so thank you.

But, with all due respect: some of us would rather do a 1000th UAC over rounding on their 250th constipated kid. Unfortunately, not many options for those of us who like thinking/ doing/ procedures/ kids.

 

[AztecTurtle]

Thank you all for the replies and input.

I do plan to give it time and explore how much of my current discontent is related the impact 2020 has had one many people as well as likely trying another job. I’m just starting to explore alternative plans.

I think one of the issues that didn’t come up in the original post is that one of the challenges I’m finding is that many of the aspects that frustrate me about PEM are most pronounced at the tertiary/quaternary academic centers that are most appealing for other aspects of my career and personal life. Meanwhile, the PICU practice at those institutions amplifies what I find enticing about it. I do realize completing a fellowship won’t necessarily grant me a job at one of those institutions and that there is logic in just sacrificing some of the other things I want to have a satisfying clinical practice without going through more training.

 

[AztecTurtle]

Sorry to semi hijack but:

I thought PEM was a ticket to daily procedures? Is my residency experience not the norm?

Is NICU or Cards (interventional, EP) the only two with pretty much guaranteed daily (or every other day) procedures?

Lacerations are fairly frequent. Sedations are common. Fracture reductions can be common if you don’t have orthopedic residents. Nose and ear foreign body removals are pretty common. Whether PICU or ED intubate more seems to vary significantly between institutions based on a number of factors. Central and arterial lines are more of a PICU procedure. Chest tubes are more of a PICU procedure.

 

[FrkyBgStok]

I think one of the issues that didn’t come up in the original post is that one of the challenges I’m finding is that many of the aspects that frustrate me about PEM are most pronounced at the tertiary/quaternary academic centers that are most appealing for other aspects of my career and personal life.

I am curious what you mean by this. Are you talking about the huge number of specialities and the triage work you see in the academic facilities coupled with the outside things like research, committees, teaching, etc?

 

[BigRedBeta]

Had something more thoughtful written out, but it disappeared, so here's the shortened version

Is it doable, of course, the main questions are is it actually what you think it is and will it be worth it?

Should be able to only need 2 years in the PICU, and many PCCM fellowships will be used to doing this given the number of people who come through after a cards fellowship to be dual boarded. Will need the 18 months of clinical time, but may even be able to shave off a few things from prior experience that are incorporated into a PICU fellowship (eg would you really need a few weeks with the transport team like most first year fellows do? Could you show airway proficiency enough to get out of a few weeks of anesthesia cases?).

Depending on location, could you also moonlight in a Peds ED to help mitigate the loss of income? Some fellowships may consider this, others might say it is a work hours violation. Would you physically be willing to do this? While not as common as it used to be, the traditional structure of a first year PICU fellowship is 10 months of q4 call, so it may not be high on your priority list to throw in ED shifts on top of this.

As far as job market, I think you there's actually a potential enhancement to your job prospects if you're dual boarded in PEM/PICU and would want to split time. I get the feeling (perhaps erroneously) that there are a number of PCCM divisions which are fractions of an FTE from where they would like to be, but not actually having a full FTE in their budget or their service time. I also suspect that partial FTE jobs are more common in the PEM world (PEM leadership always seems more chill than PICU leadership wherever I've been). Getting to split your time would solve the conundrum the divisions find themselves in, and might also provide you with a best of both worlds situation, giving you a break from the negative aspects of each field regularly.

 

[SurfingDoctor]

BigRedBeta brings up two interesting points that I had not considered that are generalizable and I think worth some further discussion: the partial FTE and splitting divisions. As mentioned, there are (and probably not infrequently) unfilled FTEs. That's true for nearly every academic division there is. Things change, people take on other or new responsibilities, and by proxy, their clinical FTE changes. Sometimes there is a lot, sometimes there is little. But generally speaking, there is ALWAYS some. BUT, the caveat to that is that from a divisional financial standpoint, it is generally better not to fill partial FTEs with new staff. The reason being that its much cheaper not to. It is makes better financial sense to give incentive pay to faculty or staff already there because it generally only equates to a couple of shift per faculty per year and if they pay a extra for shift coverage, that usually means they don't have to pay for all the associated fringes that come with being staff (403b, insurance, etc.). Additionally, because that spare FTE is flexed, sometimes things happen where a faculty will have to take on more clinical FTE to cover their salary and what is a financial drain for every division is overstaffing. That's like a nightmare financially speaking. They would 100% prefer to be understaffed than overstaffed. For instance, I think we are down 1 whole clinical FTE in a division of 14 members (I actually forget how many are in the division, something like that though). That FTE accounts for 130 shifts. So, split evenly (it really wouldn't be because they are cardiac shifts, but I digress), that would account for an additional 9 shifts/faculty/year or less than 1 shift per month. We were essentially told they weren't going to fill it until they felt like it and we were voluntold to suck it up. Additionally, since bonuses are typically based on divisional profit, the saving of not hiring and not giving out fringes has the potential to trickle down into my pocket. Thus, from a personal financial sense, the partial FTEs are money generators for me.

The splitting of divisions is a different issue. There's a reason why most people (even dual trained ones) find a home in one division and use the other as a supplement for some extra cash or for research-related purposes. That reason being is its much better to have one boss with one mission than two bosses with two missions. Especially where those divisions (ie PICU and PEM) may actually have an opposing mission. The main mission of most ERs is throughput and turnover to generate revenues. That typically runs afoul of many PICUs where chronicity creates a bottleneck and post-op care is the biggest financial generator. In my experience, from a mission standpoint, this creates a lot of head butting or "jousting" as a colleague use to say. What you don't want to be is caught in the middle of that and having to listen to colleagues gripe about other colleagues constantly. Additionally, because though division's missions may be divergent, you may be asked to do things that overstretch you because quite frankly, one boss doesn't care that the other boss is asking you to do "X". That's not their problem, that's your problem. The only time I've seen the splitting of divisions work as BigRedBeta stated (though not in the context of fellowship) and there is a need for moonlighting or random shift coverage. Like we have dual trained Cards and PICU faculty and they occasionally they'll read Echos or something (but even then, it's rare). But its all ad hoc and not something that is salaried and quite frankly, probably not something that someone would want to be salaried for the reasons I stated.

 

[gatorfan97]

Have you reached out to someone who is dual boarded? Happy to chat offline, I'm one of those people who left PCCM training (after the first year) and am now in my last year of PEM fellowship. I happened to stay at the same quaternary care institution for both fellowships. I love managing critically ill patients, until they're stabilized. I find the lower acuity stuff a nice break and it makes me feel more well rounded. One of my frustrations with PCCM was that the focus was more on the physiologic derangement rather than determining the cause of the derangement. The cultures between the two disciplines are quite different. PCCM fellowship is very intense, I felt like I handled over my life to my training. I also love myself, my family and my other interests outside of clinical medicine. Listening to your concerns, it almost sounds as though you might just be happier at an institution that has a more autonomous PEM division.

 

[Natremia]

Have you reached out to someone who is dual boarded? Happy to chat offline, I'm one of those people who left PCCM training (after the first year) and am now in my last year of PEM fellowship. I happened to stay at the same quaternary care institution for both fellowships. I love managing critically ill patients, until they're stabilized. I find the lower acuity stuff a nice break and it makes me feel more well rounded. One of my frustrations with PCCM was that the focus was more on the physiologic derangement rather than determining the cause of the derangement. The cultures between the two disciplines are quite different. PCCM fellowship is very intense, I felt like I handled over my life to my training. I also love myself, my family and my other interests outside of clinical medicine. Listening to your concerns, it almost sounds as though you might just be happier at an institution that has a more autonomous PEM division.

Do you feel that you get enough of that procedure itch in PEM? Unless procedures aren’t your thing in the first place..

 

[BigRedBeta]

One of my frustrations with PCCM was that the focus was more on the physiologic derangement rather than determining the cause of the derangement.

Speaking in very broad generalities, yes, I think diagnosis is less a concern in PCCM. The tools that I have expertise in - invasive and noninvasive ventilation, vasopressors, extracoropreal therapies, invasive monitoring are less dependent of having a clinching diagnosis than say what biologic medication needed for UC or Crohn's. Support the patient until someone smarter than me can figure out what's going on. I often think of my job as being the tug boat steering the other services around the pitfalls while they determine the larger plan. Oftentimes it's having the broad understanding of what's happening to mediate between multiple services so that no one team kills the patient. And hopefully for almost all patients, the PICU represents only a small portion of their healthcare journey.

And personally, that's where I find my fulfillment in medicine - doing the day to day management of patients with either realtime or near realtime (hours to days) feedback of my decisions. Other fields definitely cater to that House mentality in which the patient is a puzzle to figure out.

Interestingly enough, my fellowship project basically showed that PEM physicians (both attendings and fellows) don't care about physiology to the same degree as NICU/PICU folks and whenever I've shared that nugget with PEM groups, the overwhelming response is "yeah, not our cup of tea" and "we let y'all who have days and weeks with the patient to pontificate on the physiology".