PICU autonomy?

[harambe4ever]

I'm a dumb third year med student trying to pick a field right now. How much autonomy do PICU docs have? I have heard rumors that they are just there to manage the patients for the surgeons who treat them without respect and the floor just sends them the sick asthma kids or something... can somebody give me a clear answer on whether or not this is the case? I'm exaggerating obviously. But do PICU docs have the main authority over their patients, medical and surgical?

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[michigangirl]

That's absolutely not the case. We have plenty of autonomy, more than most. In fact, most PICUs, unlike many adult ICUs, are "closed" units where only the PICU team can write orders for a patient. We fight for what's right our patients, surgical or not. The sick medical patients are all ours. Sick asthmatics come to the PICU for a reason. We have collaborative discussions with surgeons about patients' care. There are disagreements, yes, but we resolve them in the best interest of the patient.

 

[Step Up]

First off, you need to step into an actual PICU and see for yourself. The reality is the exactly opposite. The degree of autonomy depends on whether the unit is closed or open. I'm sure the PICU attendings and fellows on this board will add their 2 cents about the matter of open vs. closed, as I only have the perspective of my institution. Regardless, the large majority of sick pediatric patients fall under the care of the pediatric critical care attending and not the pediatric surgeon. Common medical cases you may see in the PICU include bronchiolitis, asthma, septic shock, croup, HUS, kawasaki shock syndrome, GBS, overdose (of everything scary), pneumonia, TBI, hypoxic brain injury from NAT, botulism, status epilepticus, severe anemia, oncology pts with complications, ARDS, CHD in cardiopulmonary overcirculation, arrhythmia, encephalopathy, IEM, PRES, etc. Additionally there are many cases admitted to the PICU with diagnoses dealing with the surgical specialities including pedi surg, neurosurgical, ENT, plastics, urology and ortho. Besides the pedi surg cases, these patients are typically less interesting than the strictly medical cases, IMO, e.g. a post-op scoliosis or craniocynostosis repair in which there's not all that much to do besides pain and airway management and monitor for complications.

If autonomy, responsibility and respect is something very important to you, there's really no speciality within pediatrics with more of this.

 

[harambe4ever]

I am very glad to hear this. It sounds like PICU was made for me. This was just something I overheard my peds residents talking about on rotation so I wanted to ask a third party. I agree I need to do a PICU rotation which I will do in June. It is important I figure this out because I would rather do peds anesthesia than gen peds or another peds subspecialty.

 

[dbeast]

I read in another thread on one of the general boards on this site entitled, "Who is the most badass group in the hospital?" and PICU got just as many votes as trauma surgery. One person wrote something along the lines of, "Nobody messes with the PICU". There's a lot of truth in that statement.

The lack of autonomy idea may have come from a resident, since there's always a fellow and usually an attending overseeing them. It's true that residents (and definitely med students) don't have much autonomy, and for good reason. The PICU can be a really scary place. Once you become a PICU fellow, though, you'll be managing many of the sickest patients in any hospital, anywhere. They're also one of the only specialties where you need to know medical critical care and surgical critical care (in adults, they're usually separate). Sure, it's annoying to babysit surgical patients, but it's a different skill set, and one that can be fun to learn about.

Speaking of babysitting surgical patients, if that's unappealing to you, then definitely don't do anesthesia. PICU is legit.

 

[harambe4ever]

I read in another thread on one of the general boards on this site entitled, "Who is the most badass group in the hospital?" and PICU got just as many votes as trauma surgery. One person wrote something along the lines of, "Nobody messes with the PICU". There's a lot of truth in that statement.

The lack of autonomy idea may have come from a resident, since there's always a fellow and usually an attending overseeing them. It's true that residents (and definitely med students) don't have much autonomy, and for good reason. The PICU can be a really scary place. Once you become a PICU fellow, though, you'll be managing many of the sickest patients in any hospital, anywhere. They're also one of the only specialties where you need to know medical critical care and surgical critical care (in adults, they're usually separate). Sure, it's annoying to babysit surgical patients, but it's a different skill set, and one that can be fun to learn about.

Speaking of babysitting surgical patients, if that's unappealing to you, then definitely don't do anesthesia. PICU is legit.

Great, thanks. PICU really sounds like what I am looking for and I love working with kids so it may be a match.

I'm sure fellowship is hell, but do attendings typically do the hospitalist-like schedule of 7-on 7-off?

 

[SurfingDoctor]

Great, thanks. PICU really sounds like what I am looking for and I love working with kids so it may be a match.

I'm sure fellowship is hell, but do attendings typically do the hospitalist-like schedule of 7-on 7-off?

I assume you mean 7 days on, 7 days off. That is more of a private practice model. Many academic PICU have in-house attendings and it is typically shift work (ie 6am to 6pm or so) with some scattered 24 hour shifts with call. This is setup is a reflection of in-house and also because of the needed flexibility to conduct academic activities.

 

[harambe4ever]

I assume you mean 7 days on, 7 days off. That is more of a private practice model. Many academic PICU have in-house attendings and it is typically shift work (ie 6am to 6pm or so) with some scattered 24 hour shifts with call. This is setup is a reflection of in-house and also because of the needed flexibility to conduct academic activities.

So they do random 12 hour shifts throughout the month similar to EM?

 

[SurfingDoctor]

So they do random 12 hour shifts throughout the month similar to EM?

Call shifts tend to be random. However, places usually have a week or two of daytime shifts for daily continuity of patient care.

 

[Stitch]

I'll offer agreement with above but also a slightly different perspective. We are quickly moving into a medical world where teamwork and collegiality are becoming much more important. This sounds cheesey on the surface, but it's absolutely imperative for patient safety. Intensivists in general are an opinionated group who care a lot about their patients. We also take ownership of everyone in the unit. At the same time, we recognize the need to coordinate care.

A lot of what I do is making sure consulting services (including surgeons, but also cardiologists or GI etc) are on the same page so the patient gets consistent care and the family gets a consistent plan and message. That means directing care, but it also means not getting my way all the time, even though I'm making most of the minute to minute decisions. That's okay because I respect my colleagues, and I rarely feel that what's being asked of me/my team is in any way dangerous.

PICU is a bedside specialty. We are there when no one else is. We are there when the surgeons are in the OR, and a good surgeon recognizes that I (generally) understand physiology, vent management, pressors better than they do. They trust me to include them in the care of their patient. If you communicate well with your surgeon and show them that you are caring for their patient, they will respect you and generally back off and allow you to do your thing. If you pick fights all the time over little things and ignore them, then they are going to micromanage you, and you'll be frustrated.

Don't get me wrong. Some people (not just surgeons) are difficult to work with. Cardiac surgeons especially can be frustrating because they tend to micromanage and be less open to outside input. The culture set by the hospital administration really sets the tone for how things play out at the patient care level (always ask how admin deals with problem physicians who are constantly disruptive).

In the end, I love what I do. The PICU is really the heart of the hospital. We are the safety net, and pretty much everyone recognizes that. Our voices carry a lot of weight in terms of both patient management and overall system functioning.

 

[dbeast]

Stitch is totally right, probably best evidenced by the fact that many PICU attendings work in hospital administration during their (considerable) off-service time. Besides pressers and vent settings, they're masters of coordinating many opinionated people and making sure everybody's input is heard. Not to mention staying calm when things get heated.

It's a very special skill set, and most PICU programs actually require their fellows to take some sort of leadership course.

 

[michigangirl]

Speaking of babysitting surgical patients, if that's unappealing to you, then definitely don't do anesthesia. PICU is legit.

I'm going to put my anesthesiologist hat on now. This is a very stereotypical view of what anesthesiologists do. Please don't promote it. Anesthesia is anything but babysitting surgical patients, and anyone who says it is hasn't spent any amount of reasonable time in the OR observing what we do. Any PICU intensivist who truly understands the field knows what is involved in caring for surgical patients, which is even more nuanced as a pediatric anesthesiologist. Which is why there are some who decide to pursue dual training in the midst of their PICU training. To do anesthesia, you have to love the OR and love physiology, acuity, and pharmacology. If you don't love those things, THEN don't do anesthesia.

 

[harambe4ever]

Is the only way to be peds anesthesia and PICU trained to do a minimum of 9 years of residency/fellowship? For instance, peds/anesthesia dual residency (5 years), PICU fellowship (3 years), peds anesthesia fellowship (1 year)?

 

[Stitch]

Is the only way to be peds anesthesia and PICU trained to do a minimum of 9 years of residency/fellowship? For instance, peds/anesthesia dual residency (5 years), PICU fellowship (3 years), peds anesthesia fellowship (1 year)?

There were a couple programs that combined PICU anesthesia training and knocked off a couple of years (Hopkins comes to mind), however my understanding is that the ACGME is making it harder for those programs to exist.

 

[BigRedBeta]

I'm sure fellowship is hell, but do attendings typically do the hospitalist-like schedule of 7-on 7-off?

I'd hesitate to say hell. Depends on the program. Clinically front loaded programs will be tough for the first year then get easier, more balanced programs will be a grind for all three but aren't as terrible at any one point, so pick your poison.

As the lone private practice PICU attending on the board (as far as I know), I'm in a very large private practice group (10 docs) and we do night float that's split evenly throughout the year, and then the rest of our schedule is roughly 7 on, 7 off for our day time coverage. It's 26 weeks a year on service, compared to the 16-19 most academic centers were telling me to expect, but the other time off is my own and I don't have to worry about research commitments or hospital committees if I don't want to.

 

[michigangirl]

Is the only way to be peds anesthesia and PICU trained to do a minimum of 9 years of residency/fellowship? For instance, peds/anesthesia dual residency (5 years), PICU fellowship (3 years), peds anesthesia fellowship (1 year)?

Yes. Some have been successful petitioning ABP to do a 2 year PICU fellowship, so 8 years is doable, but only if you do the combined Peds-Anesthesia Residency. Otherwise it's at least 9-10 years.

 

[DeadCactus]

Yes. Some have been successful petitioning ABP to do a 2 year PICU fellowship, so 8 years is doable, but only if you do the combined Peds-Anesthesia Residency. Otherwise it's at least 9-10 years.

Would you be willing to elaborate on this process a bit more? Do they allow the year reduction because of the peds anesthesia fellowship and the overlap between the two?

And which organization do you approach about petitioning for this? ABP? ACGME? Do you do it through the fellowship program or inquire prior to applying to fellowship?