PICU information

[RinaBe]

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To the PICU fellows past, present and future: what drew you to the field? What are the most rewarding aspects of the field? The most frustrating? I've read that there is a high rate of burnout in this specialty. How is the lifestyle and how do you deal with the stress? In retrospect, would you have done it again? What advice would you give to a peds enthusiast pondering the various subspecialties? Thanks for your insight 🙂

 

[14022]

I will be applying for PICU fellowship in July.

Things that drew me to the field...
-work encompasses a wide array of disease processes and specialties
-caring for disease processes based heavily on physiology
-procedure heavy
-no outpatient clinic responsibilities
-depending on the size of your picu and number of faculty members, ability to work part-time in an ICU and part-time in other clinical (eg, sedation) and non-clinical (eg, education, administration, research) activities
-shift work model with no on-call responsibilities outside the unit (you work your butt off when your at work, but once you leave the hospital you won't have patient's parents calling you or having the er call you in for a consult- this makes family life a bit more predictable)
-great salary, especially in the community setting (although community picu is pretty limited in scope and may be boring, and you will work significantly more hours since the size of the unit and number of co-intensivists are much smaller)
-ability to moonlight in other areas of the hospital such as hospitalist or peds er


Lifestyle and rate of burnout is highly dependent on where you work. Many small hospitals may have 3 or 4 intensivists, giving you a Q4 call schedule with little time for activites outside of the ICU. This is very stressful. My hospital has 13 PICU attendings, each having at most 24 weeks of service time a year, and as little as 4 weeks of service time per year. When you are on service, you work 6a-6p for 7 straight days. Call is split up among the remaining attendings who are not on service (5p-7a) so you will have 3 or 4 calls per month. I think this is very doable and allows a lot of time for activity outside the ICU. Most hospitals are trying to go to this model, but many smaller hospitals will not have the volume to accomodate a large attending service.

I think if you are considering specializing, keep in mind that you have to love clinic and you have to love the bread and butter of the specialty. For example, I think pediatric liver disease is one of the most interesting areas of medicine. But as a peds GI doc, the majority of your referrals will be for constipation. Congenital lung anomolies are interesting, but peds pulm will see so much asthma and BPD that you may lose your mind. Congenital heart disease is fascinating, but you are going to see a ton of kids with innocent murmurs, benign chest pain, and palpitations. So keep this in mind when choosing a specialty. Of course you always have the ability to pursue further sub-specialization in peds liver disease or interventional peds cardiology, but this definately ties you to a large academic medical center in a large city, which may not be desireable for some.

 

[edmadison]

I agree with scholes' points and look forward to seeing him on the interview trail next Spring/Summer. Some other things that I like:

Very few BS patients. If they're in the PICU, they're sick and they need you
Support Staff is usually fantastic. In general, the PICUs don't keep crappy nurses around very often.
Unlike adult CCU (aka death's waiting room), the mortality rate is relatively low.

In terms of cons, there is certainly is burn out. To a certain extent, you can become other services' b*tch -- especially cardiac surgery. This depends on the culture of your institution.

Ed

 

[drbetty]

I think if you are considering specializing, keep in mind that you have to love clinic and you have to love the bread and butter of the specialty. For example, I think pediatric liver disease is one of the most interesting areas of medicine. But as a peds GI doc, the majority of your referrals will be for constipation. Congenital lung anomolies are interesting, but peds pulm will see so much asthma and BPD that you may lose your mind. Congenital heart disease is fascinating, but you are going to see a ton of kids with innocent murmurs, benign chest pain, and palpitations. So keep this in mind when choosing a specialty. Of course you always have the ability to pursue further sub-specialization in peds liver disease or interventional peds cardiology, but this definately ties you to a large academic medical center in a large city, which may not be desireable for some.

This is a really great point, thank you, scholes. Good luck with the application process!

 

[CrazyPeds527]

Thanks Scholes and Ed for your awesome points.

Other cool things:
-PICU is a great locale for those who love surgical pathology but hate the OR (like me). This was one of the most fascinating parts of peds surg for me, but i have too much ADD to stand in one place for a long period of time. 🙂
Yes, you can become the "medical management" team for the surgeons, but at the same time, there are many ICUs that have really good relationships with the surgeons from the different subspecialities, and it can actually be a cooperative, team environment (who knew?)

-The ability to subsepcialize or double board exists. There are definitely ID/PICU attendings, PICU/NICU attendings, PICU/Cardiology attendings that do additional fellowship and can become either super subspecialists, research gurus, or even share faculty appointments in both departments. This can be particularly attractive for those who really want to do academic teaching, but dont like research...some places will allow you to spend your 24 or so weeks in the unit and some of your "non-service" time floating to the other speciality in which you are certified.

-Also, given that all fellowships include a research component, some will even allow you to use that time to get a masters degree (MPH, MeD, MBA) if you can show how it will build your long term goals as a physician.

Downsides:
-The stress level can get to some; this can help you in residency figure out if you are the kind of person who likes the fast-paced, high stress atmospheres (PICU, NICU, ED) and whether or not you believe you want to do it for a career. Many people love the PICU or NICU during residency and think about it for fellowship without thinking about the fact that you dont necessarily have the "slow months" that you have in residency when you switch from PICU to adolescent medicine and have time to recover. Then again, this is exactly what is attractive about the field to others.

- Don't forget that this is an area where you will be dealing with death in children. Although the mortality rate is low, it is certainly higher than it would be as a hospitalist or in various subspecialties. You have to be able to deal and cope with this on your own terms.

 

[14022]

Very few BS patients. If they're in the PICU, they're sick and they need you

I agree with this for the most part, but you have to admit, and this may not be your experience as much as it has been mine, outside hospital er's in the community sometimes stretch the truth a bit, and sometimes even lie about the condition of the patient to get them transferred to the PICU and then show up smiling, eating, and playing.

But this is far and away better than the hospitals that indicate that a child is stable for transfer to your general floor then show up in septic shock or status epilepticus. I HATE direct hospital transfers! You never know what is going to show up on your floor in the middle of the night.

- Don't forget that this is an area where you will be dealing with death in children. Although the mortality rate is low, it is certainly higher than it would be as a hospitalist or in various subspecialties. You have to be able to deal and cope with this on your own terms.

This is a great point. And to take it one step further, in the PICU, it is easier to view a child's death as your fault, regardless of whether it really is or not. Children can go from stable to very sick very quickly in the PICU and it is easy to second guess your management decisions in the days leading up to their death or during the code itself. This is unlike heme-onc where you also deal with high mortality, probably even more than in the PICU, but the kids that die are often anticipated long before they pass, which is probably easier to cope with.

 

[WestcoastMedicine]

What are your thoughts on University of Buffalo's Critical Care program. The lead authors (Fuhrman, Zimmerman) of "Pediatric Critical Care" are there.

According to their website:
"Past and ongoing efforts include:
The development of the Guthrie screening test for PKU.
Clinical testing of exogenous calf lung surfactant in premature infants.
First clinical trials with nitric oxide ventilation.
First studies of the use of liquid ventilation for pulmonary oxygen delivery."

On paper it seems like they do great things there in the critical care department, but I have not heard the program come up much in discussion.

 

[BigRedBeta]

Scholes (or anyone else)

Could you discuss a little bit on how competitive it is to get into Peds CC fellowships? I'm well aware that all peds fellowships are less competitive than their adult counterparts, and I've seen the statistics for the 2007 match in which there were fewer applicants than total spots, but can you perhaps explain a little farther what that all means?

What sort of things are CCM fellowship programs looking for?
What makes you a competitive applicant?
What are things that PL-1's and PL-2's interested in CCM need to be doing while interns and residents?
Do programs prefer to be unfilled rather than take candidates they don't feel comfortable with?
What makes for a strong Critical Care program?


Any insight to the process would be great.

 

[14022]

Scholes (or anyone else)

Could you discuss a little bit on how competitive it is to get into Peds CC fellowships? I'm well aware that all peds fellowships are less competitive than their adult counterparts, and I've seen the statistics for the 2007 match in which there were fewer applicants than total spots, but can you perhaps explain a little farther what that all means?

What sort of things are CCM fellowship programs looking for?
What makes you a competitive applicant?
What are things that PL-1's and PL-2's interested in CCM need to be doing while interns and residents?
Do programs prefer to be unfilled rather than take candidates they don't feel comfortable with?
What makes for a strong Critical Care program?


Any insight to the process would be great.

As you pointed out, there are more spots than applicants, so it is VERY limited in its competitiveness, among the lowest of peds subspecialties. Many many great programs go unfilled every year. I must admit, I am not quite sure how specifically you would like me to elaborate, but I guess it says this....if you apply to every PICU program in the US and you have no major red flags on your application then you are guaranteed to match somewhere. Obviously, this statement is a bit facetious, since you are not going to apply to every program...but the numbers are in your favor. It doesn't necessarily mean you are guaranteed to match into the best program, but you are far more likely to get into a great program than you would if applying to cards, ER, or allergy. To give you an example, I know someone who applied for Allergy fellowship and did not match at any of the places they had ranked, and unable to scramble into a program. This person then applied to PICU and matched into one of the best PICU programs in the country (although the program is in a less desireable geographical area).

I think programs are looking for the same people any fellowship looks for. Competent, team-player, motivated, hard-working. For PICU specifically, they want people who can handle stressful situations. If you want to go to the best programs you need good letters of rec most importantly...research helps, leadership experience helps, but lack of either shouldn't stop you from applying anywhere you would like to go.

Most residency programs don't have you do PICU until second year, so there is nothing special that interns should be doing. Just try to learn as much as you can and be as good a resident as possible.

Obviously, all programs want to fill all their spots. But if the applicant is such that the program feels that they are not competent or would have serious interpersonal conflicts with the faculty or other fellows, they would rather go unfilled than accept that person.

When looking at programs the following are some important things that will affect your experience...volume, breadth of medical and surgical patients, relationship of picu with surgical services, research availability.

I would sit down with some PICU attendings at your program also, as they can give you better insight since they have already gone through it.

 

[edmadison]

What are your thoughts on University of Buffalo's Critical Care program. The lead authors (Fuhrman, Zimmerman) of "Pediatric Critical Care" are there.

Jerry Zimmerman is the director of Seattle Children's Hospital's PICU.

I couldn't find much on Buffalo's program. There was no fellowship website that I could locate either. I have no personal experience with Buffalo's program, either peds or PICU.

When I'm looking at programs, there are a few things that jump out. First, how many fellows are there and what services do they cover? I'm looking for a medium to large program. Does the program do everything? Cardiac Surg? Transplant? ECMO? Is the program at a Children's hospital? Does the hospital share their patients with other nearby teaching hospitals?

I also look at the current fellows and at the residents if information is available. If a majority of the housestaff are FMGs that says something about the program. If they list the fellows, look for gaps. Do they usually have 3 yearly and then dropped? If so, why?

Ed

 

[BSN2DOC]

I think the PICU atmosphere is amazing -- the RN's, MD's, and suppport staff work well together.

I work as an RN in an busy Level 1 Trauma Ctr. PICU -- we have 16 PICU beds.. and our intensivists work their asses off. We only have 4 intensivists and they work crazy hours, but they all love their jobs and are very passionate about their work.

 

[CrazyPeds527]

Could you discuss a little bit on how competitive it is to get into Peds CC fellowships?

What are things that PL-1's and PL-2's interested in CCM need to be doing while interns and residents?
Do programs prefer to be unfilled rather than take candidates they don't feel comfortable with?
What makes for a strong Critical Care program?

Something to keep in mind as demographics nationally change for fellowship: our institution has 5 people applying to PICU this year (an intense group!), and all of them have noted how many more applicants there are this year. The smaller programs may still not have very many, however, the competitive CCM programs are competitive. For example, (according to my classmates), Hopkins CCM got on the order of 160 applications and chose to interview about 30 for 3 spots. This may continue to change as a slight shift seems to be occuring nationally (according to some faculty) more towards subspecialty. This is the ebb and the flow of subspecialty versus pirmary care choices of residents.

Some other ask when interviewing for CCM (other comments were excellent):
- Is your research time protected, or are you carrying the pager?
- Is your education time protected?
- How do the subspecialty and surgical services work with you co-managing their patients. Are you in charge as the fellow, or are you the "scut-monkey" for the surgeons
- Can you moonlight? On the wards? PICU? ED? (This may be important for some)

 

[edmadison]

I have a message for all the PICU program directors out there:

Make sure you have a good website!

In preparation for the coming application season, I have been using FREIDA to look at programs. Some programs have no website link in FREIDA, others have dead links. Still more are plagued by being hidden on a hospital or medical school's website. Many websites have very little information on them. It's very frustrating for the potential applicant. Sell your program! There are enough programs and not enough applicants. We may get so frustrated by this that we'll just cross your program off the list. Don't let it happen to you.

Ed

 

[oldbearprofessor]

I have a message for all the PICU program directors out there:

Make sure you have a good website!

Ed

I could be wrong, but I bet that most PICU PDs who don't have a good website are not on SDN either.😎

 

[edmadison]

I could be wrong, but I bet that most PICU PDs who don't have a good website are not on SDN either.😎

Yeah, I thought about that when I wrote my rant. Hopefully, a "friend" will tell them.

The paradox does remind me of a funny commercial they show on American Forces Network. It shows you how to hook up your signal decoder. But if you don't have the decoder working, you cant see the commercial.



Ed

 

[Ponyboy]

Scholes (or anyone else)

What are things that PL-1's and PL-2's interested in CCM need to be doing while interns and residents?
Do programs prefer to be unfilled rather than take candidates they don't feel comfortable with?
What makes for a strong Critical Care program?

Any insight to the process would be great.

There are a few things that all PICU fellowships need to have.
1. Medical/Surgical ICU: This is the bread and butter PICU stuff. Liver transplants, heme/oncer's, respiratory distress, crazy ortho/ENT/neurosurgery operations. All of these should be present in the PICU and therefore, all of these subspecialties should be represented. Burns is a plus/minus. Most PICU's in the country are closed units and so the PICU team is usually the primary team for all of the patients in the unit.
2. Cardiac ICU: Every PICU program should be associated with a pediatric cardiothoracic surgery program. I would say that each program should see at least 250 cases a year and that should include single-ventricle physiology. On top of that, who runs the CICU should also be examined. In some programs, the PICU fellow is a guest in the CICU while it's run by the cardiology fellows. In others, vice versa. Also, who covers the CICU is also an issue. In some programs, the ICU fellows cover both the MICU and the CICU every night on call. In others, the ICU fellow only covers the CICU for two months of the year.
3. Trauma: This could also be part of the Medical/Surgical ICU part but warrants its own discussion. Traumatic Brain Injury is a basic part of PICU medicine and any PICU that has a fellowship should be THE pediatric trauma center for the region. The PICU fellows role in the trauma bay should also be addressed. Do they cover the airway? Who runs the trauma?
4. Transport: Transport is simultaneously fun, exciting and potentially a waste of time. You can spend hours flying around to pick up a kid who just has respiratory distress. Nonetheless, fellows should gain experience, at the very least, being the control doctor for flight teams.
5. Volume: There's no such thing as learning about patients by reading about them. You need to see a lot of patients. Your clinical time should be busy. Intubations, art lines and central lines (especially IJ's and subclavians) are something that you need to be comfortable with when you're done a fellowship.

That's the clinical part. The other parts of a fellowship include:
1. Teaching: How and when are didactic sessions?
2. Research: This is really important. You need to decide if you're a basic scientist, a clinical scientist, an educator, or none of the above. Once you figure this out, you should look for programs that have what you're interested in. I made the mistake of applying to programs that were big names but extremely basic science driven while I wanted to do epidemiological research. Additionally, you need to make sure that there are faculty members who are doing stuff that you're interested in. If you're interested in TBI, make sure that there is someone who is doing research that you could see yourself participating in.
3. Location, lifestyle, blah blah blah. You've done this for residency. You know the drill.

 

[oldbearprofessor]

2. Research: This is really important. You need to decide if you're a basic scientist, a clinical scientist, an educator, or none of the above. Once you figure this out, you should look for programs that have what you're interested in. I made the mistake of applying to programs that were big names but extremely basic science driven while I wanted to do epidemiological research. Additionally, you need to make sure that there are faculty members who are doing stuff that you're interested in.

I agree that research is a key aspect of picking any pedi fellowship not just PICU. I also agree that one should look for philosophy of research - are they determined to see that every fellow does basic science? Do they have options for research outside of "their" group? If you want to do research in something in, for example, infectious diseases, but you're a fellow in PICU, can you have an ID attending as a mentor?

However, the reality is that, for the overwhelming majority of fellowship applicants in pedi fields (not just PICU, NICU), they are too undifferentiated during their PL-2 and early PL-3 year to really know what they are most interested in or to assess whether any given program has mentors "close enough" to their interests. Also, many applicants will want to/be willing to give a shot at basic science even though they have little or no experience at it and can't assess mentors and projects well. Epi research is also of increasing interest, but tough to fit into in a career development approach during a 3 year fellowship with so much clinical work. Few epidemiology mentors are prepared in my experience to fit a project into the lifecycle of a pedi fellow doing this much clinical work/call.

So, although it's true that picking a fellowship based on research compatibility is a great idea, having watched this process with a lot of folks, I'm unconvinced this is very easy or possible to do. Sure, I agree you might be able to avoid a complete misfit - but beyond that, it's nearly impossible to do. Even if you think you've found the perfect mentor - they may decide not to accept you in the lab for a variety of good reasons (no appropriate project, leave of absence, etc) and of course on the interview circuit you'll never have enough chance to find mentors who might be great outside the group you're interviewing with.

So, how should the applicant assess this in practical terms on the interview trail?

 

[BigRedBeta]

Big thank yous for all the great information in this thread! Lots of things to think about and remember for the future.

 

[Stitch]

Great thoughts here, and I wanted to ask a couple more things.

To give context, I just graduated residency and am a hospitalist for now until my wife finishes her residency in the next three years. Then we're both planning to apply for fellowship (she's doing peds, then ER). I've been interested in PICU for some time and managed to see a lot of the CT surgeriers, including ECMO and single ventricle stuff from a resident's perspective in an institution without fellows. I've been thinking of applying to PICU or just redoing a residency in anesthesia and doing peds anesthesia since the care and procedures are similar. On the whole though I'd miss the asthmatics, diabetics, post op managements. The 'real' peds stuff.

How much is the post op cardiac stuff being run (or going to be run) by cards instead of PICU? I understand that it's likely institution dependent, but is the trend moving more towards CICU only?

Also how tied to doing research are you when you're done? For the fellowship I'm definitely interested in doing some research, but long term, I really don't want to publish and would be focused much more on education and teaching in a clinical setting. Do those jobs exist?

 

[rollin4thyear]

Wanted to comment a little regarding the buffalo PICU as I did a rotation there while in medical school. It was a great experience to learn under Dr. Furhman and other attendings at Buffalo. They all were solid teachers and if you are a PICU fellow, you would be able to become involved with many research projects with them.

As far as the unit, I really liked the unit! There was a wide range of pathology including trauma, NSGY, Heme/onc, respiratory, etc...just about everything. Buffalo has high volume as it draws patients from all over western NY and sometimes Canada. The one thing I don't remember much of was Cardiothorasic surgery and that was 3 years ago when I did the rotation, so maybe it changed. HOwever, we did have a kid on ECMO during my rotation, so someone had to canulate him.

As far as the fellows go...I know that they were able to get involved with many lines...Alines, central lines, chest tubes, etc. The fellows seemed happy and enjoyed their experience when I was working with them there.

Overall, I think Buffalo is underrated for its residency program and its fellowships and anyone should at least consider it for their training.

 

[tcar18]

can someone give a rough idea of proceedures done regularly in the picu?
other than picc's and centrals.