PICU job market worries

[dreeyore]

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Hi everyone

Current peds resident, at a point where I have realized I don’t really enjoy anything else except PICU but have heard recently of how terrible the job market is. When I speak to attendings they reassure me and say that markets fluctuate over time and not to make a decision based on that. So I guess my question is, for PICU attendings / fellows, have you seen or heard of this to be true? Can I be hopeful that in 6 or so years from now the market may improve?

Edit: are job prospects any better for CVICU? I understand you now need extra training in cardiology as well to do this.

 

[luckysharm411]

Hey I'm a current new PICU attending, graduated last year. You are right that the job market is crap right now. It is better in CICU as that is where the money is and most places growing their cardiac surgery programs and creating separate CICUs that need to be staffed. However the pre-req for that is 1-2 years of specialized fellowship after general PICU training and you have to LOVE it. Its honestly really challenging because those are often neonates with complex physiology and the outcomes depend heavily on the quality of the surgery. Often a situation of "too many cooks in kitchen." But yes there are jobs.

If you want an academic general PICU job its extremely competitive in the big centers and coasts without significant research experience, a research niche, a history of QI or something that makes you special. PICU itself is a very challenging clinical fellowship and so I personally had a research project I was passionate about that received a lot of accolades but it still wasn't enough to propel me to a big center. Have been advised to pursue a masters degree and get involved in QI to advance my career which is a tough thing to do in the current political climate. Yes the market can fluctuate but with a lot of places on hiring freeze and super competitive general PICU market you have to do something that distinguishes yourself to get a job if you are geographically limited. There are jobs in the midwest but smaller more community PICUs where there isn't a ton of super high acuity (ECMO, CRRT) because those get transferred out to bigger centers. No one can predict the future. If you are at a big center one piece of advice is to consider a PICU hospitalist role, build some connections with your PICU faculty if you like it there, stay for fellowship and then try to stay on as junior faculty. Making connections oftentimes is more helpful or taking time to pursue and build up the research angle because all of us are graduating with the same PICU skills into a market that is saturated and vying for research. My 2 cents.

 

[SurfingDoctor]

Its also not wrong to go into a smaller or more community-based center for a couple years. For one, the pay tends to be better. Two, if you are already employed, you have the opportunity to apply for a job at whatever part of the year you want, as opposed to straight-from fellowship jobs when you can only apply and be hired at a specific time.

Most often, jobs open up randomly when someone either leaves an institution or retires or there is a hospital-practice expansion. Those jobs opening up aren't based on July 1st in any capacity and much more often, the institution and division would much rather fill that spot immediately rather than 6 months from then.

 

[dreeyore]

Hey I'm a current new PICU attending, graduated last year. You are right that the job market is crap right now. It is better in CICU as that is where the money is and most places growing their cardiac surgery programs and creating separate CICUs that need to be staffed. However the pre-req for that is 1-2 years of specialized fellowship after general PICU training and you have to LOVE it. Its honestly really challenging because those are often neonates with complex physiology and the outcomes depend heavily on the quality of the surgery. Often a situation of "too many cooks in kitchen." But yes there are jobs.

If you want an academic general PICU job its extremely competitive in the big centers and coasts without significant research experience, a research niche, a history of QI or something that makes you special. PICU itself is a very challenging clinical fellowship and so I personally had a research project I was passionate about that received a lot of accolades but it still wasn't enough to propel me to a big center. Have been advised to pursue a masters degree and get involved in QI to advance my career which is a tough thing to do in the current political climate. Yes the market can fluctuate but with a lot of places on hiring freeze and super competitive general PICU market you have to do something that distinguishes yourself to get a job if you are geographically limited. There are jobs in the midwest but smaller more community PICUs where there isn't a ton of super high acuity (ECMO, CRRT) because those get transferred out to bigger centers. No one can predict the future. If you are at a big center one piece of advice is to consider a PICU hospitalist role, build some connections with your PICU faculty if you like it there, stay for fellowship and then try to stay on as junior faculty. Making connections oftentimes is more helpful or taking time to pursue and build up the research angle because all of us are graduating with the same PICU skills into a market that is saturated and vying for research. My 2 cents.

Thank you so much for this insight/ advice. Are PICU hospitalist positions at bigger hospitals willing to take on PICU docs? Obviously not ideal to act as a continuous fellow or resident in that role but I imagine you could continue to do research/ make connections that way and hopefully they’d take you on when someone retired.

For CICU- I really enjoy cardiology but I do worry about contentious relationships with surgeons as I’ve seen an unhealthy dynamic when I’ve shadowed (to your point about “too many cooks”). I wasn’t sure if this was a widespread issue or just at my medical school. What has your experience been with this if you don’t mind sharing?

 

[dreeyore]

Its also not wrong to go into a smaller or more community-based center for a couple years. For one, the pay tends to be better. Two, if you are already employed, you have the opportunity to apply for a job at whatever part of the year you want, as opposed to straight-from fellowship jobs when you can only apply and be hired at a specific time.

Most often, jobs open up randomly when someone either leaves an institution or retires or there is a hospital-practice expansion. Those jobs opening up aren't based on July 1st in any capacity and much more often, the institution and division would much rather fill that spot immediately rather than 6 months from then.

Hello- thanks for your time and advice ! My concern about starting out at a community hospital would be that larger academic centers wouldn’t hire me down the line as opposed to someone who had experience in academics after fellowship. And that the limitations with research at smaller facilities would hinder my ability to get a job elsewhere do. Have you found this to be true?

 

[SurfingDoctor]

Hello- thanks for your time and advice ! My concern about starting out at a community hospital would be that larger academic centers wouldn’t hire me down the line as opposed to someone who had experience in academics after fellowship. And that the limitations with research at smaller facilities would hinder my ability to get a job elsewhere do. Have you found this to be true?

Well, honestly, having been doing this for over a decade, the number of people who come from the community to academics is small. Like I can count on one hand. And that's specifically for the reason I mentioned. If you are making decent money in the community, seeing less sick pathology, why would you want to take a pay cut to see more sick patients? Now, academic centers are more urban of course, and because the number of shifts tend to be less, there is slightly more flexibility, but that's not always a really good sell. But for the reasons I mentioned, someone who had been doing this for 3 fellowship years, but 2-3 years of actual practice, has nearly double the experience of someone fresh out of fellowship. AND they can be hired at the drop of a hat. What's not to love?!

As far as skill, meh. Can you turn up a vasoactive drip and wean a ventilator? Can you put a needle into a big-ish vein and place a catheter? I mean, we really shouldn't pretend there is some great knowledge-based skillset in ICU. Fundamentally, intensivists are physiologists who sometimes can correct the physiology with the 5 things you have in your toolbox, but just mostly dependent on the patient getting better on their own (or not).

 

[SurfingDoctor]

Thank you so much for this insight/ advice. Are PICU hospitalist positions at bigger hospitals willing to take on PICU docs? Obviously not ideal to act as a continuous fellow or resident in that role but I imagine you could continue to do research/ make connections that way and hopefully they’d take you on when someone retired.

For CICU- I really enjoy cardiology but I do worry about contentious relationships with surgeons as I’ve seen an unhealthy dynamic when I’ve shadowed (to your point about “too many cooks”). I wasn’t sure if this was a widespread issue or just at my medical school. What has your experience been with this if you don’t mind sharing?

You really shouldn't be taking a PICU hospitalist job as someone who is PCCM board-eligible/certified. You are significantly hampering your earnings for no benefit.

 

[dreeyore]

Well, honestly, having been doing this for over a decade, the number of people who come from the community to academics is small. Like I can count on one hand. And that's specifically for the reason I mentioned. If you are making decent money in the community, seeing less sick pathology, why would you want to take a pay cut to see more sick patients? Now, academic centers are more urban of course, and because the number of shifts tend to be less, there is slightly more flexibility, but that's not always a really good sell. But for the reasons I mentioned, someone who had been doing this for 3 fellowship years, but 2-3 years of actual practice, has nearly double the experience of someone fresh out of fellowship. AND they can be hired at the drop of a hat. What's not to love?!

As far as skill, meh. Can you turn up a vasoactive drip and wean a ventilator? Can you put a needle into a big-ish vein and place a catheter? I mean, we really shouldn't pretend there is some great knowledge-based skillset in ICU. Fundamentally, intensivists are physiologists who sometimes can correct the physiology with the 5 things you have in your toolbox, but just mostly dependent on the patient getting better on their own (or not).

This may sound absurd, and is probably naive of me, but I would honestly rather be paid less and get to work with higher acuity / have an opportunity to teach and do research than make more in a lower acuity / smaller setting.

 

[SurfingDoctor]

This may sound absurd, and is probably naive of me, but I would honestly rather be paid less and get to work with higher acuity / have an opportunity to teach and do research than make more in a lower acuity / smaller setting.

To each their own I suppose. You've worked long and hard, but want to be paid as an NP, that's certainly an option.

The other alternative is to do part-time PICU. Also makes less and since you are part-time, so you don't get benefits. But you get your foot in the door for when I job opens up. In reality though, the only time I've seen that work is when the spouse is more desirable than the intensivist and the institution uses some nepotism to force it to happen. But it does happen.

 

[dreeyore]

To each their own I suppose. You've worked long and hard, but want to be paid as an NP, that's certainly an option.

The other alternative is to do part-time PICU. Also makes less and since you are part-time, so you don't get benefits. But you get your foot in the door for when I job opens up. In reality though, the only time I've seen that work is when the spouse is more desirable than the intensivist and the institution uses some nepotism to force it to happen. But it does happen.

I definitely do not want to be paid less than what I’m worth, just trying to figure out what I can do to optimize my chances of getting the job I initially hoped for 🥲 I thought PICU attendings in academic centers still get paid decently. Money aside I appreciate you taking the time to share all of this with me it has been super helpful for strategizing next steps.

 

[SurfingDoctor]

I definitely do not want to be paid less than what I’m worth, just trying to figure out what I can do to optimize my chances of getting the job I initially hoped for 🥲 I thought PICU attendings in academic centers still get paid decently. Money aside I appreciate you taking the time to share all of this with me it has been super helpful for strategizing next steps.

Yes, they get paid better than other pediatric academic counterparts.

They also sleep in the hospital though.

 

[luckysharm411]

I was a PICU hospitalist between residency and fellowship. There are also CICU hospitalist roles. Columbia is an example of a place that has this and I'm sure others do as well. These do not require you to be fellowship trained. Many people do this for a year prior to starting PICU or CICU fellowship. If you like cardiology and want to understand if the CICU culture is the one for you, then maybe that's something to consider. Critical care fellowships are competitive and a lot of people come after doing a chief year so this is a way to avoid administrative work, build up your competitiveness, and decide if you love CICU or general PICU. For me, going from residency to almost a "gap year" helped solidify my interest in PICU, helped me gain some contacts, understand the dynamics of PICU, and also gave me some time off from rigorous training, earn some extra money, have a decent schedule where I could study AND pass my peds boards (so I didn't have to worry during fellowship when you are working WAY harder). There are also options to take a PICU hospitalist role after critical care fellowship and there are some people who would do that if it means they get to live in the place they want to be, are near family, maybe have a spouse who needs to be in a certain area, work a slightly less rigorous schedule, etc. There are more facets to life than money and you have to prioritize for yourself what is important to you. Personally I've had co-fellows who finished fellowship consider PICU/CICU hospitalist roles...agree that pay is less but maybe you're a new parent and can't do the crazy PICU schedule. Maybe you're restricted geographically. Maybe you need a break after a fellowship that is super demanding and emotionally/physically exhausting. Maybe you just need a job because, like the topic of this post, the market is trash. Who cares? The only person who lives your life is you.

CICU culture to me is the same everywhere. Not a walk in the park. Surgeons can be mean. Cardiologists can think of things differently and be helpful or not at all. PICU people have a different skillset and personally a more holistic approach because we have to think of cardiopulmonary interactions, the brain the kidneys and not only the heart. But some people thrive. VADs are cool. ECMO is cool. Heart failure and transplant and congenital heart disease is cool. Interventional is cool. But babies and children are sick and good and bad outcomes are everywhere. It's all about exposing yourself to it and understanding if you feel good in the environment or not.

As someone who went to a small place that has a community/academic feel after training at a big center, I can say I do miss the higher acuity. I do not miss the volume. I do not miss the challenging consultants. Here, I am able to teach pediatric residents and do research but on my own time and when I want to do it, without the pressure of having to have big grant funding. But I don't see ECMO/cardiac, I rarely do CRRT and I do miss being part of the care of those patients. I do not love the location of where I am and struggling to find ways to fill my spare time. I'm lonely. I miss my family. I am homesick. Sadly, there is no perfect job, and you can't have everything all at once. Hope this helps.

 

[dreeyore]

I was a PICU hospitalist between residency and fellowship. There are also CICU hospitalist roles. Columbia is an example of a place that has this and I'm sure others do as well. These do not require you to be fellowship trained. Many people do this for a year prior to starting PICU or CICU fellowship. If you like cardiology and want to understand if the CICU culture is the one for you, then maybe that's something to consider. Critical care fellowships are competitive and a lot of people come after doing a chief year so this is a way to avoid administrative work, build up your competitiveness, and decide if you love CICU or general PICU. For me, going from residency to almost a "gap year" helped solidify my interest in PICU, helped me gain some contacts, understand the dynamics of PICU, and also gave me some time off from rigorous training, earn some extra money, have a decent schedule where I could study AND pass my peds boards (so I didn't have to worry during fellowship when you are working WAY harder). There are also options to take a PICU hospitalist role after critical care fellowship and there are some people who would do that if it means they get to live in the place they want to be, are near family, maybe have a spouse who needs to be in a certain area, work a slightly less rigorous schedule, etc. There are more facets to life than money and you have to prioritize for yourself what is important to you. Personally I've had co-fellows who finished fellowship consider PICU/CICU hospitalist roles...agree that pay is less but maybe you're a new parent and can't do the crazy PICU schedule. Maybe you're restricted geographically. Maybe you need a break after a fellowship that is super demanding and emotionally/physically exhausting. Maybe you just need a job because, like the topic of this post, the market is trash. Who cares? The only person who lives your life is you.

CICU culture to me is the same everywhere. Not a walk in the park. Surgeons can be mean. Cardiologists can think of things differently and be helpful or not at all. PICU people have a different skillset and personally a more holistic approach because we have to think of cardiopulmonary interactions, the brain the kidneys and not only the heart. But some people thrive. VADs are cool. ECMO is cool. Heart failure and transplant and congenital heart disease is cool. Interventional is cool. But babies and children are sick and good and bad outcomes are everywhere. It's all about exposing yourself to it and understanding if you feel good in the environment or not.

As someone who went to a small place that has a community/academic feel after training at a big center, I can say I do miss the higher acuity. I do not miss the volume. I do not miss the challenging consultants. Here, I am able to teach pediatric residents and do research but on my own time and when I want to do it, without the pressure of having to have big grant funding. But I don't see ECMO/cardiac, I rarely do CRRT and I do miss being part of the care of those patients. I do not love the location of where I am and struggling to find ways to fill my spare time. I'm lonely. I miss my family. I am homesick. Sadly, there is no perfect job, and you can't have everything all at once. Hope this helps.

Thank you for taking the time to give such a thorough response / answer pretty much all of my questions- I really appreciate it. This is very helpful. I’m going to try and get some elective time in the CICU to see if I enjoy it.

It makes me sad to think that after all of these years of hard work and sacrifice I could end up so far away from home/ in a setting that isn’t what I hoped for. That’s life I guess. When I entered med school I was often reassured that this field had job security like no other, which is still mostly true, but sounds like not what it used to be. Anyway, for what it’s worth, I hope you’re able to find something closer to your support system soon. 🙁

 

[luckysharm411]

Keep your chin up. Just because life doesn't pan out the way you *think* it will, that doesn't mean it's bad. Being able to shift gears and adapt and having back-up plans will serve you in PICU and your life! PICU is a good career, but its very tough. Right now the job market is not great. Try to find things that you are passionate about that will help you distinguish yourself. We are all graduating from training with the same skills so focus your efforts on something in the academic realm, be it novel research, QI, perhaps an interest/certificate in ethics, public health, etc. And/or build up some connections where you are/want to be. And you will go far and you will find a way to be happy. Its only a job and while jobs are a big piece of our life, who we are as people outside of work helps us be better doctors, so don't lose sight of that. Best of luck 🙂

 

[BigRedBeta]

Apparently never actually hit post on the reply I had typed out.

Market fluctuates, but in 10 years since I graduated fellowship there's never been a "great" year, only ranging from terrible to mildly poor. It's no where near Heme/Onc with graduating fellows going back to general peds for gainful employment...but it's also not Nephro where there are probably 100 open positions nationally, all begging for someone to come help them.

Additional fellowship years in ECMO, Sim, or obviously CICU help. CICU though is not as big as boost as it used to be though as the larger centers are reaching full staffing.

I'd be hesitant to look at very small centers with low acuity directly out of fellowship as there's still a lot of growth to be had in the first 2-3 years out of fellowship. Taking care of nothing but bronchiolitics on 8LPM HFNC or routine DKA is not going to progress your skill/decision making/comfort. However, units of 8-12 beds with enough subspecialty support to keep some interesting things in town do exist and can likely suffice. All in the details.

Absolutely need to approach fellowship as preparation for the next job, building skills that will set you apart come interviews- and the more broad based that special skill is, the better your odds. It's fine to have a niche you're passionate about, but that can paradoxically limit your options. For example, transport medicine was my passion, but I got exactly one interview because of it. Every place else, I was interviewed because I was a board eligible warm body and I had to demonstrate other skills as soon as they said "oh Dr. so and so is in charge of our transport team". If I was going through fellowship now, I would be charging hard in the direction of formal QI training or prioritizing programs that were churning out graduates with Masters in Med Education - both of which are things nearly every department needs as many as they can get. I could still be passionate about transport but would be able to explain better how my more formal credentials could benefit the division more broadly.