PICU vs MICU (complexity of management/procedures/on-your-feet thinking, etc)

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GotToGetThatGPAUp

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Hey all,

I was deadset on EM/PEM when I first entered med school, then the wave of doom and gloom had me switch focus and I tentatively looked towards Med/Peds. As I've gone through my rotations, I loved working with kids, I loved working with complex problems, and I loved the MICU. The thing is, I wont be able to get any PICU experience until after ERAS, and so deciding between IM and Peds is becoming difficult (Med/Peds really just being a back-up due to decision crisis heh).

So how does the PICU compare to the MICU? I personally enjoy treating kiddos more than adults, probably like a 70/30 teeter towards kiddos. I also prefer children's hospitals and the culture therein, at least with my experience you find a lot more driven folks and a lot less complaining about patients. However, I really enjoy the cerebral sitting down and management of complex conditions, the occasional split decision life-saving decisions/resus, and the procedures I get to do in the MICU. It also pays better which is a bonus, though to be frank i dont know how much the salaries actually differ and I don't think it'd alter my lifestyle much anyways.

Also I know folks say don't go for a subspecialty if you can't enjoy the specialty. I enjoy peds, I actually really enjoy office visits and just meeting with and talking with patients, well-child is fun and rewarding even if parts may get mundane I enjoy talking to the patients and parents. As for IM, I enjoy hospitalist work and could go into primary care easily enough.

Any input would be super appreciated <3

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From a medical complexity standpoint, there’s not really that much difference. The most complex adult patients are comparable to the most complex children, there’s just less of children that have MODS. In both situations you have to deal with difficult families and the care of the chronically critically ill. Some procedures can be challenging in both, but getting central IV access is easier in bigger people.

The biggest difference is probably the job market. There’s more jobs and more community positions in adult ICU than pediatrics.

At least from my standpoint, I picked kids over adults because kids are never really responsible for their disposition, where as adults, life (and illness) is can often be a lifetimes result of bad decisions. Like a pediatric COVID patient whose parents refused to vaccinate them versus an adult COVID patient who willfully refused vaccination. Makes it easier to sympathize.
 
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You will get the medical complexity, the resuscitation and procedures and the time to think about puzzling cases in various ratios that very greatly based on the specific PICU (academic vs community, size, ECMO capabilities, transplant capabilities, ect). I have never works or rotated in a MICU, but the things you list are definitely found in PICUs. Plus it sounds like you would enjoy the Peds residency much more.

In addition to the benefits listed above, kids also survive things that adults never would. And when a healthy kid comes in with an acute issue they often never come back and go on to live for decades and decades.

Even if you cannot do a full rotation can you go shadow for a few days in a PICU before ERAS is due to get some exposure?
 
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Even if you cannot do a full rotation can you go shadow for a few days in a PICU before ERAS is due to get some exposure?
Thanks for the input everyone!

As for this, I've reached out to a couple folks and hopefully will be able to get in a weekened soon in the PICU at a local children's hospital
 
25% mortality rate (or higher) or 3%? Angel of Death or having nearly all of your patients get better?


Asking in a peds forum is going to give you a biased account obviously, but I think there are some very objective things to consider. Mortality is just one of several examples and what that means for your typical day. I think all of us here in this forum will tell you that taking care of kids has major advantages over adults, otherwise we wouldn't be pediatricians.

It's hard, but I also think it's important to consider what life is like when you are no longer a trainee or early career attending. There comes a point when lines and tubes and drains are no longer exciting, a threshold where because of everything else you have going on (your own kids/family/research/administration) a day with fifteen bronchiolitics on 12LPM of high flow is more desirable than an intellectually challenging crashing/burning patient.

In addition to overall job numbers, it's also the types of jobs available. PICU jobs are 90%+ academic, which comes with its own set of considerations. PICU jobs are also much more concentrated in major cities. Depending on your background, the flexibility to be in smaller cities may be a priority for you.
 
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25% mortality rate (or higher) or 3%? Angel of Death or having nearly all of your patients get better?


Asking in a peds forum is going to give you a biased account obviously, but I think there are some very objective things to consider. Mortality is just one of several examples and what that means for your typical day. I think all of us here in this forum will tell you that taking care of kids has major advantages over adults, otherwise we wouldn't be pediatricians.

It's hard, but I also think it's important to consider what life is like when you are no longer a trainee or early career attending. There comes a point when lines and tubes and drains are no longer exciting, a threshold where because of everything else you have going on (your own kids/family/research/administration) a day with fifteen bronchiolitics on 12LPM of high flow is more desirable than an intellectually challenging crashing/burning patient.

In addition to overall job numbers, it's also the types of jobs available. PICU jobs are 90%+ academic, which comes with its own set of considerations. PICU jobs are also much more concentrated in major cities. Depending on your background, the flexibility to be in smaller cities may be a priority for you.
At this juncture, I live for the bronchiolitics and DKAs…
 
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I have worked in both so I can offer you a balanced perspective.

Kids get better mostly which is gratifying. They have interesting physiology and hide their degree of illness better which makes decision making both challenging and interesting. A lot of critical illness looks the same in small kids which can make diagnosis challenging. Congenital heart disease is unmatched in terms of cool physiology.

However c/w adults Procedures and lines can be a nightmare. The primary teams try to interfere in your decision making too much (especially surgeons). I found that a lot of people who work with kids are chronically stressed out. And there’s a lot of moral injury because people find it hard to say “stop” when it comes to children. You see a lot of the effects of poverty.

Adults are more medically complex and have a broader range of things that go wrong with them. 90% have underlying comorbidities as well as what made them critically unwell. People are generally happier to say “grandma had a good life, we can skip the ecmo”. Good palliative care can actually be an extremely rewarding part of the job.

Difficult airways are much more unpredictable (whereas normal looking kids are generally easy and funny looking ones generally aren’t). You see a lot of effects of bad lifestyle. Adults have a hard time returning back to their baseline level of function after critical illness (things like critical illness weakness/neuropathy seem to last forever). There’s a lot of death.

This is from the point of view of someone who trained primarily in intensive care rather than medicine vs peds.
 
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