If anyone knows they want to go into a procedurally heavy field (NICU/PICU/Cards/PEM) prior to starting residency, they should search out programs that actually encourage residents to get enough exposure at procedural skills. They do exist, though they are increasingly rare. That said, I also think any general pediatrician who is thinking about a more exurban or rural practice location should also consider places with the expectation for becoming procedurally sound. Not going to become a complete airway expert in the span of a 3 year peds residency, but should feel comfortable enough to attempt in an emergent situation. I fully believe that all graduating peds residents should be able to place a proper splint, do simple laceration repair, straight forward I&D, complete an LP on a febrile neonate, place a UVC, intubate a newborn and most importantly Bag-valve Mask a patient of any size. The change in meconium aspiration protocols has certainly altered the airway skills of pediatric residents. Other things like peripheral arterial lines, ultrasound exams, CVL's, PICC's, chest tubes are not bread and butter enough outside of the ICU's to be an absolute necessity.
Newsflash - this means actively avoiding programs at the biggest names. Look for places with some but not a full complement of fellowships (e.g. Neo and PEM but no PICU). Ask specifically during interviews multiple people how procedures are divided up. Drop places that say things like "fellows do everything" or "well if you really want them you can get them" and focus on places that say "interns get the first shot". Pick places that give more time in the ED. Look at places sending people to these specific fellowships year after year. Stay away from places that advertise things like cast technicians or suture techs in the ED that are literally paid to take away your learning opportunities.
If you are already in residency and only now figuring out you are heading into one of these fields, then shout it from the rooftops. Ask every attending and fellow you run into to let you do the procedure. People will help you if they know they should. If you can, try to schedule rotations in your desired field in the 2nd half of the year so that you have given the first year fellows time to accrue procedures and make them more prone to let you try. If your program's holiday schedule needs coverage in your desired unit, volunteer to your Chiefs that you want that time - true story I got essentially an extra 2 weeks of PICU time by volunteering for nights in the unit for the holidays - was easily some of the most fun times because I never had to sit through rounds, only complete H&P's, spent one on one time with the fellows to pick their brains, and got first crack at a lot of procedures (I did my first chest tube, my first unsupervised arterial line, and my first IJ during the holidays).
If it's too late for all of this...well, NICU, cards, and PICU fellowships are designed to get you technical skill to function independently. The evidence for proficiency in PEM fellowships is less certain...
