Rural, Small City Pediatric Residency Programs

[Staphylococcus Aureus]

Anyone know of a list/opinions of programs with good rural peds focus, or even simply programs that are not in big cities (say <150k population)? Thank you!

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[SurfingDoctor]

Anyone know of a list/opinions of programs with good rural peds focus, or even simply programs that are not in big cities (say <150k population)? Thank you!

I don't have list perse (FRIEDA would probably create the best list), but I think midwestern programs with a small number of resident per class would probably give you that. There has been data showing that programs with a small number of residents do more outpatient and advocacy work.

https://www.aap.org/en-us/professio...ospital-Status-on-Ped-Residency-Training.aspx

The board pass rates are typically lower at smaller programs, but I suspect that is a reflection of the applicants (who probably have lower Step scores and thus lower board pass rate) and not a reflection of the training. Additionally, in a small, midwestern program I would imagine you could set up a continuity clinic in a quite rural area.

 

[SurfingDoctor]

Additionally, some places have rural training tracks. Likely not pediatric specific, but there would be precedence at least...

https://www.traindocsrural.org/pdf/train-rural-handbook.pdf
(On page 8)

 

[Perrotfish]

Anyone know of a list/opinions of programs with good rural peds focus, or even simply programs that are not in big cities (say <150k population)? Thank you!

The weird thing about rural Peds is that the way you get ready for it is to do as many rotations as possible through a high acuity, procedure heavy NICU. Its not the clinic that gets you, its being on call for every delivery related catastrophe in your hospital. I'm not sure that rotating through a rural area would do a very good job of getting you ready to work in a rural area.

 

[Staphylococcus Aureus]

The weird thing about rural Peds is that the way you get ready for it is to do as many rotations as possible through a high acuity, procedure heavy NICU. Its not the clinic that gets you, its being on call for every delivery related catastrophe in your hospital. I'm not sure that rotating through a rural area would do a very good job of getting you ready to work in a rural area.

Interesting, so inpatient heavy at a larger hospital may be more beneficial?

I ask because I want to practice rural peds but also do residency in a smaller city.

 

[Perrotfish]

Interesting, so inpatient heavy at a larger hospital may be more beneficial?

I ask because I want to practice rural peds but also do residency in a smaller city.

Really just heavy inpatient NICU at a larger hospital. PICU and wards time aren't particularly helpful. More clinic/Peds ED and less wards/subspecialty time would be more helpful for your clinic, but honestly rural clinic isn't terribly hard to figure out. What is difficult is nursery call.

The big difference between rural Pediatrics and urban Pediatrics is that a rural Pediatrician normally is on call for emergencies in the local delivery room and newborn nursery, with a neonatologist 2 hours away in a best case scenario. It takes a lot of NICU months to do enough Neonatal resuscitation that you get comfortable with it. 5-6 months of NICU and a month of Pediatric Anesthesia is a good goal if you want to practice rural Peds.

 

[Mountaineer12]

My home program of WVU may be something worth looking into if West Virginia isn't too rural for you. There's 6 peds residents and 4 med/peds a year. The wards are about 30 beds, PICU is large at around 20 beds, NICU probably has 40-50ish. They're just opening a new peds ED pod, too. Almost all subspecialties are represented. Lots of opportunities for rural medicine even though Morgantown is more of a suburban town (about 60,000 people with the college students). Rural medicine is one of the pillars of our med school.


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[mvenus929]

It takes a lot of NICU months to do enough Neonatal resuscitation that you get comfortable with it. 5-6 months of NICU and a month of Pediatric Anesthesia is a good goal if you want to practice rural Peds.

With the clarification that the extra NICU months are those attending deliveries. At my program, the NICU residents stay in the NICU, and the SCN residents are the ones who attend deliveries. But the SCN residents do less lines than the NICU residents, which is also a useful skill to have if you're far away from a NICU. So be sure to clarify when you go on interviews.

 

[Staphylococcus Aureus]

Thank you all. Any other general advice on rural peds for a med student (i.e. 4th year electives, ECs)?

 

[Perrotfish]

With the clarification that the extra NICU months are those attending deliveries. At my program, the NICU residents stay in the NICU, and the SCN residents are the ones who attend deliveries. But the SCN residents do less lines than the NICU residents, which is also a useful skill to have if you're far away from a NICU. So be sure to clarify when you go on interviews.

I agree its about attending deliveries. I will disagree that lines are actually that useful. For all the emphasis our Neonatologists placed on them I have done exactly none in 2 years of rural Pediatric practice. Odds are if you need one you're just going to place a low lying UVC, which a monkey could do. Odds are before you even get to that juncture your ER attending will be in the room with you and will have an IO that works just as well.

You need experience with chest tubes, needle decompressions, the farther end of the NRP spectrum (Pressors and chest compressions), emergent intubations, and most of all lots and lots of repetitions with effective PPV. If you can do that the NICU team will handle the rest when they get there. Bonus points if you remember to start PGE when you need it, but odds are the hospital won't stock it anyway so its probably a non issue.

 

[SurfingDoctor]

Thank you all. Any other general advice on rural peds for a med student (i.e. 4th year electives, ECs)?

For practical experience, see if you can take a wilderness medical elective. Having had referrals from rural areas... people get bitten and injured by all sorts of random animals and insects (though admittedly there is regionslness to those exposures).

 

[Perrotfish]

Thank you all. Any other general advice on rural peds for a med student (i.e. 4th year electives, ECs)?

More advice:

1) Subspecialties that require frequent follow up to be effective, like derm, devo, and psych, effectively don't exist in rural practice. So get used to giving out medications that would usually be handled by those specialties.

2) You need nursing skills. Chances are your nurses will be fresh grads who are beginning in the country to build a resume, and they are working on a multi-service ward where they get relatively few reps with Pediatric procedures. That means you will be on call for Peds IVs, NG tubes, caths, and arterial sticks that you would normally be completely unexperienced in as a doctor. If your Peds ED offers a procedure rotation (or if you can create one) that would be extremely helpful.

3) Learn Spanish, if you don't know Spanish. Not really unique to rural medicine, but rural clinics are even less likely to have translator phones than urban clinics.

For practical experience, see if you can take a wilderness medical elective. Having had referrals from rural areas... people get bitten and injured by all sorts of random animals and insects (though admittedly there is regionslness to those exposures).

I think this is a misunderstanding of what wilderness medicine is. Wilderness medicine is usually a combination of getting people ready to go to the wilderness (altitude medicine, malaria prophylaxis, dive medicine, etc) and treating people in the wilderness (when/how to reheat a frozen limb, when to tourniquet a bleeding wound vs compressing it, how to treat decompression and altitude injuries, etc.). When the injuries of the wilderness come back to you in a hospital that's just ER medicine.

Also, rural =/= wilderness. Rural medicine is basically urban medicine, but without the ability to easily refer to subspecialists. Despite what you see in the movies rural people do not spend their days plodding through the forest, hunting big game with a bow and arrow. They spend their days either in, or in transit to, houses, jobs, and bars.

 

[SurfingDoctor]

More advice:

1) Subspecialties that require frequent follow up to be effective, like derm, devo, and psych, effectively don't exist in rural practice. So get used to giving out medications that would usually be handled by those specialties.

2) You need nursing skills. Chances are your nurses will be fresh grads who are beginning in the country to build a resume, and they are working on a multi-service ward. That means you will be on call for Peds IVs, NG tubes, caths, and arterial sticks that you would normally be completely unexperienced in as a doctor. If your Peds ED offers a procedure rotation (or if you can create one) that would be extremely helpful.

3) Learn Spanish, if you don't know Spanish. Not really unique to rural medicine, but rural clinics are even less likely to have translator phones than urban clinics.



I think this is a misunderstanding of what wilderness medicine is. Wilderness medicine is usually a combination of getting people ready to go to the wilderness (altitude medicine, malaria prophylaxis, dive medicine, etc) and treating people in the wilderness (when/how to reheat a frozen limb, when to tourniquet a bleeding wound vs compressing it, how to treat decompression and altitude injuries, etc.). When the injuries of the wilderness come back to you in a hospital that's just ER medicine.

Also, rural =/= wilderness. Rural medicine is basically urban medicine, but without the ability to easily refer to subspecialists. Despite what you see in the movies rural people do not spend their days plodding through the forest, hunting big game with a bow and arrow. They spend their days either in, or in transit to, houses, jobs, and bars.

I did not say they were the same. The OP asked about electives, I gave a suggestion. More useful than an Anesthesia or Neurology in IMO (follow AED levels and possible side effects and talk with specialists maybe). A PCP in a rural area doesn't need to know how treat simple complex seizures versus absence seizures, but they better know how to treat bites and simple wounds.

 

[Perrotfish]

I did not say they were the same. The OP asked about electives, I gave a suggestion. More useful than an Anesthesia or Neurology in IMO (follow AED levels and possible side effects and talk with specialists maybe). A PCP in a rural area doesn't need to know how treat simple complex seizures versus absence seizures, but they better know how to treat bites and simple wounds.

I'm just saying my experience has been the opposite. I have fewer bites and simple wounds than I did in my urban residency. There generally isn't much of a wait for the ED in rural America, so my care of acute injuries has dropped to basically nothing as no one even has the minor disincentive of an 8 hour weight for their Medicaid ED appointment. On the other hand I am managing subspecialty crap that I would always have referred in residency because patients just flat out will not (or cannot) drive to a subspecialist who is two hours away.

The single most useful elective I think you could do, (other than NICU) would be anesthesia. If the single anesthesiologist on call is in a C-section then the Pediatrician is the last line of defense for IVs and Intubations in the hospital. Anyone who wants to work out in the sticks should do at least a month of Pediatric Anesthesiology. Though maybe that should wait until residency when they will actually let you do all of the procedures.

 

[SurfingDoctor]

I'm just saying my experience has been the opposite. I have fewer bites and simple wounds than I did in my urban residency. There generally isn't much of a wait for the ED in rural America, so my care of acute injuries has dropped to basically nothing as no one even has the minor disincentive of an 8 hour weight for their Medicaid ED appointment. On the other hand I am managing subspecialty crap that I would always have referred in residency because patients just flat out will not (or cannot) drive to a subspecialist who is two hours away.

Fair enough.

 

[arewethereyet...]

Of the places I've interviewed Geisinger is very much rural and would be my favorite program if it wasn't in the middle of nowhere, and then Maine Medical Center has opportunities for electives in rural Maine. In terms of not in big cities (sorry don't know if they are <150,000) a few in the northeast would be U Buffalo, U Rochester, SUNY upstate, Albany, Baystate, Lehigh Valley, Penn State, U Mass, Dartmouth, U Vermont.