Why the relatively low autonomy in Peds residency?

[MedicineZ0Z]

I'm family med and I noticed that when we admit kids, we have way more autonomy compared to when we rotate with the Peds residents. Of course, my observation is nothing new and this is very well known. But what's the reasoning? Kids are far less sick than adults so medical management is not as overwhelming. Even on the outpatient side on very healthy kids, attendings will always be way more hands on compared to other staff.
I also noticed new grads who are staff tend to run things by other attendings quite frequently. And now there's a peds hospitalist fellowship.
Any thoughts?

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[FrkyBgStok]

I don't disagree with this and it is one of my annoyances with peds in general, however there are different factors. when FP takes care of kids (in my experience) they are generally the healthy and easy kids and when we assign patients to the FP residents, a lot of time it is the healthier kids or the kids that you will see. the bronchiolitics, those needing IV antibiotics, the general bread and butter inpatient peds. I give my peds residents the difficult and complicated kids.

but it is a problem in peds. that's how things were done for me, and that's how things will be done. it isn't right and we definitely have autonomy problems in the inpatient side. and my residency caused me rage because I had more autonomy in the PICU than the floors at times. and as work in fellowship, I worry it is setting me up for an academic job and not to have that autonomy. I don't know how to fix it.

kids also have the added layer of parents. we also have a higher proportion of the "omg this kids favorite stuffed animal is the pooh bear and it is so cute." I feel like these personalities are less risk taking, less active in getting that autonomy, and less likely push against the system. all this makes the culture more supervisory and I am not a fan.

one thing I would caution you is that you don't know what you don't know. I know that people say that all the time, but kids compensate really well until they don't. I see EM providers come in and say "this kid is fine" and in reality, the level of tachycardia isn't the fever, it is compensated shock. And I have seen FP doctors do some really dicey stuff with kids that they didn't need to do. for example, we see hemolysis in the BMP every day so when we have a FP provider say "no worries about this 6.2 potassium, I gave calcium chloride and albuterol" and I say "was the sample hemolyzed" and they say "how do I tell that" (which is a scenario similar to what all us pediatricians have seen), it makes me think that maybe your FP program gives you too much autonomy and you need more supervision. kids really aren't small adults and not understanding children in the same way can easily cause problems.

but I get your general point and I agree with you.

 

[MedicineZ0Z]

I don't disagree with this and it is one of my annoyances with peds in general, however there are different factors. when FP takes care of kids (in my experience) they are generally the healthy and easy kids and when we assign patients to the FP residents, a lot of time it is the healthier kids or the kids that you will see. the bronchiolitics, those needing IV antibiotics, the general bread and butter inpatient peds. I give my peds residents the difficult and complicated kids.

but it is a problem in peds. that's how things were done for me, and that's how things will be done. it isn't right and we definitely have autonomy problems in the inpatient side. and my residency caused me rage because I had more autonomy in the PICU than the floors at times. and as work in fellowship, I worry it is setting me up for an academic job and not to have that autonomy. I don't know how to fix it.

kids also have the added layer of parents. we also have a higher proportion of the "omg this kids favorite stuffed animal is the pooh bear and it is so cute." I feel like these personalities are less risk taking, less active in getting that autonomy, and less likely push against the system. all this makes the culture more supervisory and I am not a fan.

one thing I would caution you is that you don't know what you don't know. I know that people say that all the time, but kids compensate really well until they don't. I see EM providers come in and say "this kid is fine" and in reality, the level of tachycardia isn't the fever, it is compensated shock. And I have seen FP doctors do some really dicey stuff with kids that they didn't need to do. for example, we see hemolysis in the BMP every day so when we have a FP provider say "no worries about this 6.2 potassium, I gave calcium chloride and albuterol" and I say "was the sample hemolyzed" and they say "how do I tell that" (which is a scenario similar to what all us pediatricians have seen), it makes me think that maybe your FP program gives you too much autonomy and you need more supervision. kids really aren't small adults and not understanding children in the same way can easily cause problems.

but I get your general point and I agree with you.

I think that's institution dependent. We admit a lot of kids on our inpatient family med service and some are very sick. I'm actually writing up a case report for one currently. When we rotate with Peds, we get a very equal shot at the complex patients including zebra cases.

I do agree that many doctors don't understand kids well though. And that does play a big role. But remember I'm mostly talking about Peds residents' experiences. It's also quite similar in the clinic? I have very little supervision doing well child checks for example unless I tell the staff something alarming. They may very quickly say hi. Yet in Peds clinic, pediatricians will come in and repeat the whole exam, and they do that with the Peds residents too.

 

[FrkyBgStok]

I think it depends on who you ask and where you are. We have 3 family medicine residencies in my home town and they are very different. one has autonomy like you say and the others have a little more oversight. and as a second year and third year peds resident, I had very little supervision in clinic. my inpatient months, I had a little autonomy, my PICU months when they knew me, I had a good amount of autonomy, my ED months I had almost full autonomy, my clinic months same. Not all residencies are set up like that and not all the residents in my program had good autonomy.

so I don't know what the answer is.

 

[MedicineZ0Z]

I think it depends on who you ask and where you are. We have 3 family medicine residencies in my home town and they are very different. one has autonomy like you say and the others have a little more oversight. and as a second year and third year peds resident, I had very little supervision in clinic. my inpatient months, I had a little autonomy, my PICU months when they knew me, I had a good amount of autonomy, my ED months I had almost full autonomy, my clinic months same. Not all residencies are set up like that and not all the residents in my program had good autonomy.

so I don't know what the answer is.

That's fair. How are you defining autonomy btw? Is it just being allowed to do stuff? For me it's more that the attending trusts *most* of what you do and doesn't feel a need to repeat it.
Like even as off-service FM on Peds or in the NICU even, I intubated babies and put in lines, did lots of LPs among other stuff (is this the norm for your off-service rotators?). So I was doing stuff constantly but when it came to medical management, attendings would be repeating things I already presented.

 

[mvenus929]

That's fair. How are you defining autonomy btw? Is it just being allowed to do stuff? For me it's more that the attending trusts *most* of what you do and doesn't feel a need to repeat it.
Like even as off-service FM on Peds or in the NICU even, I intubated babies and put in lines, did lots of LPs among other stuff (is this the norm for your off-service rotators?). So I was doing stuff constantly but when it came to medical management, attendings would be repeating things I already presented.

The FM residents at my program would not be doing procedures like that. But, the FM residents at my program were known for being very weak residents in general, so were supervised more heavily than the Peds residents, in general.

But as a Peds resident in my second and third year, I did a ton without direct supervision. Not as much as a IM resident, perhaps, but for deliveries, it was often just me, the respiratory therapist, and the intern, unless the infant was super premature (then they called the Neo as well, and depending on the neo, they would still just stand back and let us work). For premie twins, the intern and Neo would take the first twin, and the second year and RT would take the second twin, who was often sicker.

Our hospitalist were also good about letting the senior resident run rounds and make decisions, and trusted the senior to do what was best for the patient.

And in clinic, we had the culture of the attending coming in for most patients (no so much the indirect supervision that is allowed for residents in the medical home), but if it was busy, they would either literally come in and say hi, or would waive coming in for the senior residents.

So, yes, Peds has more supervision than other fields. But how much autonomy exists depends on the culture of the program as well. And I’d agree with @FrkyBgStok that the FM residents probably should be getting a little,more supervision at their own programs in the care of pediatric patients, because it really is a world different than adults.

 

[DO2015CA]

the off service residents that I’ve seen get into trouble are the ones that don’t understand their boundaries regarding kids.

 

[sliceofbread136]

I’m basing this on my experience with only 2 academic institutions but... peds academic hospitalists are somewhat “special”. Think that’s where this silly fellowship comes from too.

 

[MedicineZ0Z]

I’m basing this on my experience with only 2 academic institutions but... peds academic hospitalists are somewhat “special”. Think that’s where this silly fellowship comes from too.

What do you mean?

 

[WheezyBaby]

From a med peds standpoint, we work with plenty of fine off service FM residents, but I always watch what they do considerably more closely than the categoricals. From a general peds trainee vs medicine trainee experience and autonomy standpoint, yeah, it's always a little annoying going from the medicine side where I'll do invasive procedures and manage critically ill patients independently with a heads up to the fellow who isn't even in house vs going to peds hospitalist and staffing a bronchiolitic on room air for half an hour. Interestingly for me as well, the degree of autonomy in the PICU is actually quite strong in contrast to floor management, basically a "try anything once as long as you have good pathophysiologic rationale and call for help if it doesn't work" mentality. Part of the culture I think stems from tradition and from the fear of harming a healthy child who potentially has a full life in front of them (it is probably ageist to feel worse about a preventable bad outcome in a formerly healthy 2 year old than a comorbiditis 85 year old, but I think most people feel that way regardless).

I have strong feelings toward the hospitalist fellowship that I won't get into but they're not favorable.

That being said, while I think the general culture of peds nationwide is one of micromanaging and oversupervision, it's not universal and the staffing models some places seem excellent.

Edit: I will actually say something about the hospitalIst fellowship. Of my 24 months on the peds side of training, 4.5 of those months were spent on outpatient rotations. I'd love an explanation of how I'm well prepared to practice outpatient gen peds competently but am going to need another 2-3 years of training to competently practice as a peds hospitalist. Yeah, I'm not about to be a PGY-6/7 peds hospitalist fellow redoing clinical training I've already received and getting paid as a trainee to do administrative/QI work I could just be doing as a staff. Who thought that pushing this fellowship in the direction of a de facto requirement rather than an option for masochists to subject themselves to was a good idea?? The only population it makes sense for are community program trainees who want to shift into tertiary academic center hospitalist

 

[SurfingDoctor]

From a procedural standpoint, the reasoning is easy, the patient are tinier and little mistakes can lead to bigger problems. This certainly bares out in the literature regarding resident procedures. Now one could argue it’s because residents don’t do enough, which is true, but procedures in general are on a downtrend, so you give procedures to trainees mostly likely to need that skill in the future, ie not a general resident who just wants to get that intubation that they will never do again.

From a knowledge base, there should be increased supervision initially that graduates to less supervision overtime. I think most places follow that rule. Now, if by less autonomy, you mean calling an attending at telling them about a patient you just admitted even though you are an upper level, I think that is person depend. Personally, I prefer to be woken up and hear and see all admissions (we have in house call mind you). And I do that for every level of fellowship training. And it’s not because I don’t trust a third year fellow, it’s mostly so A) I know how much clinical and paperwork I have ahead of me for the admission and B) so I don’t walk into any surprises. At the end of the day, it’s my name on the chart for the person most responsible for the patient, not the trainee.

If instead by lack of autonomy one means, calling a consultant and having a consultant for everything, I think that’s just academic medicine. It’s probably over the top, but it is what it is.

If there is one think I think that has decreased provider autonomy overall, it’s that everything is protocolized. You don’t need to think through problems and troubleshoot as much as you used to, you just put them on the protocol. I certainly understand the potential benefits, but also have seen associated harm. Not sure that will change though as that is a cultural thing.

 

[MedicineZ0Z]

From a procedural standpoint, the reasoning is easy, the patient are tinier and little mistakes can lead to bigger problems. This certainly bares out in the literature regarding resident procedures. Now one could argue it’s because residents don’t do enough, which is true, but procedures in general are on a downtrend, so you give procedures to trainees mostly likely to need that skill in the future, ie not a general resident who just wants to get that intubation that they will never do again.

From a knowledge base, there should be increased supervision initially that graduates to less supervision overtime. I think most places follow that rule. Now, if by less autonomy, you mean calling an attending at telling them about a patient you just admitted even though you are an upper level, I think that is person depend. Personally, I prefer to be woken up and hear and see all admissions (we have in house call mind you). And I do that for every level of fellowship training. And it’s not because I don’t trust a third year fellow, it’s mostly so A) I know how much clinical and paperwork I have ahead of me for the admission and B) so I don’t walk into any surprises. At the end of the day, it’s my name on the chart for the person most responsible for the patient, not the trainee.

If instead by lack of autonomy one means, calling a consultant and having a consultant for everything, I think that’s just academic medicine. It’s probably over the top, but it is what it is.

If there is one think I think that has decreased provider autonomy overall, it’s that everything is protocolized. You don’t need to think through problems and troubleshoot as much as you used to, you just put them on the protocol. I certainly understand the potential benefits, but also have seen associated harm. Not sure that will change though as that is a cultural thing.

I'm curious but how much do you supervise midlevels then?

 

[SurfingDoctor]

I'm curious but how much do you supervise midlevels then?

In what regard? Midlevels don’t function independently (even though some of feel as they should). I consider them like senior residents if I had to draw an analogy.

 

[MedicineZ0Z]

In what regard? Midlevels don’t function independently (even though some of feel as they should). I consider them like senior residents if I had to draw an analogy.

Senior residents after... how many years of exp? I don't see how 2 years of (a much easier version of med school) education suddenly makes someone into a senior resident. A decade of experience in one narrow specialty? Sure...

 

[WheezyBaby]

Senior residents after... how many years of exp? I don't see how 2 years of (a much easier version of med school) education suddenly makes someone into a senior resident. A decade of experience in one narrow specialty? Sure...

Surfing is a peds intensivist. Peds residents by and large are not interested in going in to the ICU and get very little actual time in the ICU, like 2 months, mixed between their other rotations. PA's and NP's have a knowledge base that is less in depth and of narrower scope, but they still have enough to build on and function well under supervision. It doesn't take 10 years for them to be able to learn through pattern recognition if nothing else how attendings respond to certain situations in the unit, each attendings own quirks and preferences, etc. My experience with mid-levels is also mostly in the ICU setting (adult, peds, and nicu), but I also have experience with them on different transplant services and my experience is similar with the addition that they also become very familiar with all the patients due to their continuity of care that it's impossible for residents to have. Their knowledge base again is going to not be the same as a residents, the ability to type II think won't be the same, and there's a lower ceiling of growth potential, but as far as overall ability to function in a given setting I don't think it's an unfair comparison.

 

[SurfingDoctor]

Senior residents after... how many years of exp? I don't see how 2 years of (a much easier version of med school) education suddenly makes someone into a senior resident. A decade of experience in one narrow specialty? Sure...

Most of the ones I interact with have been there for greater than 3 years and have significantly more bedside and clinical experience. I wasn’t referring to fresh graduates.

 

[pedstar09]

Just fresh out of residency at a semi community/semi academic program- I think in first year, I had a ton of supervision, for the better I guess. I had a senior resident and on top of that an attending. We did not have fellows which might be why? However, when we would do new admissions, we would have more autonomy and decision making power if it made sense. We did not do PICU in fist year, but did 2 rotations of NICU in first year, and with that too, I had a lot of procedural success with the help of midlevels and attendings.

In 2nd and 3rd year, you had a TON of autonomy. You could be admitting all day and just updating the attending later, unless, obviously, you had questionable patients being admitted. Overnight, when you are admitting, you can update the attending in the morning on "board rounds". Only once I have woken up an attending, and it was because a 17 year old kid was threatening to leave AMA at 3am, In PICU, only 2-3 times I had to call an attending in because once, we were withdrawing care and once because an asthmatic was not improving on high levels o continuous albuterol.

I am now in fellowship and I feel like at this different institute, the culture is totally different than my previous institute..so, I think it all depends on where you are and what your reference point is.

And a word about Pedi hospitalist- I think that "subspeciality" lost out on a ton of doctors like me, who chose a different field because they would spend 2/3 years on a field that will pay them a lot more and you will become good at something very specialized, thus increasing your market value.

 

[calvnandhobbs68]

Surfing is a peds intensivist. Peds residents by and large are not interested in going in to the ICU and get very little actual time in the ICU, like 2 months, mixed between their other rotations. PA's and NP's have a knowledge base that is less in depth and of narrower scope, but they still have enough to build on and function well under supervision. It doesn't take 10 years for them to be able to learn through pattern recognition if nothing else how attendings respond to certain situations in the unit, each attendings own quirks and preferences, etc. My experience with mid-levels is also mostly in the ICU setting (adult, peds, and nicu), but I also have experience with them on different transplant services and my experience is similar with the addition that they also become very familiar with all the patients due to their continuity of care that it's impossible for residents to have. Their knowledge base again is going to not be the same as a residents, the ability to type II think won't be the same, and there's a lower ceiling of growth potential, but as far as overall ability to function in a given setting I don't think it's an unfair comparison.

huh? I mean maybe they become more familiar with the long term transplant kids but in the PICU and NICU, attendings would often give the resident teams the patients they wanted the most continuity of care for since you were there 6 days a week for a month not 2-3 12 hour shifts a week. Way less handoffs on resident teams.

 

[WheezyBaby]

huh? I mean maybe they become more familiar with the long term transplant kids but in the PICU and NICU, attendings would often give the resident teams the patients they wanted the most continuity of care for since you were there 6 days a week for a month not 2-3 12 hour shifts a week. Way less handoffs on resident teams.

The sentence may be poorly phrased. The comment is reference to the transplant APPs

 

[Stitch]

The biggest mistake I see from people who don't regularly take care of kids is missing the one who's sick but looks relatively well. I say this as a peds intensivist.

Partly because of this, and partly just because we are pediatricians, most of us worry about our patients a lot. In general we supervise our interns very closely then give the second and third year residents a lot more autonomy when they show they can be trusted. Some of this trust comes from time and familiarity with the resident and off service residents, no matter how good they are, don't have the regular presence that generates that trust.

In regards to our NPs, most of the ones in the PICU were former PICU nurses, and any resident can testify that they are very good at recognizing a sick kid and taking steps to stabilize them. Yes they are often better than a second or third year resident at knowing how to manage a vent or approach the more complicated things like congenital heart disease, which simply can't be learned in a month rotation (these kids are extremely fragile and care is often dependent on the surgeon).

NPs absolutely lack the breadth of pediatrics knowledge that physicians have as well as the deeper knowledge of basic science/pharmacology/microbiology, but they are still extremely valuable and have a place in the unit. Most residents recognize this and can learn from them; the best NPs for their part, also learn a ton from residents, and NPs in this setting are very good at recognizing when they need help. NPs in the outpatient world are a different ballgame and I can't really comment other than to say it's not a valid comparison.

 

[DO2015CA]

The biggest mistake I see from people who don't regularly take care of kids is missing the one who's sick but looks relatively well. I say this as a peds intensivist.

Partly because of this, and partly just because we are pediatricians, most of us worry about our patients a lot. In general we supervise our interns very closely then give the second and third year residents a lot more autonomy when they show they can be trusted. Some of this trust comes from time and familiarity with the resident and off service residents, no matter how good they are, don't have the regular presence that generates that trust.

In regards to our NPs, most of the ones in the PICU were former PICU nurses, and any resident can testify that they are very good at recognizing a sick kid and taking steps to stabilize them. Yes they are often better than a second or third year resident at knowing how to manage a vent or approach the more complicated things like congenital heart disease, which simply can't be learned in a month rotation (these kids are extremely fragile and care is often dependent on the surgeon).

NPs absolutely lack the breadth of pediatrics knowledge that physicians have as well as the deeper knowledge of basic science/pharmacology/microbiology, but they are still extremely valuable and have a place in the unit. Most residents recognize this and can learn from them; the best NPs for their part, also learn a ton from residents, and NPs in this setting are very good at recognizing when they need help. NPs in the outpatient world are a different ballgame and I can't really comment other than to say it's not a valid comparison.

I think that is also why NPs are best utilized in the subspecialties but since PC is the easiest point of entry that’s where they mistakenly believe they are competent. I have witnessed how good the NICU midlevels are and have also witnessed how poor outpatient ones are. When you don’t have the ability to create the entire differential diagnosis, it is hard to come up with the right answer. PCP is still the speciality of the undifferentiated.

 

[GonnaBeADoc2222]

It's a problem because pediatrics residents then graduate with no procedural experience, which if they want to go and say be a hospitalist in a lower resource setting is a big issue.

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[NurWollen]

It's a problem because pediatrics residents then graduate with no procedural experience, which if they want to go and say be a hospitalist in a lower resource setting is a big issue.

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I can't say I disagree with this. I think the problem is multifactorial. Everyone wants to be super careful with kids, sure, there aren't as many procedures to be had as with adults. In the NICU, NNP's now fill many of the roles formerly taken on by residents. And attendings often assume we're not interested in critical procedures (and too many peds residents aren't). Finally, many attendings trained at big institutions where fellows did all procedures and are out of touch with how many private hospitalist jobs want general pediatricians to attend deliveries and stabilize a baby when things go wrong.

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[SurfingDoctor]

I can’t speak to newborn, but if you are a hospitalists jacking around with intubations and CVLs in toddlers and older, your ability to safely manage that patient has already sailed right out the door. If instead you placed an IO and know how to properly bag a patient and call for help, then that’s probably the best for the patient.

 

[MedicineZ0Z]

I can't say I disagree with this. I think the problem is multifactorial. Everyone wants to be super careful with kids, sure, there aren't as many procedures to be had as with adults. In the NICU, NNP's now fill many of the roles formerly taken on by residents. And attendings often assume we're not interested in critical procedures (and too many peds residents aren't). Finally, many attendings trained at big institutions where fellows did all procedures and are out of touch with how many private hospitalist jobs want general pediatricians to attend deliveries and stabilize a baby when things go wrong.

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I did a bunch of critical care procedures as an FM resident on those rotations.

I can’t speak to newborn, but if you are a hospitalists jacking around with intubations and CVLs in toddlers and older, your ability to safely manage that patient has already sailed right out the door. If instead you placed an IO and know how to properly bag a patient and call for help, then that’s probably the best for the patient.

If you did a peds-anesthesia block, why can't you tube kids? Usually people doing it will do additional training via courses on top of elective time in residency, on top of additional time doing critical care.

 

[SurfingDoctor]

I did a bunch of critical care procedures as an FM resident on those rotations.


If you did a peds-anesthesia block, why can't you tube kids? Usually people doing it will do additional training via courses on top of elective time in residency, on top of additional time doing critical care.

I hope this isn’t a serious question. I’ve done over 100 intubations at last count and they still make me anxious. Intubations are one of the few procedures you can easily kill someone with if you make mistakes or don’t have an adequate understanding of cardiopulmonary interactions.

 

[WheezyBaby]

I did a bunch of critical care procedures as an FM resident on those rotations.


If you did a peds-anesthesia block, why can't you tube kids? Usually people doing it will do additional training via courses on top of elective time in residency, on top of additional time doing critical care.

 

[calvnandhobbs68]

I can’t speak to newborn, but if you are a hospitalists jacking around with intubations and CVLs in toddlers and older, your ability to safely manage that patient has already sailed right out the door. If instead you placed an IO and know how to properly bag a patient and call for help, then that’s probably the best for the patient.

Uh yeah have fun bagging the kid for an hour while you wait for transport to come from the nearest academic picu 50 miles away? Not everyone lives near a picu. Even if you are relatively near a picu it can take quite a bit of time to get actual physical assistance there.

There’s plenty of community peds hospitals jobs where you’re the pediatrician on call and that’s it. Kinda like there’s plenty of gen surg jobs where if you’re at a community hospital where you just handle everything critical that comes through the ER overnight...you don’t have time to wait for transport to show up for every surgical emergency.

Yeah you should get them over to a picu or NICU ASAP but you need to make sure they have stable access and an airway long before they get there.

 

[SurfingDoctor]

Uh yeah have fun bagging the kid for an hour while you wait for transport to come from the nearest academic picu 50 miles away? Not everyone lives near a picu. Even if you are relatively near a picu it can take quite a bit of time to get actual physical assistance there.

There’s plenty of community peds hospitals jobs where you’re the pediatrician on call and that’s it. Kinda like there’s plenty of gen surg jobs where if you’re at a community hospital where you just handle everything critical that comes through the ER overnight...you don’t have time to wait for transport to show up for every surgical emergency.

Yeah you should get them over to a picu or NICU ASAP but you need to make sure they have stable access and an airway long before they get there.

And in those settings, the most skilled person in the entire hospital who has intubated a person is a peds hospitalist? That’s just plain dangerous if true.

 

[calvnandhobbs68]

And in those settings, the most skilled person in the entire hospital who has intubated a person is a peds hospitalist? That’s just plain dangerous if true.

Again is it ideal to wait for he anesthesiologist on call to come help you out? Sure, except you measure reassessments in 30 second intervals in NRP.

Yeah , things get dicey in a lot of community hospitals. You may be the only person whose intubated a newborn or young kid in the entire hospital.

 

[SurfingDoctor]

Again is it ideal to wait for he anesthesiologist on call to come help you out? Sure, except you measure reassessments in 30 second intervals in NRP.

Did you miss this part?

I can’t speak to newborn, but if you are a hospitalists jacking around with intubations and CVLs in toddlers and older, your ability to safely manage that patient has already sailed right out the door. If instead you placed an IO and know how to properly bag a patient and call for help, then that’s probably the best for the patient.

Edit: I see you edited your comment after my reply. If it was my child who was desaturated with respiratory failure, I would rather the intubation be done by an Anesthesiologist or an ER physician who has intubated 200+ 80 year olds and never touched a child, than a pediatrician who got to practice a couple of times during residency a couple years prior. To each their own I guess.

 

[calvnandhobbs68]

Did you miss this part?

There’s a difference between how comfortable someone feels managing a patient and what they have to do to keep them stable until transport shows up or someone else with more experience shows up. An IO isn’t gonna help directly stabilize an airway. You can be very uncomfortable managing something but you do what you have to do to keep them going until you can get them to somewhere with a higher level of care. In many community hospitals the most immediate person to help out is going to be an adult ED doc or RT...who may have had assisted/done as many pediatric intubations as you did during residency depending on what you both have been doing in the meantime.

This is why I agreee it’s a problem that people that go into hospitalist positions or community peds positions with hospital coverage/call may not have had a lot of procedural experience.

 

[calvnandhobbs68]

Edit: I see you edited your comment after my reply. If it was my child who was desaturated with respiratory failure, I would rather the intubation be done by an Anesthesiologist or an ER physician who has intubated 200+ 80 year olds and never touched a child, than a pediatrician who got to practice a couple of times during residency a couple years prior. To each their own I guess.

Didn’t mean to edit it after you response I just realized my thoughts weren’t totally complete. Sure I can see that.

I think that speaks back to this orignial question though of pediatric procedures being seen as gold by hospitalists/picu attendings/ED attendings etc that they have to hoard for themselves and their fellows while IM residents are running codes/intubating people and throwing in central lines on their floors then finally shipping them off to the MICU.

 

[SurfingDoctor]

There’s a difference between how comfortable someone feels managing a patient and what they have to do to keep them stable until transport shows up or someone else with more experience shows up. An IO isn’t gonna help directly stabilize an airway. You can be very uncomfortable managing something but you do what you have to do to keep them going until you can get them to somewhere with a higher level of care. In many community hospitals the most immediate person to help out is going to be an adult ED doc or RT...who may have had assisted/done as many pediatric intubations as you did during residency depending on what you both have been doing in the meantime.

This is why I agreee it’s a problem that people that go into hospitalist positions or community peds positions with hospital coverage/call may not have had a lot of procedural experience.

Fortunately, in my experience, I've only ever seen pediatric patients transferred from community hospitals wards by people who realized they were in over their head and never had a patient transferred intubated from a outside community ward who wasn't triaged by someone with more procedural skills then they were. It always dangerous to have overconfidence in unfamiliar situations.

 

[SurfingDoctor]

Didn’t mean to edit it after you response I just realized my thoughts weren’t totally complete. Sure I can see that.

I think that speaks back to this orignial question though of pediatric procedures being seen as gold by hospitalists/picu attendings/ED attendings etc that they have to hoard for themselves and their fellows while IM residents are running codes/intubating people and throwing in central lines on their floors then finally shipping them off to the MICU.

You say this like you have any concept of a procedural subspecialty.

Declining Procedures by Pediatric Critical Care Medicine Fellowship Trainees - PMC

Background: Pediatric Critical Care Medicine Fellowship trainees need to acquire skills to perform procedures. Over the last several years there have been advances that allowed for less invasive forms of interventions. Objective: Our hypothesis was ...

www.ncbi.nlm.nih.gov

Even though intubations/fellow are static, 15/year is not that many. But you're saying it's "hoarding" for someone who needs that skill for their profession. Hmm, okay. What is a good number of intubations that 15/year fellow should give to random residents to make those resident feel competent at the expense of the fellow? They should give away what 1/3, 1/2 to the 5 to 7 different residents that rotate throughout the year? What number is the right number is your mind that isn't hoarding?

 

[SpacemanSpifff]

You say this like you have any concept of a procedural subspecialty.

Declining Procedures by Pediatric Critical Care Medicine Fellowship Trainees - PMC

Background: Pediatric Critical Care Medicine Fellowship trainees need to acquire skills to perform procedures. Over the last several years there have been advances that allowed for less invasive forms of interventions. Objective: Our hypothesis was ...

www.ncbi.nlm.nih.gov

Even though intubations/fellow are static, 15/year is not that many. But you're saying it's "hoarding" for someone who needs that skill for their profession. Hmm, okay. What is a good number of intubations that 15/year fellow should give to random residents to make those resident feel competent at the expense of the fellow? They should give away what 1/3, 1/2 to the 5 to 7 different residents that rotate throughout the year? What number is the right number is your mind that isn't hoarding?

Agreed - these procedures, especially intubation, are rare and getting more rare with high flow and advanced vascular access techniques. At least one study on pediatric intubation in a referral center ED suggested that no one does enough strictly peds airways to be proficient (did not include anesthesia, I believe). It’s just the way the world is moving.

 

[WheezyBaby]

Didn’t mean to edit it after you response I just realized my thoughts weren’t totally complete. Sure I can see that.

I think that speaks back to this orignial question though of pediatric procedures being seen as gold by hospitalists/picu attendings/ED attendings etc that they have to hoard for themselves and their fellows while IM residents are running codes/intubating people and throwing in central lines on their floors then finally shipping them off to the MICU.

Fwiw, my medicine program specifically prohibits residents from unsupervised intubation unless there is no one available and the patient is going to die without (for that to be the case, both anesthesia on call and CCM fellow or staff on call would have to be otherwise occupied), and even then you should be temporizing with an LMA if at all reasonable. I've gotten about 20 tubes in residency. My EM friends have dramatically more, probably well into the 100's, and they'll continue to get them in practice whereas a hospitalist won't. Most of those won't be peds airways but the skills do translate, particularly if you have a systematic / stepwise approach to visualization.

I have done unsupervised lines on the adult side, but they are way easier than kids and regardless, there are few lines that truly need to be emergently placed. If a line doesn't look easy, you can typically temporize with a combination of peripherals or if truly emergent an I/O for access, including for pressors (through peripheral or io). I have run codes independently on the adult side, but adult codes... tend to not have good outcomes whereas kids usually at least get ROSC. Unless the initial rhythm is vf/vt/pmvt or there's an obviously reversible cause the neurologically intact survival rates for adult are abysmal

 

[WheezyBaby]

Agreed - these procedures, especially intubation, are rare and getting more rare with high flow and advanced vascular access techniques. At least one study on pediatric intubation in a referral center ED suggested that no one does enough strictly peds airways to be proficient (did not include anesthesia, I believe). It’s just the way the world is moving.

I just quickly looked at that study. 20 lines a year? Our adult fellows can get that in a month. I realized the volume was different, but my time in the picu didn't make it feel that dramatic. I was grateful for the peds lines/tubes I've been offered in PICU, but if that's the volume I'll get as a fellow I'll probably be pretty greedy

 

[SurfingDoctor]

I just quickly looked at that study. 20 lines a year? Our adult fellows can get that in a month. I realized the volume was different, but my time in the picu didn't make it feel that dramatic

While those numbers are from a single institution (CHLA) they are about on par with what I’ve seen. It clearly is variable between fellows based on random chance, but I was on call with a 2nd fellow the other night who had never put in a IJ. Actually, the NP wanted to try, and I told them no. Unfortunately, the patient ended up not needing a line at all in the end, so that fellow still hasn’t put in an IJ yet. In comparison, a co-fellow of theirs in the same class has put in about 10+ IJs. It’s just random luck. With the development of PICC services, that number has reached a historic low.

 

[MedicineZ0Z]

I hope this isn’t a serious question. I’ve done over 100 intubations at last count and they still make me anxious. Intubations are one of the few procedures you can easily kill someone with if you make mistakes or don’t have an adequate understanding of cardiopulmonary interactions.

I've mentioned in another thread that intubating is the only true dangerous procedure we do. Not a new concept to me. The point is, someone who is doing it likely has lots of reps over the years of training + additional training and focused learning.

You do realize paramedics intubate right? They need 5 or 10 tubes in the OR. That was one single day of anesthesia for me in med school. Same with RTs.

 

[SurfingDoctor]

I've mentioned in another thread that intubating is the only true dangerous procedure we do. Not a new concept to me. The point is, someone who is doing it likely has lots of reps over the years of training + additional training and focused learning.

You do realize paramedics intubate right? They need 5 or 10 tubes in the OR. That was one single day of anesthesia for me in med school. Same with RTs.

Yep paramedics attempt intubations. I’ve had a handful of dead children come in from their attempts. I’m not sure that’s helping your point. Nor is the fact that Pediatric residency is not designed to teach “lots of reps” of anything but how to diagnose sick children. I didn’t pick my kids pediatrician because he told me he did “lots of reps” with a laryngoscope nor do I think that would ever be helpful.

Maybe you should consider doing an ER residency if you're so interested in intubations.

 

[Stitch]

I completely agree with SurfingDoc. The fact is that you are good at what you do every day. Everything seems easy until it's not. Peds residents don't intubate kids every day, they don't manage airways. Neither do FM residents or paramedics for that matter. Doing a 'block' in residency under supervision gives you a taste, but it doesn't give you the required skill to do it regularly. Out patient medicine is very different from inpatient and even inpatient medicine is very different from ICU care. I take my kids to a pediatrician because they see regular kids all day every day and though I am boarded in general pediatrics, it would challenging to just jump back into it if I left critical care.

As SurfingDoc alluded, there's plenty of evidence that medics don't do a great job of managing pediatric airways. Something like less than 1% of their calls involve a kid in respiratory failure, and attempts at securing an airway with an ETT often go sideways. It's far better to place an LMA or simply mask them until arrival. This is not a failure on their part, and it does not mean they aren't 'smart' enough to manage kids. It simply means they don't have enough daily experience to do it safely. Like most things, it's a system issue. EM residency directly addresses the system and makes people more proficient with airways, but most tell me the peds airways still make them a little nervous.

Lines are relatively simple, but if your patient needs a line, they need an intensivist. And of course subsequent care of the line falls into ICU/IMC nurse territory who undergo specific training for it. Not much reason (or general inclination) for hospitalists to take that procedure on.

 

[shepardsun]

As a pediatrician who is now finishing an anesthesia residency, I have a million thoughts on both the autonomy and airway management themes of this thread.

Suffice it to say, my expanded experience and knowledge has made me more respectful of how dangerous and precarious even the seemingly straightforward airway can be. The best pediatric anesthesiologists I have worked with are incredibly conservative and careful and have a huge degree of humility and I have tried to learn from their example.

Some of the cavalier comments in here scare me.

The autonomy differential is definitely a thing. I went from having attending still look over my shoulder as a graduating third year resident for well child checks to being tossed into an OR by myself and expected to keep a sick patient alive through major surgery. Steep learning curve, but pushed me way outside my comfort zone in a way that has really benefited me as a physician.

 

[captianplanet]

I'm family med and I noticed that when we admit kids, we have way more autonomy compared to when we rotate with the Peds residents. Of course, my observation is nothing new and this is very well known. But what's the reasoning? Kids are far less sick than adults so medical management is not as overwhelming. Even on the outpatient side on very healthy kids, attendings will always be way more hands on compared to other staff.
I also noticed new grads who are staff tend to run things by other attendings quite frequently. And now there's a peds hospitalist fellowship.
Any thoughts?

This person is trolling right???

If you end up intubating children in practice let me know where you are at so I don't go there. It's one thing to get procedures with a trained provider over your shoulder, backing you up. Its a completely different beast to do it alone.

Don't get me wrong, I loved procedures during residency, but when I was a hospitalist I knew my limits of what is appropriate and what is not. I a fan of "learn how to bag/mask" versus "intubate twice a year for that sick kid" You would be surprised how many people don't bag well....

 

[Socrates25]

The autonomy differential is definitely a thing. I went from having attending still look over my shoulder as a graduating third year resident for well child checks to being tossed into an OR by myself and expected to keep a sick patient alive through major surgery. Steep learning curve, but pushed me way outside my comfort zone in a way that has really benefited me as a physician.

You've touched on a crucial difference between IM and peds.

I did a combined med/peds residency. A bad outcome on an adult patient is treated with less consternation than a bad outcome on a peds patient. Period. That's why codes in the MICU were easily 1/3 to 1/4th the time that we would spend on a PICU code.

Given that bad outcomes on adult patients are more "acceptable" than for peds patients, that changes training and therefore attendings are more willing to give autonomy to their trainees compared to the peds side.

 

[MedicineZ0Z]

You've touched on a crucial difference between IM and peds.

I did a combined med/peds residency. A bad outcome on an adult patient is treated with less consternation than a bad outcome on a peds patient. Period. That's why codes in the MICU were easily 1/3 to 1/4th the time that we would spend on a PICU code.

Given that bad outcomes on adult patients are more "acceptable" than for peds patients, that changes training and therefore attendings are more willing to give autonomy to their trainees compared to the peds side.

Yeah I think that's a no **** thing we hate saying out loud. An older person who's going to die in <1 year anyway is different than a kid who can leave the hospital and live for 70 more years. I'd take it a step further actually. Kids raised in good families etc. with good support and social situations will go onto live likely meaningful decades of quality life and yes their care should be even more uptight vs an 80 year old with 45 things on their problem list.

 

[miacomet]

It's really concerning that our pediatricians say they can't attend deliveries and resuscitations (this is a rural hospital) because that's the territory of NNPs, and that they aren't comfortable doing procedures or admitting patients. They pull the intern trick, worst in the book, of saying that maybe the patient can go home, and if not they need the ICU. Peds residency is in crisis.

As to recognizing sick kids- I dunno. The tertiary care Peds hospital is ALWAYS blowing me off on the phone when I try and send kids there, even when they are obviously really sick and end up in the PICU. I used to attend their ED meetings- woah, they stuff they missed. They just aren't used to sick and so they send everyone home. Seemed like bad outcomes were just not that concerning to them.

 

[MedicineZ0Z]

It's really concerning that our pediatricians say they can't attend deliveries and resuscitations (this is a rural hospital) because that's the territory of NNPs, and that they aren't comfortable doing procedures or admitting patients. They pull the intern trick, worst in the book, of saying that maybe the patient can go home, and if not they need the ICU. Peds residency is in crisis.

As to recognizing sick kids- I dunno. The tertiary care Peds hospital is ALWAYS blowing me off on the phone when I try and send kids there, even when they are obviously really sick and end up in the PICU. I used to attend their ED meetings- woah, they stuff they missed. They just aren't used to sick and so they send everyone home. Seemed like bad outcomes were just not that concerning to them.

They aren't comfortable admitting patients? Why? It's like 2/3 of the residency.

 

[miacomet]

They aren't comfortable admitting patients? Why? It's like 2/3 of the residency.

They are outpatientologists. It's pretty crazy. They don't seem to practice any actual medicine at all.

 

[Perrotfish]

It's really concerning that our pediatricians say they can't attend deliveries and resuscitations (this is a rural hospital) because that's the territory of NNPs, and that they aren't comfortable doing procedures or admitting patients. They pull the intern trick, worst in the book, of saying that maybe the patient can go home, and if not they need the ICU. Peds residency is in crisis.

Have you ever looked at hiring actual hospitalists? It sounds like you're trying to get the local outpatient Pediatricians to do admissions between clinic patients.