Daily life as a PICU fellow/attending

[user7717]

It looks like the last PICU thread is over 10 years old and wanted to bring it up again since I'm interested in critical care.

What is the average day like for a PICU fellow? I know programs will differ, but how much is clinical versus research? How about life as an academic attending? Any thoughts on the personality types who go into PICU? I've heard the field suffers from a lot of burnout, is there any truth to this?

Thanks for all the advice!

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[SurfingDoctor]

There are a lot of different permutations and practice models to the questions you ask and thus, you'll probably get a variety of answers. Likewise it is hard to define an "average day" but I'll give you my broad strokes.

Fellowship: Most places break up clinical and research time 50/50. There are variations to this breakup and within the clinical and research time, there are further variations of month blocks of clinical/research time, versus weeks/days. Most clinical blocks will be PICU, CVICU and Anesthesia with electives and other variables thrown in (practice attending, sedation time, etc.). Most places (I think) have some version of day shifts (6am to 6pm) and night shifts (6pm to 6am). You show up when you are requested to, but you leave when the work is done and patients are stable for handover, as long as you don't break the 80 hour work week and don't take on new patients after 24 consecutive hours. It is impossible to say what that day looks like on average because there are a lot of variables that go into the day (acuity, bed space, admissions, discharges/transfers, family meetings, educational opportunities, procedures). In fact, the absence of the "average day" is what makes the job interesting. Like momma Gump said, "You never know what you are going to get". Actually, the clinical aspects, though there is variability among programs, is pretty standard from place to place. The ACGME regulates this pretty closely and every program is expected to train fellows with the same basic skills to take care of critically ill patients. The research, or scholarly project, on the other hand is highly variable. More so than clinical time, the research time has no typical day because 1) people do lots of different projects and 2) there is no daily time table, so people kinda do with their time how they see fit within the scope of the project. I did bench research and showed up at 8am (earlier than lab mates) and at 5pm or when experiments were finished. Sometimes, I stayed post-call or on my weekends off (though I made sure I never recorded those hours or told the PD. I'm not suggesting other do that, but it was just an example because I didn't want to get in trouble for going over work hours). Either way, because of the variability in research training, or scholarly projects, the only thing I've observed is that the more effort fellows put into it, the more they get out of it and the more successful they are.

Attending: So, here there are many different models (more so than fellowship). There are academic positions and private practice positions (locums or stationary). I don't work in private practice, but maybe someone who has or does can comment. The typical model I've seen it 2 weeks on, 2 weeks of per month, however I'm sure there is tons of variability to that model. Typically when you are on, you are on 24/7 for the duration of your service time, but when you are off, you are off. The acuity is probably variable depending if your practice is attached to a bigger medical center, or a community hospital. As far as academics go, again variations depending on the track. Typically tracks include clinician-educator, clinician-scientist and in some place master-clinicians. The master-clinicians are essentially clinician only members of the group and don't, or have limited, educational and administrative responsibilities. Their goal is really only to see patients. The clinician-educators see less patients than master clinicians, but more than clinician-scientists, and have the added duty of administrative and education roles (student/resident/fellow education, curriculum development, stimulation training, didactics, student development, etc.) as well as committee assignments, QI development and have to maintain productivity in the those extra-clinical roles. In my experience, a majority of the PICU attendings at academic centers are going to be in this role, but institutions variety. Clinician-scientists usually have the least clinical duties, but because of that, have to supplement their salary with grants and external funding and are typically held to higher standards as far as publication numbers. These attendings typically do bench or clinical research, or a derivation of the two, and in some instances QI depending on funding opportunities available. Again, given the diversity of practice models in academics, there is no average day, it is highly person dependent. Additionally, because in most places, salary is mainly decided by the number of patients you see and not whether you have extra-clinical projects, the degree of involvement in extra-clinical activities varies, typically depending on 1) a desire to get promoted or not fired (speaking to tenure tract) and 2) work-life balance. There are some academic centers that have part-time models, though I haven't seen that commonly. So the average work week could be 24 to 36 hours for some and 80 hours for other, again depending on personal preference of work-life balance, income need, career goals, etc.

There are several other PICU attendings on here that I'm sure could give you their own experience as well.

 

[67552931811]

There are a lot of different permutations and practice models to the questions you ask and thus, you'll probably get a variety of answers. Likewise it is hard to define an "average day" but I'll give you my broad strokes.

Fellowship: Most places break up clinical and research time 50/50. There are variations to this breakup and within the clinical and research time, there are further variations of month blocks of clinical/research time, versus weeks/days. Most clinical blocks will be PICU, CVICU and Anesthesia with electives and other variables thrown in (practice attending, sedation time, etc.). Most places (I think) have some version of day shifts (6am to 6pm) and night shifts (6pm to 6am). You show up when you are requested to, but you leave when the work is done and patients are stable for handover, as long as you don't break the 80 hour work week and don't take on new patients after 24 consecutive hours. It is impossible to say what that day looks like on average because there are a lot of variables that go into the day (acuity, bed space, admissions, discharges/transfers, family meetings, educational opportunities, procedures). In fact, the absence of the "average day" is what makes the job interesting. Like momma Gump said, "You never know what you are going to get". Actually, the clinical aspects, though there is variability among programs, is pretty standard from place to place. The ACGME regulates this pretty closely and every program is expected to train fellows with the same basic skills to take care of critically ill patients. The research, or scholarly project, on the other hand is highly variable. More so than clinical time, the research time has no typical day because 1) people do lots of different projects and 2) there is no daily time table, so people kinda do with their time how they see fit within the scope of the project. I did bench research and showed up at 8am (earlier than lab mates) and at 5pm or when experiments were finished. Sometimes, I stayed post-call or on my weekends off (though I made sure I never recorded those hours or told the PD. I'm not suggesting other do that, but it was just an example) because I didn't want to get in trouble for going over work hours. Either way, because of the variability in research training, or scholarly projects, the only thing I've observed is that the more effort fellows put into it, the more they get out of it and the more successful they are.

Attending: So, here there are many different models (more so than fellowship). There are academic positions and private practice positions (locums or stationary). I don't work in private practice, but maybe someone who has or does can comment. The typical model I've seen it 2 weeks on, 2 weeks of per month, however I'm sure there is tons of variability to that model. Typically when you are on, you are on 24/7 for the duration of your service time, but when you are off, you are off. The acuity is probably variable depending if your practice is attached to a bigger medical center, or a community hospital. As far as academics go, again variations depending on the track. Typically tracks include clinician-educator, clinician-scientist and in some place master-clinicians. The master-clinicians are essentially clinician only members of the group and don't, or have limited, educational and administrative responsibilities. Their goal is really only to see patients. The clinician-educators see less patients than master clinicians, but more than clinician-scientists, and have the added duty of administrative and education roles (student/resident/fellow education, curriculum development, stimulation training, didactics, student development, etc.) as well as committee assignments, QI development and have to maintain productivity in the those extra-clinical roles. In my experience, a majority of the PICU attendings at academic centers are going to be in this role, but institutions variety. Clinician-scientists usually have the least clinical duties, but because of that, have to supplement their salary with grants and external funding and are typically held to higher standards as far as publication numbers. These attendings typically do bench or clinical research, or a derivation of the two, and in some instances QI depending on funding opportunities available. Again, given the diversity of practice models in academics, there is no average day, it is highly person dependent. Additionally, because in most places, salary is mainly decided by the number of patients you see and not whether you have extra-clinical projects, the degree of involvement in extra-clinical activities varies, typically depending on 1) a desire to get promoted or not fired (speaking to tenure tract) and 2) work-life balance. There are some academic centers that have part-time models, though I haven't seen that commonly. So the average work week could be 24 to 36 hours for some and 80 hours for other, again depending on personal preference of work-life balance, income need, career goals, etc.

There are several other PICU attendings on here that I'm sure could give you their own experience as well.

Hopefully @user7717 doesn't mind me asking a tangential question here. But, as a med student who is extremely interested in picu/nicu, what would you say to this student, i.e. me, if they are going to have massive debt (ergo: graduate med school with 400K in debt at 7% interest-- so who knows how much that will balloon to during res/fellowship). I love kids and would love to do picu or nicu but am terrified of the debt. I've gotten some financial info via a few nicu docs because I know some who are in PP but I have never met a pure PP PICU doc (granted, my searching has been minute). To be clear, I am not wanting to do nicu/ picu for the monetary prospect of it all. If I had no debt or significantly less then I wouldn't even be asking this. But, the debt gives me nightmares...

 

[DeadCactus]

Tangentially related, do most PICU programs have a medical director or similar person whose focus and academic buy-down comes from running the transport side of things? If so, is it generally competitive to get that position?

 

[SurfingDoctor]

Tangentially related, do most PICU programs have a medical director or similar person whose focus and academic buy-down comes from running the transport side of things? If so, is it generally competitive to get that position?

Yes and no. It depends on which division/department takes ownership of medical transport. In some places it is the ER (which gets a majority of the transports), PICU or NICU (which also gets a lot of transports). Additionally, if the pediatric department is associated with a larger adult medical center, then the a centralized medical transport system may be in place and may be run by adult physicians. Typically, the PICU medical director (or in a rarer case, a PICU attending who is transport director) will be the PICU representative or liaison for the hospital transport system. That being said, it is not even close to a full time job and while administrative roles do buy-down clinical time, I suspect it would be no more that 10% at max (depending on the degree of PICU ownership of transport).

 

[michigangirl]

Tangentially related, do most PICU programs have a medical director or similar person whose focus and academic buy-down comes from running the transport side of things? If so, is it generally competitive to get that position?

As surfing said, depends on which department runs transport. At our center PICU and ED share transport leadership although all of the operations run out of the PICU with PICU nurses trained in transport. We have a specific PICU transport director with protected time for that activity, in addition to a medical director.

 

[DeadCactus]

Is it an active field of research where one could reasonably build a niche combining an academic/research role and an administrative role for a more robust clinical buy-down?

 

[SurfingDoctor]

Is it an active field of research where one could reasonably build a niche combining an academic/research role and an administrative role for a more robust clinical buy-down?

I don't know the answer to how robust a field transport is, though they do have medical journals dedicated to transport medicine (http://www.airmedicaljournal.com/). In fact the AAP has a section on Transport Medicine (http://www2.aap.org/sections/transmed/). However to buy-down time for research, you need grant funding or some source of external funding. And it order to get grant funding, you need to dedicate a lot of time to it and the research you propose to do, as well as publish your research. Thus, typically researchers with grant funding have (or at least try to have) as little administrative time as possible so they can focus on research. You really can't be a robust researcher and administrative person, at least not very successfully. Now, most academic positions have a certain allotment of extra non-clinical time. So you could get do transport in the administrative capacity to buy down time and use the extra non-clinical time you have to study whatever you wanted in relation to transport. But as a general rule of thumb, if you don't have money supporting it, you can't buy it down. Typically, in my experience, clinicians involved in administration don't focus on one specific niche. I suppose that there are always exceptions to the rule, but usually people in administration have multiple administrative endeavors that may have a theme, ie transport + trauma + CPR committee. The more roles you have, the more external funding you can get to buy down time. One possible way to focus on transport solely would to be selected to be part of a national committee (as mentioned above) and well as offer regional education to either referral centers or EMS department. I don't know how much time that buys, but travelling for national committees and/or education will get something.

If you really wanted to know, I would suggest reaching out to someone on the AAP section on Transport Medicine and ask their advice. It probably is possible to make a career out of it, and like most career paths that you want to be successful in, you just need the right environment, mentoring and networking.

 

[BigRedBeta]

Transport medicine is one of my passions, the point that I looked into doing a one year Emergency Medical Systems Fellowship (it's most routinely out of Adult EM), but the timing and particularly the funding of it all was problematic so I didn't. And I'm part of the SOTM, though for various reasons I've yet to really get involved with the transport team at my new institution as I've transitioned into an attending (it will happen though).

I don't know of anyone right now who is getting sufficient grant funding in transport to warrant a decrease in service time in the Unit - whether that's ED/PICU or NICU. That doesn't mean there isn't someone, but it'd be rare. The NIH only gave out its first pediatric transport grant to the group at Arkansas Children's about 5-6 years ago. I'm not sure if they've given out another award since. There are other entities that give out money such as Air Medical Physicians Association, but the grants are typically small. Probably the best chance at a really large grant, at this juncture, is to go through a group like PALISI or PCORI with a really good idea.

However, from a research standpoint, because so little has been done in the past, it's really a wide open field to ask questions. Much of what's going on at the national level is about benchmarking and trying to find best practices in a QI model rather than an RCT methodology (in part, because as you can imagine, true informed consent is hard to manage in most patient transport scenarios). There is also a lot of "proof of concept" work that needs to be done as well - most transport teams now at least say they are trying to bring the NICU or PICU or Peds ED to the patient, but to outsiders (and those paying the bills) it needs to be shown that this is better than just the old "scoop and run" approach. Teams are buying rigs and aircraft that can deliver iNO and Heliox at significant expense and need to prove it's of benefit. It seems strange but if you were to repeat a great number of studies in the ED, everyone would go "yeah, of course" but do it in the back of an ambulance or a helicopter and it becomes novel.

When I was doing my job search, most places were okay with transport being my administrative/research niche, but it only became a positive in places that really felt they had a need for someone to step into that role soon. Everywhere else, I think I would have been a more attractive candidate if I would have something more broadly applicable like neurocritical care or a master's in MedEd.

In the end I ended up with multiple job offers, but chose a private practice group.
What I'll say about being a PP attending is that it's highly variable. Unit size and acuity make a huge difference, and no two places in PP are likely to be the same. I did some locum tenens jobs in small towns with 6 and 8 bed units, one had pediatric hospitalists and in the other, I was covering the peds ward and the PICU. Some places are 24/7 coverage for a week or two at a time. My current home practice is much larger than those with much higher acuity, 8 full time PICU attendings (and a couple that add into our night shift rotation) and we do roughly 7 on/7off with rotating weeks of night shift so 5-6 weeks per year. In our model, we're doing 26 weeks of service compared to the 14-17 weeks I would have done at at the academic places I got job offers and with roughly the same total number of yearly night calls. But those other 26 weeks are completely my time if I want, which in an academic center I'd still be coming in to remain "academically productive". Coming out of fellowship, private practice PICU requires finding exactly the right spot that has enough volume and acuity to continue your maturation as an intensivist and so it isn't something I'd recommend considering as a routine option. If it's something that because of family, geography or disillusionment with the academic grind that appeals to you, it's probably best to grind out 3-5 years in academics before transitioning to one of the smaller PP units.

 

[bjackrian]

I agree with what's been posted above. I'm at a big academic center, so that's where my opinions below come from.

Transport: Our hospital has multi-disciplinary transport direction with representation from PICU, CICU, NICU, and ED. I'm our PICU rep and don't get dedicated time for it specifically, but am able to use that time to cover some of my "other administrative duties" that are part of my regular clinical job. Our ED director gets a small amount of funded time for her work (mostly because she's the one who travels to our regional meetings and does most of the external coordination). I do it mostly because I like working with our transport team and I think a lot of the medical issues that go along with transport are interesting (plus, ambulances, helicopters, airplanes--it's possible I never grew up from that wide-eyed little boy!) If you're interested in transport medicine the AAP transport medicine section, as mentioned, is a great resource. If you happen to be going to the AAP national meeting, the transport section usually does a pretty good program and it's easy to chat with people from a lot of different places and hear the diversity in how transport programs are run.

Fellow life: Surfing Doctor provided a nice overview of the life of fellows and attendings. At our program, fellows over 3 years are about 50/50 research/clinical time. Clinical rotations are about 2/3 medical PICU, 1/6 CICU, and 1/6 miscellaneous. Those are pretty standard ICU inpatient clinical days (in terms of hours, not workflow) that won't seem a lot different from residency--come in around 7a, leave around 6p. The work was more interesting (since it's what you want to be doing, hopefully) and was less note-writing, slog-through-the-day than residency. I was definitely tired at the end of service months, but rarely felt like I was truly drowning.

Attending life: Our attendings also have a variety of niches. We have a cohort of attendings who are primarily clinical who work 14-17 service weeks per year. We have a cohort who do significant research who work fewer weeks (sometimes down to 3-5/year). There are also people like me who have other niches that we get paid for (I get paid to do clinical ethics work and to serve as an IRB chair; others get paid for work on fellowship and residency programs and the like). Clinically, we work one week on, and during that week we only cover days. On our off weeks, we have in-house night coverage that we share (so the attendings on service for the week don't take night call during their service week). Days typically run from about 730a-6p when on service. The primarily clinical people all have at least a few responsibilities when off service, but have many fewer non-clinical requirements than the folks who have protected time (who are busy doing whatever their time is protected for). In short, even within our program there's a lot of variation in what people are doing and how their time is balanced. That only expands as you consider more programs and practice models, so I think you'd be able to find something that works.

Debt: Finally, for ChiTownBHawks, there are a lot of ways to manage debt when you're in practice. There are programs to help limit how much you pay and/or provide repayment if you choose to work in academics. If you think pediatrics is right for you, I'd urge you to do it--there are a lot of us out there with v. large medical school debt who are able to make it work. Am I going to drive a $100,000 car, fly around on a private jet, and head off to the islands a few times a year? No. But we're able to comfortably afford a nice house in a nice city with good schools, a reasonable amount of travel, retirement savings, and generally a life that I think is basically the good life. My opinion: It's possible to make pediatrics work whether you choose to go an academic route or a private practice route, even when you come out of school with a crap-ton of debt!

 

[DeadCactus]

Any willing to comment on the job market or salary? Should I be concerned about finding a job if I'm limited to locations based on my spouse's job prospect in a different pediatric subspecialty? What salary range would be reasonable to anticipate for working 18 clinical weeks a year in a tertiary referral center?

 

[SurfingDoctor]

Should I be concerned about finding a job if I'm limited to locations based on my spouse's job prospect in a different pediatric subspecialty?

This will limit you to some degree since you both have to find jobs. My wife also works full-time in healthcare administration. When I applied for jobs, I had to look at places where 1) we could afford to live without being house poor 2) where I could have the opportunities I needed for my career (as a physician-scientist) 3) where my wife could find a job that she would be satisfied in. Most places you interview at will try to arrange a job interview for your significant other or at least help them network locally to find something they could do, but the amount of effort they put in was highly variable in my experience. For my wife, some arranged for her to meet several leaders (CEOs and the like) across the hospital/university system and discuss job opportunities, while other arranged a 5 minute phone call. Clearly, if you are some well-established, highly-funded person, they will bend over backwards to get you, but if you are just out of fellowship, you take what you can get. If your spouse is in pediatric subspecialist, then obviously you will need to find a place that has a job for you both and that will limit your choices. In the end, you both will likely have to compromise to both be satisfied (ie, not your favorite city, not your ideal pay, etc.).

What salary range would be reasonable to anticipate for working 18 clinical weeks a year in a tertiary referral center?

Generally speaking, academics is going to pay less (sometime considerably so) than private practice (though you tend to have less service time as well). Additionally, at least in my experience, the bigger or more renown the center is, the less competitive the salary is. There are also many regional differences based on cost of living, financial model of the school/university/hospital, non-salary fringe benefits, etc.. If I was going to give a ballpark at a large academic center for someone straight out of fellowship, I would say 150-200K/year.

 

[BigRedBeta]

Any willing to comment on the job market or salary? Should I be concerned about finding a job if I'm limited to locations based on my spouse's job prospect in a different pediatric subspecialty? What salary range would be reasonable to anticipate for working 18 clinical weeks a year in a tertiary referral center?

Having to find two jobs is always more challenging than finding one. But, having someone medical might actually be easier because you can both find "suitable" jobs in places like Iowa City, Little Rock or Morgantown, or in bigger cities like Dallas, Atlanta or Denver. For me, my wife's expertise in marketing put the best/most jobs in her industry in SF, Chicago or NYC and going outside of those locations automatically meant a drop in title, prestige and salary if she stayed in the same niche.

Coming out of fellowship last year, my co-fellows and I were all in the northern half of that salary range SurfingDoctor mentioned for the job offers we got. Things like overnight call bonuses can be substantial. Agree though that the bigger the name, generally the worse the salary structure.

 

[DeadCactus]

There seem to be a number of combination routes to PICU with cardiology and anesthesiology being the most common I see (with rarer situations like nephrology, ID, EM, etc). Any insight into what affects this has on a career? Does it make it easier to find a job in the location of your choice? Do salaries adjust to a middle ground between the two specialties? Do sections/departments play nice with one another and allow you to have a role in both areas?

 

[SurfingDoctor]

There seem to be a number of combination routes to PICU with cardiology and anesthesiology being the most common I see (with rarer situations like nephrology, ID, EM, etc). Any insight into what affects this has on a career? Does it make it easier to find a job in the location of your choice? Do salaries adjust to a middle ground between the two specialties? Do sections/departments play nice with one another and allow you to have a role in both areas?

Certainly, PICU and Cardiology is probably the most common route, Anesthesiology and PICU being the second most common. I won't pretend to now the facets of these career paths (maybe someone on here with more experience can weight in), but it has been my general observation that despite being dual-boarded, most people end up picking one versus the other. I have seen PICU + Anesthesia be a little better at keeping a feet in both world (ie having OR time and service time) as opposed to PICU + Cardiology which typically leads to CVICU + Echo time. I will say that the more versatile your skill set, the more marketable you are, but that comes at the price of doing extra training time with lost revenue. Likewise, it is hard to maintain certification and expertise in multiple areas when it comes to board certification. Most people have a hard time (expense and time wise) managing two board certification, if you add another one, it is a challenge. As far as do divisions/departments play nice, well I suppose this is institution dependent, but the reality is section chiefs are going to view their divisions best interests over yours or your other divisions. Thus you end up working in one division with one role for simplicity sake. I think you should ask yourself, where do you see yourself in 10 to 20 years. This will likely be the best guide in determining your career path.

If you want my honest advice as far as marketability at the current time (assuming marketability changes), PICU plus a CVICU extra fellowship gives you the most opportunity as you can handle PICU patients but have the added training to handle CVICU patients. Academic marketability is a slightly different manner, but again PICU + CVICU year will get you the most job responses. Others are welcome to disagree, but this has been my observation over the past several years.

 

[WheezyBaby]

Certainly, PICU and Cardiology is probably the most common route, Anesthesiology and PICU being the second most common. I won't pretend to now the facets of these career paths (maybe someone on here with more experience can weight in), but it has been my general observation that despite being dual-boarded, most people end up picking one versus the other. I have seen PICU + Anesthesia be a little better at keeping a feet in both world (ie having OR time and service time) as opposed to PICU + Cardiology which typically leads to CVICU + Echo time. I will say that the more versatile your skill set, the more marketable you are, but that comes at the price of doing extra training time with lost revenue. Likewise, it is hard to maintain certification and expertise in multiple areas when it comes to board certification. Most people have a hard time (expense and time wise) managing two board certification, if you add another one, it is a challenge. As far as do divisions/departments play nice, well I suppose this is institution dependent, but the reality is section chiefs are going to view their divisions best interests over yours or your other divisions. Thus you end up working in one division with one role for simplicity sake. I think you should ask yourself, where do you see yourself in 10 to 20 years. This will likely be the best guide in determining your career path.

If you want my honest advice as far as marketability at the current time (assuming marketability changes), PICU plus a CVICU extra fellowship gives you the most opportunity as you can handle PICU patients but have the added training to handle CVICU patients. Academic marketability is a slightly different manner, but again PICU + CVICU year will get you the most job responses. Others are welcome to disagree, but this has been my observation over the past several years.

Would you mind expanding on the bolded?

 

[SurfingDoctor]

Would you mind expanding on the bolded?

Sure. Academics can mean a lot of things. Typically, it means falling into one of several categories, namely a physician-scientist, a physician-educator, or a master physician (a relatively new role that only sees patients). Certainly, there are times when a PICU or CVICU is short staffed or has extra shifts to be filled and in that case, most units just need a person to fill in. However, this is regional and unit-need specific. In general, a graduate of fellowship who wants to pursue academics as a career, needs to have a niche to make themselves marketable. For instance, if there is a need for a PICU intensivist at an academic center, there will likely by 10 to 20 applicants for 1-2 spots. On paper, people can look the same so you really need a niche or skill set that differentiates you for the rest. Now I will say that this skill set may be dependent on the needs of the institution and thus, somewhat regional, but for instance if you have two applicants for an academic position, there is really little from a general PICU fellowship that differentiates the two. Both know how to put in central lines, both know how to intubate, both know how to wean to determine someone is ready to decannulate from ECMO. The ACGME makes sure that is pretty standardized. However, if one applicant has done additional QI training and taking a course in QI and PDSA cycles and show that they know how to implement it, or someone has undergone additional training in Bioethics and earned a certification in palliative care, or has done additional time on a T32 training grant and published a paper on their research, they are far more likely to be hired. A division chief is going to pick someone who is a good clinical intensivist based on letters of recommendation and word of mouth, but what is going to get them hired compared to the other applicants is that they bring a skill set to the division that the applicant has already begun and the division chief can help cultivate into someone where they are a leader in their respective field (and likewise, the division chief can brag about to his superior, the department chair). This is why the "scholarly activity" portion is so critical in fellowship training. Now if one doesn't want to do academics, then how you spend you scholarship time is more or less irrelevant (though I still thing you should try to maximize that time that you get something out of it to help your career), but if you want to do academics, it is one's time to really start the foundation of a career in academics that will not only get you hired, but bring more satisfaction to your career.

BTW, I don't say this only as my opinion. My division chief tells this to each and every fellow applicant (and the division chief determines future hires).

 

[Obnoxious Dad]

Sure. Academics can mean a lot of things. Typically, it means falling into one of several categories, namely a physician-scientist, a physician-educator, or a master physician (a relatively new role that only sees patients). Certainly, there are times when a PICU or CVICU is short staffed or has extra shifts to be filled and in that case, most units just need a person to fill in. However, this is regional and unit-need specific. In general, a graduate of fellowship who wants to pursue academics as a career, needs to have a niche to make themselves marketable. For instance, if there is a need for a PICU intensivist at an academic center, there will likely by 10 to 20 applicants for 1-2 spots. On paper, people can look the same so you really need a niche or skill set that differentiates you for the rest. Now I will say that this skill set may be dependent on the needs of the institution and thus, somewhat regional, but for instance if you have two applicants for an academic position, there is really little from a general PICU fellowship that differentiates the two. Both know how to put in central lines, both know how to intubate, both know how to wean to determine someone is ready to decannulate from ECMO. The ACGME makes sure that is pretty standardized. However, if one applicant has done additional QI training and taking a course in QI and PDSA cycles and show that they know how to implement it, or someone has undergone additional training in Bioethics and earned a certification in palliative care, or has done additional time on a T32 training grant and published a paper on their research, they are far more likely to be hired. A division chief is going to pick someone who is a good clinical intensivist based on letters of recommendation and word of mouth, but what is going to get them hired compared to the other applicants is that they bring a skill set to the division that the applicant has already begun and the division chief can help cultivate into someone where they are a leader in their respective field (and likewise, the division chief can brag about to his superior, the department chair). This is why the "scholarly activity" portion is so critical in fellowship training. Now if one doesn't want to do academics, then how you spend you scholarship time is more or less irrelevant (though I still thing you should try to maximize that time that you get something out of it to help your career), but if you want to do academics, it is one's time to really start the foundation of a career in academics that will not only get you hired, but bring more satisfaction to your career.

BTW, I don't say this only as my opinion. My division chief tells this to each and every fellow applicant (and the division chief determines future hires).

This post reads like a description of the job market for attorneys. If this post is accurate, the PICU market is oversupplied. If someone is in a two career marriage, he or she had better think twice about PICU fellowship.

 

[michigangirl]

Sure. Academics can mean a lot of things. Typically, it means falling into one of several categories, namely a physician-scientist, a physician-educator, or a master physician (a relatively new role that only sees patients). Certainly, there are times when a PICU or CVICU is short staffed or has extra shifts to be filled and in that case, most units just need a person to fill in. However, this is regional and unit-need specific. In general, a graduate of fellowship who wants to pursue academics as a career, needs to have a niche to make themselves marketable. For instance, if there is a need for a PICU intensivist at an academic center, there will likely by 10 to 20 applicants for 1-2 spots. On paper, people can look the same so you really need a niche or skill set that differentiates you for the rest. Now I will say that this skill set may be dependent on the needs of the institution and thus, somewhat regional, but for instance if you have two applicants for an academic position, there is really little from a general PICU fellowship that differentiates the two. Both know how to put in central lines, both know how to intubate, both know how to wean to determine someone is ready to decannulate from ECMO. The ACGME makes sure that is pretty standardized. However, if one applicant has done additional QI training and taking a course in QI and PDSA cycles and show that they know how to implement it, or someone has undergone additional training in Bioethics and earned a certification in palliative care, or has done additional time on a T32 training grant and published a paper on their research, they are far more likely to be hired. A division chief is going to pick someone who is a good clinical intensivist based on letters of recommendation and word of mouth, but what is going to get them hired compared to the other applicants is that they bring a skill set to the division that the applicant has already begun and the division chief can help cultivate into someone where they are a leader in their respective field (and likewise, the division chief can brag about to his superior, the department chair). This is why the "scholarly activity" portion is so critical in fellowship training. Now if one doesn't want to do academics, then how you spend you scholarship time is more or less irrelevant (though I still thing you should try to maximize that time that you get something out of it to help your career), but if you want to do academics, it is one's time to really start the foundation of a career in academics that will not only get you hired, but bring more satisfaction to your career.

BTW, I don't say this only as my opinion. My division chief tells this to each and every fellow applicant (and the division chief determines future hires).

This is one of the best posts I've seen on SDN in a long time. Should be a sticky. SurfingDoc summed it up re: PICU attending jobs in ACADEMIC institutions. Its no longer enough to finish a fellowship and do a scholarly activity project. Yes, the job market is more challenging than before-- to be clear, there are jobs at smaller, private non-academic PICUs, but anecdotally it's clear the jobs in large academic PICUs are limited. Faculties are filled, many are young so won't be going anywhere for a while. You have to be able to fill an administrative, education, qi/innovation or research need with your niche to be marketable. That is the game right now, for better or for worse.

 

[jl lin]

There are a lot of different permutations and practice models to the questions you ask and thus, you'll probably get a variety of answers. Likewise it is hard to define an "average day" but I'll give you my broad strokes.

Fellowship: Most places break up clinical and research time 50/50. There are variations to this breakup and within the clinical and research time, there are further variations of month blocks of clinical/research time, versus weeks/days. Most clinical blocks will be PICU, CVICU and Anesthesia with electives and other variables thrown in (practice attending, sedation time, etc.). Most places (I think) have some version of day shifts (6am to 6pm) and night shifts (6pm to 6am). You show up when you are requested to, but you leave when the work is done and patients are stable for handover, as long as you don't break the 80 hour work week and don't take on new patients after 24 consecutive hours. It is impossible to say what that day looks like on average because there are a lot of variables that go into the day (acuity, bed space, admissions, discharges/transfers, family meetings, educational opportunities, procedures). In fact, the absence of the "average day" is what makes the job interesting. Like momma Gump said, "You never know what you are going to get". Actually, the clinical aspects, though there is variability among programs, is pretty standard from place to place. The ACGME regulates this pretty closely and every program is expected to train fellows with the same basic skills to take care of critically ill patients. The research, or scholarly project, on the other hand is highly variable. More so than clinical time, the research time has no typical day because 1) people do lots of different projects and 2) there is no daily time table, so people kinda do with their time how they see fit within the scope of the project. I did bench research and showed up at 8am (earlier than lab mates) and at 5pm or when experiments were finished. Sometimes, I stayed post-call or on my weekends off (though I made sure I never recorded those hours or told the PD. I'm not suggesting other do that, but it was just an example because I didn't want to get in trouble for going over work hours). Either way, because of the variability in research training, or scholarly projects, the only thing I've observed is that the more effort fellows put into it, the more they get out of it and the more successful they are.

Attending: So, here there are many different models (more so than fellowship). There are academic positions and private practice positions (locums or stationary). I don't work in private practice, but maybe someone who has or does can comment. The typical model I've seen it 2 weeks on, 2 weeks of per month, however I'm sure there is tons of variability to that model. Typically when you are on, you are on 24/7 for the duration of your service time, but when you are off, you are off. The acuity is probably variable depending if your practice is attached to a bigger medical center, or a community hospital. As far as academics go, again variations depending on the track. Typically tracks include clinician-educator, clinician-scientist and in some place master-clinicians. The master-clinicians are essentially clinician only members of the group and don't, or have limited, educational and administrative responsibilities. Their goal is really only to see patients. The clinician-educators see less patients than master clinicians, but more than clinician-scientists, and have the added duty of administrative and education roles (student/resident/fellow education, curriculum development, stimulation training, didactics, student development, etc.) as well as committee assignments, QI development and have to maintain productivity in the those extra-clinical roles. In my experience, a majority of the PICU attendings at academic centers are going to be in this role, but institutions variety. Clinician-scientists usually have the least clinical duties, but because of that, have to supplement their salary with grants and external funding and are typically held to higher standards as far as publication numbers. These attendings typically do bench or clinical research, or a derivation of the two, and in some instances QI depending on funding opportunities available. Again, given the diversity of practice models in academics, there is no average day, it is highly person dependent. Additionally, because in most places, salary is mainly decided by the number of patients you see and not whether you have extra-clinical projects, the degree of involvement in extra-clinical activities varies, typically depending on 1) a desire to get promoted or not fired (speaking to tenure tract) and 2) work-life balance. There are some academic centers that have part-time models, though I haven't seen that commonly. So the average work week could be 24 to 36 hours for some and 80 hours for other, again depending on personal preference of work-life balance, income need, career goals, etc.

There are several other PICU attendings on here that I'm sure could give you their own experience as well.

Thank you for sharing.

The highlighted is definitely an issue, b/c if a great learning opportunity arises, in medicine, it's not like you are being interviewed on the air, and they say, "That's it. We have to leave it at that." The beauty of learning in medicine is to experience and learn in RT, in person, working through the issues/problems. I think they should make exceptions for the 80 hours. If someone can sign-off that it was a stellar experience that they resident/ fellow needed to continue with, what is the problem? People that are controlling things at the top refuse to except that medicine isn't like making donuts or widgets. It's really a shame.