My heart is set on peds but everything else is telling me not to

[shishka32]

Rising MS4 really struggling with specialty choice. My heart is in peds. I love working with kids. In my weekly med-peds clinic I really enjoyed every peds clinic visit and was neutral to unhappy with most adult visits.

That being said, I find typical gen peds and general ward medicine a little dull after a while. I would want to do a subspecialty like NICU or PICU or cards. This would limit my future practice geographic location, have a lower salary (I have a ton of debt), and probably be more intense compared to radiology which I am considering (it's either see kids or don't see patients at all... exaggeration but kind of true). I am fascinated by the tech in rads and the fact I would know a unique skillset most other physicians need help with. My wife and I are dying to get back to my smallish hometown that doesn't have a PICU or peds cardiologist. There is a small NICU though. I would make more money in radiology and probably have more time off for family. I have mentors telling me I really should not do a lower paying specialty because reimbursements will just continue to go down.

I feel this is a major, major life decision and that I cannot even fully grasp the consequences. If I choose peds, I likely will never be moving home to my extended family and I will have a lesser lifestyle but I may enjoy my work more. I honestly do like radiology and enjoy learning about it, but I love pediatrics.

Any advice would be appreciated.

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[christmasindr]

How about pediatrics radiology? You do have some patient interactions there for procedures/imaging studies.

 

[EarthtoneJon]

Hi there,

I'm an incoming peds intern, so obviously a little biased. 2 pieces of advice for you:

1. A mentor once told me to "choose the specialty in which you enjoy (or least detest) the most boring type of encounter." In other words, pick the specialty whose boring or bread-and-butter stuff is most enjoyable for you. For example, certain eyeball diseases fascinate me, but I couldn't possibly be happy managing glaucoma all day. Ophthalmology was a definite no-go! On the other hand, in med school I loved the peds well visits. I loved learning about how kids were doing in school, providing anticipatory guidance to parents, and counseling about diet, exercise, etc. That's how I knew peds was right for me.

2. I'll probably draw a lot of flack for this one. I am not a personal finance expert, but The White Coat Investor (good book, highly recommend) demonstrably concludes that all physicians (even those employed in primary care specialties, and even those with worst-case-scenario student loan debt) have tremendous potential to accumulate wealth, provided they "spend like residents" for a few years after residency, and make sound financial investments. What this tells me is that, if the goal is to get as fabulously wealthy as possible as soon as possible, ortho, derm, or plastics may be the way to go. But if the goal is to do what I love and also accumulate considerable wealth, only the specialty I love will do (and I need not fear financial ruin). This notion changed the game for me, and made higher-earning specialties with poorer associated lifestyles lose their appeal. Another disclaimer: I grew up in a 5-person household with net income under $50,000, and so the prospect of tripling that yearly income before age 40 seems unreal. Still, your lifestyle goals are your own, and don't let anyone guilt you out of factoring income into your decision! Anyone who scoffs at money-talk and says "it's all about the calling" pisses lemonade and probably thinks Roth IRA was a character on Friends.

 

[Cuthbert]

+1 for The White Coat Investor. Read the book. Visit his website often. Lots of good information there.

What is your loan amount?

 

[shishka32]

How about pediatrics radiology? You do have some patient interactions there for procedures/imaging studies.

Absolutely would be a great way to combine my interests. Unfortunately, this doesn't get around the geography goals (not many peds radiologists) but would otherwise be a great fit I Think.

Hi there,

I'm an incoming peds intern, so obviously a little biased. 2 pieces of advice for you:

1. A mentor once told me to "choose the specialty in which you enjoy (or least detest) the most boring type of encounter." In other words, pick the specialty whose boring or bread-and-butter stuff is most enjoyable for you. For example, certain eyeball diseases fascinate me, but I couldn't possibly be happy managing glaucoma all day. Ophthalmology was a definite no-go! On the other hand, in med school I loved the peds well visits. I loved learning about how kids were doing in school, providing anticipatory guidance to parents, and counseling about diet, exercise, etc. That's how I knew peds was right for me.

2. I'll probably draw a lot of flack for this one. I am not a personal finance expert, but The White Coat Investor (good book, highly recommend) demonstrably concludes that all physicians (even those employed in primary care specialties, and even those with worst-case-scenario student loan debt) have tremendous potential to accumulate wealth, provided they "spend like residents" for a few years after residency, and make sound financial investments. What this tells me is that, if the goal is to get as fabulously wealthy as possible as soon as possible, ortho, derm, or plastics may be the way to go. But if the goal is to do what I love and also accumulate considerable wealth, only the specialty I love will do (and I need not fear financial ruin). This notion changed the game for me, and made higher-earning specialties with poorer associated lifestyles lose their appeal. Another disclaimer: I grew up in a 5-person household with net income under $50,000, and so the prospect of tripling that yearly income before age 40 seems unreal. Still, your lifestyle goals are your own, and don't let anyone guilt you out of factoring income into your decision! Anyone who scoffs at money-talk and says "it's all about the calling" pisses lemonade and probably thinks Roth IRA was a character on Friends.

Thanks! I appreciate your response. For #1, I think that is great advice. But to play devil's advocate I think I would love my "dull" days on PICU for instance which would be what I would do for decades after fellowship. For #2, I read that book. It is very good. But I am still scared out of my mind having 375k in loans, probably will be more like 450k once I'm done with fellowship. That combined with usually needing to live in a bigger city to do some of these peds subspecialties is frightening. Probably doable, but frightening.

+1 for The White Coat Investor. Read the book. Visit his website often. Lots of good information there.

What is your loan amount?

Love the book and website. 375K by graduation, like 425-475K once I'm done with fellowship. I took the cheapest possible options I had available to me for both undergrad and med school.

 

[Ismet]

First, congrats on matching!

Secondly, as to the bolded: my family has always told me me this same exact thing but I'm not sure if I buy it. For example, how many PICU and peds cards doc really enjoyed doing well visits during residency? I don't think I'm taking a giant leap by saying that number will probably be very low.

It really varies by person. One of our graduating residents who matched to PICU still enjoys clinic. On the other hand, another resident going into PICU is more "all about PICU" and cares less about other things. Another resident is toying between gen peds and cards. I plan on gen peds outpatient but I've honestly enjoyed all aspects of my intern year, from acute clinic to wards to ICU. I would never want to do NICU or PICU for my whole life, but for a couple months per year I can suck it up and learn some stuff, and it's not that bad. So it varies by person, personality, and how open minded you are. Even if you're deadset on PICU and hate gen peds, there is gen peds stuff that you NEED to learn in order to be a great PICU doc. You're never going to love all aspects of residency, no matter what residency you choose. Look at the outcome - if you really truly see yourself being happy in the PICU or NICU or being a pediatric cardiologist, you can suck up the less appealing months of residency. It's only 3 years out of the rest of your life.

 

[shishka32]

Same for me. Though, 425 seems to be an awfully conservative estimate unless your rates aren't about 6.5% consolidated and or unless your spouse has a well paying job. I did the math and if I don't touch my debt till I'm done with residency and fellowship, at 6.7% consolidation, my loans will go from 375 to about 550.

I have a working spouse and we plan to do loan consolidation as soon as possible after graduation. The loan balance could certainly go up to 500K though.

 

[oldbearprofessor]

Radiology and pediatrics are not similar. Go with your heart, 20 years from now you'll be glad. Neonatology is commonly the highest paid pediatric specialty and I'm far from convinced that by the time you are done the salary difference between them will be large or even exist. But, I can't predict future salaries and neither can anyone else. Lifestyle? Neonatologists (and PICU docs, etc) work nights and sometimes work hard. But we love what we do. So do a lot of other specialties. The lifestyle of a neonatologist may not be as easy as (presumably) a radiologist, but it's not torture or difficult to raise a family and have plenty of time for them. I'm also not convinced that it's harder to get a neonatology job in most middle sized cities than a radiology job, but it's true that level 4 nurseries are in big cities.

My advice, is to go with what you want to do. Ultimately, you and your family will be happier, even if you are home a bit less and take a bit longer to pay off your debts, etc.

 

[oldbearprofessor]

everyone says to only pursue peds if you can see yourself being a general pediatrician (which I cannot).

Who says that? There is a shortage of most pedi specialists (some notable exceptions) and plenty of jobs for most specialists who graduate. You do have to be willing to tolerate the gen peds aspect of residency, but that's different.

 

[oldbearprofessor]

For example, how many PICU and peds cards doc really enjoyed doing well visits during residency? I don't think I'm taking a giant leap by saying that number will probably be very low.

Well, I'm not a PICU or peds cards doc but remarkably, from my experience most residents interested in those fields or neo don't really mind well visits during training cuz we know it's short term and there is a lot to be learned from that education relevant to our fields. I can't say we "really enjoy" it, but I'm not sure that's a criteria for much in residency.

 

[SurfingDoctor]

I didn't mind my continuity clinic during residency. I actually really enjoyed the attendings I worked with, the clinic nursing staff and have some fond memories of patients and their families. It was more the speed of clinic and frustration of scheduling that I didn't particularly like, but the patients and their families I did enjoy. And all that being, said I'm keeping my General Pediatric board certification active because I can't see myself waking up to run a code with trainees at 2am when I'm 60 years old. Maybe someone has that kind of stamina, but the average intensivist does not... and I am very average.

 

[shishka32]

Radiology and pediatrics are not similar. Go with your heart, 20 years from now you'll be glad. Neonatology is commonly the highest paid pediatric specialty and I'm far from convinced that by the time you are done the salary difference between them will be large of even exist. But, I can't predict future salaries and neither can anyone else. Lifestyle? Neonatologists (and PICU docs, etc) work nights and sometimes work hard. But we love what we do. So do a lot of other specialties. The lifestyle of a neonatologist may not be as easy as (presumably) a radiologist, but it's not torture or difficult to raise a family and have plenty of time for them. I'm also not convinced that it's harder to get a neonatology job in most middle sized cities than a radiology job, but it's true that level 4 nurseries are in big cities.

My advice, is to go with what you want to do. Ultimately, you and your family will be happier, even if you are home a bit less and take a bit longer to pay off your debts, etc.

Yes, pediatrics and radiology are very dissimilar but I like them for different reasons. I think this is the answer I need and I need to give myself "permission" to do pediatrics. My spouse supports me 100% which is great so it is more my hesitancy. I am doing a NICU rotation this summer which should help me as well. Thank you.

 

[oldbearprofessor]

And all that being, said I'm keeping my General Pediatric board certification active because I can't see myself waking up to run a code with trainees at 2am when I'm 60 years old.

Serious question "Why not?" I speak as someone who is well, lets say, about that age and although it's true that I recently stopped doing night call in the NICU, it was not for the reason of age. I know lots of neos taking call into their late 60's early 70's and although fewer PICU docs are over 60, plenty still work at night from what I've seen. In neo, when one does get tired of night call, there are lots of level 2 type jobs and even some level 3/4 jobs that are day/weekend day only. I think step-down (IMC) type jobs might be fewer for intensivists, but I don't think you'll need to do gen peds at 60 unless you want to. An interesting question is whether anyone would care if you are boarded in gen peds at that point or just have specialty boards, but that's waaay off topic here. I'm a lifer in gen peds so I haven't thought about it.

As I've gotten older, I'm less inclined to use age as a barrier to what I want to keep doing. As far as retiring to a fishing boat kind of thing, I'd hate that more than gen peds and my wife would leave me if I was home that much. YMMV, but don't be surprised if you are still doing some form of critical care at age 60.

 

[oldbearprofessor]

Yes, pediatrics and radiology are very dissimilar but I like them for different reasons. I think this is the answer I need and I need to give myself "permission" to do pediatrics. My spouse supports me 100% which is great so it is more my hesitancy. I am doing a NICU rotation this summer which should help me as well. Thank you.

Yes, do give yourself permission to do what you are intended to do with your life (religiously stated, what God wants you to do with your life, but regardless, it's a choice you are making based on understanding what is right for you). Once you do the NICU rotation you're ours

 

[SurfingDoctor]

Serious question "Why not?" I speak as someone who is well, lets say, about that age and although it's true that I recently stopped doing night call in the NICU, it was not for the reason of age. I know lots of neos taking call into their late 60's early 70's and although fewer PICU docs are over 60, plenty still work at night from what I've seen. In neo, when one does get tired of night call, there are lots of level 2 type jobs and even some level 3/4 jobs that are day/weekend day only. I think step-down (IMC) type jobs might be fewer for intensivists, but I don't think you'll need to do gen peds at 60 unless you want to. An interesting question is whether anyone would care if you are boarded in gen peds at that point or just have specialty boards, but that's waaay off topic here. I'm a lifer in gen peds so I haven't thought about it.

As I've gotten older, I'm less inclined to use age as a barrier to what I want to keep doing. As far as retiring to a fishing boat kind of thing, I'd hate that more than gen peds and my wife would leave me if I was home that much. YMMV, but don't be surprised if you are still doing some form of critical care at age 60.

It is an interesting question to which I don't have a specific answer. While you have been doing this longer than I, I will say even the decade plus when I was a resident, there were Neo attendings in there 60+, but no PICU attendings in that range. One could only speculate why, but I suspect it is what you mentioned, far more common place of lesser acuity units (relative abundance of Level II compared to step-down or transitional care ICUs), and the capacity to absorb daytime shift work in NICU (as opposed to daytime PICU work). Maybe the models will change (they have slightly in the time I've been practicing), but most PICU attendings I know phase themselves out, mostly through leaving PICU and doing clinic or complex care (inpatient versus outpatient), buying time through through academic endeavors, or less commonly, finding a step-down ICU unit. I suppose I could always phase myself into a at-home hospitalist (the equivalent of a Level II I think), but with board certification, who knows. Anywho, this is far more discussed I think in the adult medicine ICU world (The Aging Intensivist and Younger Colleagues - Springer; The greying intensivist: ageing and medical practice - everyone's problem. - PubMed - NCBI). Personally, a transitionally care unit or hospitalist position plus a bulk of research would be my ideal, but who knows what the future holds. As in most aspects of life, gotta keep your options open and I know all of my direct colleagues who at 20+ my years, feel the same. I have never approached my career without planning for Option B (or C).

 

[Step Up]

My mentors and or pediatricians (either General or subspec) that I worked with before med school. They were more so responding to my desire to only be a pedi subspec and not a gen pediatrician. Since fellowship isn't guaranteed! I suppose that's what I took from it.

Whoever said this is either thinking of a speciality besides pediatrics (e.g. OBGYN or gen surg) and/or they are entirely out of touch with what it's currently like to apply for a pediatric fellowship. Many pediatric fellowships go unfilled every year. Even in the more competitive fields there will be a few open programs after match day. I would encourage you to review the NRMP fellowship match data (google it!). Look at some of the programs and specialities you may be interested in. If you plan to sub-specialize within pediatrics, you ARE going to get a fellowship spot. Period. Unless you have some glaring, highly troubling, red flag holding you back, I guess. The more competitive fields like cards and H/O are MUCH less competitive at the less desirable programs. Specialities like ID, GI, endocrine, etc. struggle to even fill some/many of the less desirable programs.

In my opinion, this is completely a non-issue! Getting into fellowship at a top program is one issue, but simply getting into a fellowship in your desired field, will not be a problem... Just wanted to add my two cents!

 

[stevo2365]

Rising MS4 really struggling with specialty choice. My heart is in peds. I love working with kids. In my weekly med-peds clinic I really enjoyed every peds clinic visit and was neutral to unhappy with most adult visits.

That being said, I find typical gen peds and general ward medicine a little dull after a while. I would want to do a subspecialty like NICU or PICU or cards. This would limit my future practice geographic location, have a lower salary (I have a ton of debt), and probably be more intense compared to radiology which I am considering (it's either see kids or don't see patients at all... exaggeration but kind of true). I am fascinated by the tech in rads and the fact I would know a unique skillset most other physicians need help with. My wife and I are dying to get back to my smallish hometown that doesn't have a PICU or peds cardiologist. There is a small NICU though. I would make more money in radiology and probably have more time off for family. I have mentors telling me I really should not do a lower paying specialty because reimbursements will just continue to go down.

I feel this is a major, major life decision and that I cannot even fully grasp the consequences. If I choose peds, I likely will never be moving home to my extended family and I will have a lesser lifestyle but I may enjoy my work more. I honestly do like radiology and enjoy learning about it, but I love pediatrics.

Any advice would be appreciated.

(Preface: I'm an incoming pediatric resident.) I'm pretty sure if you go back a year from now, you'll find the exact same post from me as an MS-4. Every single negative you're associating with pediatrics, I was wrestling with it too. Namely, I couldn't return to the geographical location I desired ( a alotsmall town in FL) and the pay was something I had a hard time dealing with too. Now, obviously take this 100% with a grain of salt, because first of all as an MD in the US you will be in the top % of the **world** in pay (everything is relative), but there is a saying I've been heara lot from other doctors since I matched into Peds which is "Congrats! You're going to be so happy... but poor." Obviously it's an over exaggeration, but it is the general consensus that if you are a doctor going into it for money (which isn't always as bad as it sounds, almost every other person does their job for the money) you shouldn't do peds, just be honest with yourself in those regards. But if you see life as the gift it is, and using it to really really help others, to make long lasting impacts, and really doing such a great deed to families in that you are caring for their most precious thing (their child), pediatrics is a great field (and I'm biased, but I'd even say the best and most rewarding).

Nothing will beat that time in my peds cardio rotation when a child came out of a Norwood procedure and when the parents were told their baby was healthy and safe to be discharged, they just held him, cried, and said "you saved his life... thank you." It's as if the reason I went into medicine was finally being fulfilled in a way. In all honesty, it makes me want to do pro-bono work when I get to a point in life when hopefully I can provide enough for my family. The money is insignificant in moments like those.

As far as the geography, that was almost a tougher one. I grew up on a tiny beach town in FL where everyone surfs, doesn't lock their doors, and is chill as all get out. Then, as I decided I wanted to do subspecialty peds, it almost required of me to be in a big city... for me, the nearest children's hospital is an hour away. Which isn't terrible, but I still couldn't live at "home". But the more I thought about it, I would rather be happy where I will spend a majority of my living hours (the hospital doing what I love) then the hours I will be spending living in my hometown being miserable at work doing another field. But this is a personal decision, some others would come out with the opposite conclusion.

I'll just leave with this: If you love kids more than anything in this world, no amount of money will make working with adults worth it. I couldn't walk around in my IM rotation or surgery rotation without stopping and giving stickers to a kid walking in the hospital halls just because seeing them smile was worth it, and a lifetime of smiles, there ain't no price on it.

Just think through this decision. The pay will be lower (obviously adjustable), the location will be more constricted, but also factor in your happiness and goals of your life. And at the end of the day, don't be a hero in your eyes when making this decision, just be as honest as you can with yourself. Good luck and PM me if you have any more questions!

 

[shishka32]

(Preface: I'm an incoming pediatric resident.) I'm pretty sure if you go back a year from now, you'll find the exact same post from me as an MS-4. Every single negative you're associating with pediatrics, I was wrestling with it too. Namely, I couldn't return to the geographical location I desired ( a alotsmall town in FL) and the pay was something I had a hard time dealing with too. Now, obviously take this 100% with a grain of salt, because first of all as an MD in the US you will be in the top % of the **world** in pay (everything is relative), but there is a saying I've been heara lot from other doctors since I matched into Peds which is "Congrats! You're going to be so happy... but poor." Obviously it's an over exaggeration, but it is the general consensus that if you are a doctor going into it for money (which isn't always as bad as it sounds, almost every other person does their job for the money) you shouldn't do peds, just be honest with yourself in those regards. But if you see life as the gift it is, and using it to really really help others, to make long lasting impacts, and really doing such a great deed to families in that you are caring for their most precious thing (their child), pediatrics is a great field (and I'm biased, but I'd even say the best and most rewarding).

Nothing will beat that time in my peds cardio rotation when a child came out of a Norwood procedure and when the parents were told their baby was healthy and safe to be discharged, they just held him, cried, and said "you saved his life... thank you." It's as if the reason I went into medicine was finally being fulfilled in a way. In all honesty, it makes me want to do pro-bono work when I get to a point in life when hopefully I can provide enough for my family. The money is insignificant in moments like those.

As far as the geography, that was almost a tougher one. I grew up on a tiny beach town in FL where everyone surfs, doesn't lock their doors, and is chill as all get out. Then, as I decided I wanted to do subspecialty peds, it almost required of me to be in a big city... for me, the nearest children's hospital is an hour away. Which isn't terrible, but I still couldn't live at "home". But the more I thought about it, I would rather be happy where I will spend a majority of my living hours (the hospital doing what I love) then the hours I will be spending living in my hometown being miserable at work doing another field. But this is a personal decision, some others would come out with the opposite conclusion.

I'll just leave with this: If you love kids more than anything in this world, no amount of money will make working with adults worth it. I couldn't walk around in my IM rotation or surgery rotation without stopping and giving stickers to a kid walking in the hospital halls just because seeing them smile was worth it, and a lifetime of smiles, there ain't no price on it.

Just think through this decision. The pay will be lower (obviously adjustable), the location will be more constricted, but also factor in your happiness and goals of your life. And at the end of the day, don't be a hero in your eyes when making this decision, just be as honest as you can with yourself. Good luck and PM me if you have any more questions!

Hey, thanks so much for this. This is very helpful. I will PM you.