MD NICU fellow AMA

[MEN2C]

I got a couple questions via PM and someone said I should do a AMA, so here it is. Happy to answer any questions!

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[JohnDenver]

Day in the life? What drew you to the field? I'm not well educated on the path to a NICU fellowship, so what was your path to get there?

 

[deleted407021]

Thanks doc!

Are you starting fellowship out of residency or with a gap? Has life in fellowship been different than life in residency? Do y’all only work in the NICU or are there other responsibilities like PICU or ER?

 

[MEN2C]

I'll answer questions one at a time:

• I started fellowship right out of residency. Fellowship is nicer than residency. You have to do a pediatrics residency first to do Neonatology, and in residency, I was generally doing ~80hrs/week on most inpatient rotations (which is most of the year). All NICU fellowships are generally ~12-14 months of clinical time, and ~22-24 months of research. So it's very nice in a sense because you have breaks from your service months. I am really enjoying life as a fellow, one because the schedule is easier, second because I like having the responsibility and the autonomy, and third because this is what I want to do with my life!
• We don't have other responsibilities outside of the NICU except as a consult. Sometimes we will be consulted in the ED, PICU, CICU or the floor for a question (e.g baby needs an exchange transfusion, help putting in umbilical lines, nutrition/respiratory questions for an ex preemie, airway help from the ED, someone precipitously delivering in the ED), or if they want to transfer a patient. During fellowship, we do rotations in the CICU and MFM. But after graduation, you don't have responsibilities there. We also do NICU follow up clinic (frequency of which varies by fellowship program) - generally about a month's worth over your three years of fellowship. Most people end up not doing any clinic once they are attendings, while some others make it a major focus of their career (esp. those who are into developmental research).

 

[afib123]

why is there so much research in pediatric fellowships. Noticed the same with pediatric nephrology. can you really learn everything in a fellowship in a year? why have everyone waste the other 2 years with mandatory research? Of course there might be some that like the research

 

[deleted407021]

It’s interesting that there are NICU docs who are into developmental medicine. I imagine that there’s a lot of reward when you see kids you helped as sick babies grow to be healthy. What other aspects of the job do you find particularly rewarding?

If one isn’t massively into bench research, are there niches for research work focused more on social or public health matters? How about behavioral?

 

[MEN2C]

It’s interesting that there are NICU docs who are into developmental medicine. I imagine that there’s a lot of reward when you see kids you helped as sick babies grow to be healthy. What other aspects of the job do you find particularly rewarding?

If one isn’t massively into bench research, are there niches for research work focused more on social or public health matters? How about behavioral?

• I would rather die than run gels for my research. You can certainly do basic science, and some fellowship or fellowship programs may push that. But in NICU at least, people are doing lots of bench work, lots of clinical and clinical trials, stuff with public health and global health, psych research (e.g looking at parental coping during long NICU stays, or communication between staff or to parents), QI, education, neurodevelopmental, and all sorts of other types of research. I am doing clinical research. People these days are open to a lot. Many fellowship programs will pay for you to have your masters degree as part of your fellowship (such as Masters in Clinical Investigation, MPH, Masters in Education, etc etc). They obviously want people to go into academia.
• As for reward - I actually don't like clinic at all . It's just not my style, but yes, people do enjoy that aspect of it. As for what I find rewarding - first, I've been saying all positive things but just like any other field, there's negatives too. It's not perfect, but it's great for me. I'll quote a post I made in another thread about an incident that really hits it home for me:

  • I got called out on transport for a delivery the other day where a kid was crashing from an otherwise low risk delivery. Likely some birth trauma and HIE. The pH on the cord gas was less than 7 and they couldn't get the saturations above 70. They didn't know what to do. We get there STAT. The kid also had a pneumothorax that I saw when I got there. I intubate, do a needle decompression and put in a chest tube, put in an urgent central line, and start cooling on the way to home base. A week and a half later, he is discharged in room air, with a completely normal MRI and a normal neuro exam. It felt good. Worth the hours of USMLE, the residency..all of it! Seeing those parents walk out with that baby made it all worthwhile. They sent me a card yesterday thanking me personally. All the paperwork and all the nonsense you have to do - stuff like this makes up for it.
    ...
    Somehow I'm managing a marriage and a family too.
    Keep your chin up. It's worth it!

why is there so much research in pediatric fellowships. Noticed the same with pediatric nephrology. can you really learn everything in a fellowship in a year? why have everyone waste the other 2 years with mandatory research? Of course there might be some that like the research

• I think you can - it's very concentrated learning. It's 12 months of being on service, plus cross covers/weekends during your research time, so it ends up being more. Some specialties are a little more, closer to 15-17 months. Whether research should be required is a big source of debate, and I personally think they should offer shorter fellowships in the fields with shortages. But the bottom line is that it's not going away. I want to have research as ~50% of my career, so it's not as big of a deal for me. But another thing to consider is that many pediatric specialties (NICU actually being one of the exceptions), there are no jobs in private practice. You used the neprhology example - for an adult nephrologist, you can do private practice or you can do academics. In Pediatrics, I think there might be around ZERO nationwide jobs for private practice nephrologists. Maybe not zero, but I don't know of a single one and it's certainly not a large amount. That's because kids are mostly healthy and the type of problems you need to see these specialists for are rare and frequently require the services of a children's hospitals and the resources they have. So if you're in a fellowship, and your fellowship wants you to get a job afterwards in academia - research is important. As I said, NICU is actually one of the ones with a very large private practice component (mainly because any large delivery hospital will have some form of a NICU and will need Neonatologists, and so you can practice away from large children's hospitals if you wanted. But then you are more likely to see only bread and butter NICU cases, and will transfer out the more complex or weirder cases.)

When I have a few more minutes, I'll post a day in the life and other specialties I was considering before I chose NICU.

 

[afib123]

• I would rather die than run gels for my research. You can certainly do basic science, and some fellowship or fellowship programs may push that. But in NICU at least, people are doing lots of bench work, lots of clinical and clinical trials, stuff with public health and global health, psych research (e.g looking at parental coping during long NICU stays, or communication between staff or to parents), QI, education, neurodevelopmental, and all sorts of other types of research. I am doing clinical research. People these days are open to a lot. Many fellowship programs will pay for you to have your masters degree as part of your fellowship (such as Masters in Clinical Investigation, MPH, Masters in Education, etc etc). They obviously want people to go into academia.
• As for reward - I actually don't like clinic at all . It's just not my style, but yes, people do enjoy that aspect of it. As for what I find rewarding - first, I've been saying all positive things but just like any other field, there's negatives too. It's not perfect, but it's great for me. I'll quote a post I made in another thread about an incident that really hits it home for me:

• I think you can - it's very concentrated learning. It's 12 months of being on service, plus cross covers/weekends during your research time, so it ends up being more. Some specialties are a little more, closer to 15-17 months. Whether research should be required is a big source of debate, and I personally think they should offer shorter fellowships in the fields with shortages. But the bottom line is that it's not going away. I want to have research as ~50% of my career, so it's not as big of a deal for me. But another thing to consider is that many pediatric specialties (NICU actually being one of the exceptions), there are no jobs in private practice. You used the neprhology example - for an adult nephrologist, you can do private practice or you can do academics. In Pediatrics, I think there might be around ZERO nationwide jobs for private practice nephrologists. Maybe not zero, but I don't know of a single one and it's certainly not a large amount. That's because kids are mostly healthy and the type of problems you need to see these specialists for are rare and frequently require the services of a children's hospitals and the resources they have. As I said, NICU is actually one of the ones with a very large private practice component (mainly because any large delivery hospital will have some form of a NICU and will need Neonatologists, and so you can practice away from large children's hospitals if you wanted. But then you are more likely to see only bread and butter NICU cases, and will transfer out the more complex or weirder cases.)

When I have a few more minutes, I'll post a day in the life and other specialties I was considering before I chose NICU.

Interesting. That makes sense. The pediatric nephrologist that I worked with was great, knew his stuff, was seeing incredibly complex patients which was surprising to me because I am guessing adult nephrologists do the 3 year fellowship with not much research. Good for you guys. I think pediatric specialities are fascinating and learning it in a such a short time is great.

 

[deleted407021]

• I would rather die than run gels for my research. You can certainly do basic science, and some fellowship or fellowship programs may push that. But in NICU at least, people are doing lots of bench work, lots of clinical and clinical trials, stuff with public health and global health, psych research (e.g looking at parental coping during long NICU stays, or communication between staff or to parents), QI, education, neurodevelopmental, and all sorts of other types of research. I am doing clinical research. People these days are open to a lot. Many fellowship programs will pay for you to have your masters degree as part of your fellowship (such as Masters in Clinical Investigation, MPH, Masters in Education, etc etc). They obviously want people to go into academia.

• As for reward - I actually don't like clinic at all . It's just not my style, but yes, people do enjoy that aspect of it. As for what I find rewarding - first, I've been saying all positive things but just like any other field, there's negatives too. It's not perfect, but it's great for me. I'll quote a post I made in another thread about an incident that really hits it home for me:

Thank you! I’m really interested in psych and it’s my first choice, but peds -> higher acuity subspecialty is my close number 2. I’m very into the idea that neonatologists could make use of mental health knowledge, basic psychology and maybe even counseling skills. Is there any possibility at all of someone getting a master’s or additional training in psychology or mental health during that research period?

 

[MEN2C]

Thank you! I’m really interested in psych and it’s my first choice, but peds -> higher acuity subspecialty is my close number 2. I’m very into the idea that neonatologists could make use of mental health knowledge, basic psychology and maybe even counseling skills. Is there any possibility at all of someone getting a master’s or additional training in psychology or mental health during that research period?

That's not something I can answer. You'd have to talk directly to fellowship programs. You'd want to go to a place that has a history of allowing fellows to pursue a variety of masters degrees, and ideally the exact degree you're going for (it's always hard to be the first). And then you'll likely have to justify your choice and how this degree is essential to your research career in the future. To that end, you have to build up your CV so that it tells a story and makes sense.

 

[700825]

Not super familiar with the field, but from what I have since heard of it, it sounds quite interesting. What is the lifestyle like? I know adult critical care is pretty rough, but wondered how NICU compared?

 

[MEN2C]

Not super familiar with the field, but from what I have since heard of it, it sounds quite interesting. What is the lifestyle like? I know adult critical care is pretty rough, but wondered how NICU compared?

I am going to give a long and complicated answer to this simple question because speaking as someone with a family, I think lifestyle should be an important consideration, and people should pick their fields with their eyes wide open. If you don't want to read the details, skip to the last line of this post.

To understand the wide variety of lifestyle possibilities, let me give some breakdown (and this also goes into why I picked NICU over PICU and Cardiology - the other fields I was considering):

• Nurseries are divided into four levels generally:
  • Level 1: Normal newborn nursery. For full term babies. Generally no capability for any respiratory support. Covered by Family Practice or Pediatricians - they round in the morning on the babies and make sure they get all their stuff before going home (gaining weight, bilirubin is normal, get their Vitamin K shots, feeding OK, teaching parents what to do and when to call, etc)
  • Level 2: NICUs that take care of 32 weeks gestational babies and above. Generally have a weight limit too (minimum of 1.5kg or 1.8kg or whatever it might be). They can provide respiratory support, usually up to CPAP. They usually can provide mechanical ventilation only for a short period of time (e.g stabilize and transfer if patient is sicker). These are covered during the day by either pediatricians, or (for larger level IIs) Neonatologists. At night, some are covered from home only with no provider on site. Others, especially if there are a lot of deliveries at the hospital, by a nurse practitioner at night with a backup by neonatologist or a pediatrician (who come in if needed).
  • Level 3: NICUs that take care of any gestational age and weight (e.g as low as 22 weeks and can be as small as 300-400g babies - the smallest I've personally seen survive for more than a few hours was 294 grams, but there have been reports of lower). They are covered by Neonatologists during the day, and at night also have either Neonatologists and/or NPs in house (with Neo backup that come in for complicated deliveries or if patients decompensate). In the past, almost all of these units used to be covered from home by Neonatologists who would come in as needed, but more and more of them are now 24/7 in house (for patient safety and legal reasons). But a significant portion of them are still coverage from home after hours (with another provider on site, such as NPs).
  • Level 4: NICUs that take care of any gestational age plus complex congenital conditions that require multiple subspecialites and surgeries. So kids with pediatric nerosurgery needs, or kids that need to be on ECMO. These are in children's hospitals, have fellowship programs, and have other pediatric subspecialties (e.g pediatric anesthesia, pediatric neurosurgery, pediatric interventional cardiology, etc etc). With only a few remaining exceptions, these have an attending Neonatology presence 24/7 in house (I only know a few remaining ones that have a fellow in house at night with attending for backup - and my guess is that they will all become in house within the next ten years, but who knows).
• So your lifestyle depends on: 1) type of NICU, 2) type of position - eg private practice or academics, 3) type of coverage. For level 2s, and some level 3s, you often have two people covering the whole unit - 7 days on/7 days off. And you rarely have to come in at night if the unit is small. For larger units, you may have 4-5 people covering 24/7. The Level 2s will continue to be staffed from home but the trend over the past 20 years has been more and more attending in house coverage for level IIIs (and level IV is already pretty much there). For my career, I am expecting to cover in house 24/7 - so just like any other inpatient/ICU unit, that means you will work days, nights, weekends, holidays. The nature of the work though is generally not as stressful as an adult ICU (and the nature of the patients are also different), as you have a bunch of chronic kids at most places just working on feeding and growing, with a few active kids at any given time who may be on significant ventilatory support and/or pressers. In addition, some people, as they get older, transition to more level II work instead of being in house. Some places have ability where the more senior people don't do overnights, which also helps. In terms of being on service, it ranges from being on call half the year (in small units with only two people), to 18 weeks/year (plus scattered night coverage) for a large unit with 24/7 in house, to as little as 5-6 weeks a year for those on a research track in academia.
• A common job, if you want a decent level of acuity, might be (for example) a purely clinical position that involves 18 weeks of service per year, plus thirty nights of in house call per year when you're not on service. Some nights you're up a lot. Other nights, you sleep all the way through (this also depends on who you have such as residents, NPs, fellows, or if you are solo).
• Pediatric subspecialties and NICU generally score very high in terms of satisfaction on physician surveys.

TL;DR Short answer: it's not a 9-5 job - expect to work weekends and unusual hours. Don't do it if what you want is a 9a-5p job.

 

[MEN2C]

I'm not well educated on the path to a NICU fellowship, so what was your path to get there?

To do a Neonatology fellowship, you have to do a three year Pediatrics residency and then match into a three year Neonatology fellowship. Neither of which are particularly competitive (though, as you can imagine, the top programs in any specialty are hyper competitive). But if you're a US medical student, you will match into a pediatrics residency. And unless you're a terrible resident, you will match into a NICU fellowship. I like procedures, and I like acuity. So I was deciding between Cardiology, PICU and NICU in the end. I don't like outpatient much, and most Cardiology positions these days require a fourth year fellowship, which wasn't super appealing to me - even though I like the physiology. Plus, interventional or EP, which would be the two things I'd be most interested in, are very much oversaturated, and I have a severe geographic restriction due to family, and I know for a fact there would be almost no chance of a job in the area I'm in doing that. So that was out. PICU vs NICU was very hard and it was a last minute decision. I liked the variety and the acuity of PICU and I loved the longer term management (combining both acute and then when they stabilize) and I LOVE the delivery room in the NICU. In the end, the opportunity to practice in a larger variety of settings - (esp. as I get older) overcame PICU and its larger day to day variety of patients. I also liked that NICU is a more enclosed unit than the PICU. We don't like consulting, and often ignore the consultants when we don't like what they say. Whereas the PICU felt like every patient had a bunch of consults. I recognize that could also just be my experience with it. Either way, it was a close decision and I know I would have been happy doing either.

 

[mvenus929]

Since a couple of these questions are more broad and deal with Peds fellowships in general, I’ll chime in

why is there so much research in pediatric fellowships. Noticed the same with pediatric nephrology. can you really learn everything in a fellowship in a year? why have everyone waste the other 2 years with mandatory research? Of course there might be some that like the research

As MEN2C indicated, a good chunk of the Peds specialties are academic in nature. There are jobs that are primarily clinical at academic centers, but there aren’t much in the way of private practice jobs. So the extra time in fellowship allows you to build up your CV.

That said, I think a year could easily be shaved off most fellowships. Adult Endo is 2 years, and Peds Endo is 3. I think many of the other adult fellowships are similar. I don’t think I would see enough pathology in a year to feel comfortable managing some of the more complex things as an attending, but 2 is probably more than enough. There’s also the aspect of seeing patients over time that you would miss out on if you only did 1 year.

 

[usctrojans24]

To do a Neonatology fellowship, you have to do a three year Pediatrics residency and then match into a three year Neonatology fellowship. Neither of which are particularly competitive (though, as you can imagine, the top programs in any specialty are hyper competitive). But if you're a US medical student, you will match into a pediatrics residency. And unless you're a terrible resident, you will match into a NICU fellowship. I like procedures, and I like acuity. So I was deciding between Cardiology, PICU and NICU in the end. I don't like outpatient much, and most Cardiology positions these days require a fourth year fellowship, which wasn't super appealing to me - even though I like the physiology. Plus, interventional or EP, which would be the two things I'd be most interested in, are very much oversaturated, and I have a severe geographic restriction due to family, and I know for a fact there would be almost no chance of a job in the area I'm in doing that. So that was out. PICU vs NICU was very hard and it was a last minute decision. I liked the variety and the acuity of PICU and I loved the longer term management (combining both acute and then when they stabilize) and I LOVE the delivery room in the NICU. In the end, the opportunity to practice in a larger variety of settings - (esp. as I get older) overcame PICU and its larger day to day variety of patients. I also liked that NICU is a more enclosed unit than the PICU. We don't like consulting, and often ignore the consultants when we don't like what they say. Whereas the PICU felt like every patient had a bunch of consults. I recognize that could also just be my experience with it. Either way, it was a close decision and I know I would have been happy doing either.

I'm just wondering is there a particular reason why Cardiology/EP is over saturated in most areas people wanna live because I looked at jobs online and you're right. Most jobs available are not in desirable areas.

 

[djsbaseball2014]

As an incoming MS1 who was inspired to go into medicine by my pediatricians and NICU physicians who saved my life, thank you so much for all that you do. I was born approx 13 weeks premature with pulmonary hypoplasia and a Pseudomonas infection in my lungs and was placed on an ECMO machine for the first month or two of my life and I am indebted to the clinical staff that cared for me during this time.

1.) Do you ever get the feeling of burnout, I have heard from alot of people that Neonatologists have a higher propensity for burnout in their field. Just wanted to get your thoughts on it, as I am considering multiple specialties and would love to go full circle and care for premature babies!

 

[MEN2C]

I'm just wondering is there a particular reason why Cardiology/EP is over saturated in most areas people wanna live because I looked on jobs online and you're right. Most jobs available are not in desirable areas.

There was an increase in fellowship spots but there was no increase in the prevalence of congenital cardiac disease. Plus it’s the era of hyper specialized centers so you have fewer centers with extremely high volume (so you need less overall people, but the people who do it are very busy). Good for patient outcomes but may suck if you want to do it and aren’t a superstar.

 

[usctrojans24]

There was an increase in fellowship spots but there was no increase in the prevalence of congenital cardiac disease. Plus it’s the era of hyper specialized centers so you have fewer centers with extremely high volume (so you need less overall people, but the people who do it are very busy). Good for patient outcomes but may suck if you want to do it and aren’t a superstar.

Do you think that job market will change? (Cardio jobs = Available in desirable locations) (Seems right now EP has some jobs in desirable locations)

 

[MEN2C]

Literally no one can make a prediction like that. It’d be pure guessing. Right now there’s very few jobs so very few people are going in. Pediatric EP and interventional cards are cool as hell so my guess is if and when the jobs open up, they’ll be very quickly filled by more cards fellows going doing that fellowship. Almost immediately leading to a pretty saturated market. But who knows??? That’s a complete guess.

You may want to ask pedi EP or pedi interventional cards people that though - rather than a NICU fellow . My involvement with them these days are just when I call them when I need a hole closed (or opened) or need some Cath data .

 

[Birdman15]

As someone who’s interested in neonatology, I’m wondering what the job market’s like? How’s the compensation? Do most fellowship grads go into academics or PP?

 

[MEN2C]

As someone who’s interested in neonatology, I’m wondering what the job market’s like? How’s the compensation? Do most fellowship grads go into academics or PP?

Job market is pretty good. I would say more go into PP but a significant portion go into academics. In many cases, the lines are blurred. As you may work for an academic center and have fellows and residents, but you don't have any non-clinical responsibilities. Or you may be in private practice and still do some teaching. Obviously, there's still a good portion who are traditional academics (e.g either grant support for research, or going into education, etc etc) or traditional PP. Compensation is amongst the highest (along with PICU and cardiology) for a pediatrics sub-specialty but you're never really going to make Adult GI money. For private practice, the MGMA median when I last checked was about $350k (not starting - this is median for all who are practicing) or so. Academics is academics and you're generally gonna make less for the most part. Obviously, there's going to be differences in terms of your contract - how many weeks of service, your geographical location, your benefits, etc etc.

Of course, my (HOPE) is to be a grant supported researcher with like 6-7 weeks of service per year, so my salary will likely be much lower compared to the median.

 

[MSTP18]

Why do you guys write the interval events, assessments, and plans multiple times in your notes and carry so much stuff over in your notes from day to day such that it becomes impossible to figure out what the most up to date assessment and plan is? Or is that just how the NICU at my hospital operates?

 

[MEN2C]

No it’s a NICU thing. Our notes are horrible. The patients are there for months sometimes so there’s a lot of carry forward and the note gets jumbled. Every NICU I’ve rotated at has had horrendous notes. I’ll tell you when I’m an attending if my notes are better

 

[MEN2C]

Day in the life?

Day in the life, this is what happened on monday (I picked monday because it seemed to be a day with a decent amount of things that happened, but wasn't insane). I am on service:

• 7:00AM - show up, and get signout on overnight events and any expected deliveries
• 7:15AM - Delivery page goes off for shoulder dystocia, we run to the room. Baby comes out a little stunned, I stand back while the resident is at the head of the bed. Some stimulation doesn't do much. I tell the resident to begin PPV, and the baby perks up within a few seconds. Switched to CPAP and easily transitioned to RA by 3 minute of life
• 7:40AM - rounds, able to get through rounds without any deliveries. We really only have a few sick patients. One on ECMO. Two on multiple pressors, and two more on significant ventilator support. The rest are stablely intubated, on CPAP or just feeding and growing. The surgery and CDH kids are doing fine.
• 11:00AM - I have three consults. One for a mom of 22+4 week gestation, going over mortality and morbidity of such a small gestational age. Parents elect to only do comfort care until 23 weeks. Second consult is for a congenital hydrops case at 33 weeks gestation. I tell them the high mortality associated with that, and parents want everything done. The third is a simple consult for a 29 week gestation mom here in preterm labor. The outcomes for her are likely very good, so we go over the expected course and most likely problem.
• 1:00PM - I get lunch. One of the older kids with very severe bronchopulmonary dysplasia and a history of NEC is getting sicker, so I try switching vent modes. Already on epi and phenylephrine due to sepsis and Nitric Oxide for pHTN. The kid kind-of-sort-of stops getting worse for now. But her outcome is not likely good. We set up a family meeting for tomorrow to go over our options (e.g they were thinking about before, to go over the current situation and whether they would like comfort care or compassionate extubation at this point)
• 2:15PM - STAT c-section for 26+3 twins! This is under 28 weeks (and twins), so the attending also comes. We go with two residents, two NPs, two RTs, four nurses, myself and the attending and set up the room. By convention, attending will take baby A and I will take baby B (baby B is usually sicker). Resident is airway for baby B, NP is airway for baby A. We assign roles and wait. Baby A comes out with some cries and they start working on her. She's making effort and crying intermittently so they immediately put her on CPAP and she starts pinking up. Around this time baby B comes out limp and apenic. We start PPV immediately but it's not working despite going up on pressures. Senior resident attempts one unsuccessful intubation, and then I successfully intubate. HR comes up and sats are within normal limits. We take them back to the unit, give surfactant to baby B, and I help the resident put in central lines and come up with a plan for both. They are both doing well.
• 4PM - random odds and ends for various babies, answering questions from people as they come, updating signout. Talked to the attending about a question I had regarding one of the babies (a patient was having dyssyncrony with the ventilator, and I couldn't fix it so I wanted to troubleshoot the problem with her).
• 5PM - I sign out to the overnight fellow.

 

[deleted407021]

Are you the Ms. Frizzle, could've just as easy been a kindergarten teacher type of pediatrician; or are you more of the serious type? I really enjoy working with kids and I love the idea of interventions having lasting impacts, but I just can't do the "kiddo", super jolly thing some peds docs do.

 

[MEN2C]

That is an interesting question. In fellowship, I don't really interact with kids who can talk back to me...or are old enough to do much. I've been an intensivist at heart, all the way from the beginning. In med school, I initially wanted to do IM --> Pulm/CC or EM-->CC, and when I chose peds, I was always between PICU, NICU and Cardiology. Didn't even consider anything else. So I am not the kindergarten teacher type - though you will definitely have those during residency. Fewer of those types of personalities in fellowships like this one, but sometimes still there. Generally, and this is definitely a biased view, you get many fewer personality disorders in pediatrics. People just tend to be more chill and happier, which makes for a much better work environment. Overall, there definitely tends to be more chill atmosphere in all peds specialties compared to their adult counterparts, but when you're in a situation where you have to deal with kids who are dying or very seriously sick, there is an expected decorum and seriousness that you have most of the time.

 

[deleted407021]

That is an interesting question. In fellowship, I don't really interact with kids who can talk back to me...or are old enough to do much. I've been an intensivist at heart, all the way from the beginning. In med school, I initially wanted to do IM --> Pulm/CC or EM-->CC, and when I chose peds, I was always between PICU, NICU and Cardiology. Didn't even consider anything else. So I am not the kindergarten teacher type - though you will definitely have those during residency. Fewer of those types of personalities in fellowships like this one, but sometimes still there. Generally, and this is definitely a biased view, you get many fewer personality disorders in pediatrics. People just tend to be more chill and happier, which makes for a much better work environment. Overall, there definitely tends to be more chill atmosphere in all peds specialties compared to their adult counterparts, but when you're in a situation where you have to deal with kids who are dying or very seriously sick, there is an expected decorum and seriousness that you have most of the time.

This sounds great, honestly. I need some more exposure in 4th year and get the chance to see this dynamic first hand.

 

[ATP to ADP]

Hey, thanks for this! I'm really interested in going into NICU, it's actually one of my top 2 interests - the other being psych.

Could you talk about how you decided on peds/NICU rather than other specialties? What qualities of NICU pushed you towards it, and did any qualities push you away?

 

[deleted407021]

Hey, thanks for this! I'm really interested in going into NICU, it's actually one of my top 2 interests - the other being psych.

Could you talk about how you decided on peds/NICU rather than other specialties? What qualities of NICU pushed you towards it, and did any qualities push you away?

It’s interesting the number of people I’ve happened across (myself included) who are bouncing between peds and psych

 

[deleted407021]

I really don't see the interest overlap... at all.. It's like being torn between surgery and pathology

Right? There's a lot of overlap in my mind, though. Think about all the social factors and the psychological stages kids go through in quick succession as they grow up. There's also the very interesting social psych stuff involving parents and investigating unspoken family dynamics. I think what draws a lot of people to psychiatry is the social aspect where environment plays a huge role in putting the patients into context. Similar for peds. Both groups also tend to be easier going in my experience.

 

[Espressso]

Great thread, thank you!! A general question for those mentioning job opportunities in specific geographic regions. Any advice on how to find credible information on this? I'm a measly 2nd year but a lot of my future career plans are geographic-dependent, so I'd like to be able to see this information as well!

 

[NurWollen]

Peds resident here.

How are your overall responsibilities different than a resident's? Do residents write most of your notes for you, put it orders, etc? How do your call nights compare to when you were a resident?

In a different vein, are you able to moonlight as a fellow? If so, what kind of opportunities are there? I'm likely going to be doing a fellowship, but escaping the relative poverty of being a resident with kids to support would be nice.

 

[SurfingDoctor]

why is there so much research in pediatric fellowships. Noticed the same with pediatric nephrology. can you really learn everything in a fellowship in a year? why have everyone waste the other 2 years with mandatory research? Of course there might be some that like the research

It's a misguided attempt at forcing people into academia left over from the 1990s. There's not really more to it than that. 1 year is probably too short for clinical proficiency and adequate experience, but 18 months is probably reasonable. At least for more procedure based specialties.

 

[MEN2C]

Peds resident here.

How are your overall responsibilities different than a resident's? Do residents write most of your notes for you, put it orders, etc? How do your call nights compare to when you were a resident?

In a different vein, are you able to moonlight as a fellow? If so, what kind of opportunities are there? I'm likely going to be doing a fellowship, but escaping the relative poverty of being a resident with kids to support would be nice.

I don't put in any orders, or write any notes, except for code events and stuff like that. Call nights vary. If I am at my level IV hospital, it tends to be much busier than my nights as a resident as I'm constantly doing something. At my delivery hospital, it's more variable, especially depending on the residents or NPs, as most problems can be handled and I only wake up for crazy deliveries or if someone is super sick or for more interesting questions. The type of work I do is much more interesting though - I don't generally called for a butt rash or a tylenol prn or for going up on the PIP by two on a ventilator. But there are definitely lots of nights where I don't get any sleep at all. Don't expect that.

Most places allow you to moonlight, but not all. It's something you're gonna have to ask each program. At most places, the opportunities in your first year will be limited because your clinical schedule will be pretty significant, so you just don't have time to moonlight a lot.

 

[xALIAx]

any predictions on the future of the field? seems easy to automate out to NPs

 

[MEN2C]

I don’t think it is, though I know that many people who go through delivery hospitals may think so. Neonatal Nurse Practitioners are a great resource and have been around for many many decades.

On my current level IV unit, we currently have:
1. 2 ECMO
2. 24 kids on mechanical ventilation, 4 of them on HFOV
3. Five kids on pressors, three on multiple
4. 4 kids on dialysis
5. 14 separate (known) genetic disorders
6. Six kids on NO for pHTN
7. Lots of surgery kids with stuff ranging from congenital diaphragmatic hernia s/p ecmo to chest tubes to gastroschisis to VP shunts
8. One patient being actively cooled

I think it’s a little complicated. And even if you look at level II and level IIIs, if you look for jobs, you’ll see more and more actually are now requiring 24/7 attending neonatology presence (instead of call from home) and no one is going the other way.

So I don’t know of a single fellow or an attending who is worried about that type of thing in the future. I would be more worried about artificial wombs .

 

[MEN2C]

Great thread, thank you!! A general question for those mentioning job opportunities in specific geographic regions. Any advice on how to find credible information on this? I'm a measly 2nd year but a lot of my future career plans are geographic-dependent, so I'd like to be able to see this information as well!

A lot of if it is word of mouth - at academic centers. Many times they aren’t actively hiring but will make room for you if they like your CV and you come recommended from A PD or a research big shot at your training institution. Two of my graduating fellows were just hired in NYC on non advertised jobs due to phone calls. People know each other. It’s the largest sub specialty within pediatrics but it’s still very small compared to the adult world. Private practice jobs are more likely to be openly advertised - you’ll find plenty by just googling. Especially from huge organizations like MEDNAX, which makes up a significant portion of private practice neonatology.

 

[MEN2C]

Hey, thanks for this! I'm really interested in going into NICU, it's actually one of my top 2 interests - the other being psych.

Could you talk about how you decided on peds/NICU rather than other specialties? What qualities of NICU pushed you towards it, and did any qualities push you away?

I was always going to do ICU, even in medical school. It's just something I like. I enjoy procedures and I enjoy medicine. I like some parts of the OR but I can't really see myself there all the time. So EM/ICU was a natural fit. Then I did 3rd year and realized I am not a nice enough person to do adult medicine and not become completely jaded and cynical. And I didn't want to be jaded and cynical and have contempt/dislike for my patients. Utmost respect to people who can do adult medicine without becoming jaded and hating their patients or jobs, but I don't think I could - not after the 5th re-admission for CHF because the dude won't stop eating at McDonalds or COPD who keeps smoking. I loved pediatrics because most times parents want the best for their kids, even when they disagree with you. And when a kid gets re-admitted for the fifth time - it's never the kid's own fault (it might be the parents fault in some cases, but you always have sympathy for the kid). So I can remain invested in my patient's care, regardless of the other circumstances. That's just me though. So I chose peds, and at that point, it was going to be PICU/CICU/NICU. And I've differentiated those things in other posts.

 

[Oso]

Hi MEN2C, I’ve been following this thread closely. Thank you for doing this!

This is a bit more of an individual question, but maybe it could also help someone in the future. Basically, I’m finishing up peds intern year and trying to decide between NICU and PICU. I’m wondering if you think I should keep exploring neonatology given my likes/dislikes of my experience so far.

I love physiology and intensive care. I’ve done one NICU rotation in residency so far. I enjoyed acutely ill babies in the NICU, for example, seizures, hyper/hypotension, respiratory distress, sepsis, meningitis. I think vents are super interesting. I love intubations, placing lines, etc.

However, I was never crazy about deliveries. If a patient needs bag mask ventilation or intubation I thought it was interesting. But was not a fan of most deliveries, especially being called for things like shoulder dystocia. Basically I didn’t like going whenever we went and the baby was fine, which I know is dumb because you obviously never know in advance, but still. Also, the feeding/growing part killed me and adjusting O2 by 0.5 liters slowly over 1-3 days also killed me.

I do PICU in a few months. Do you think it would be worthwhile to continue to explore NICU? I have the option to do a NICU away at a busy community hospital in town, so I could get a little different perspective.

Thanks!

 

[deleted407021]

I was always going to do ICU, even in medical school. It's just something I like. I enjoy procedures and I enjoy medicine. I like some parts of the OR but I can't really see myself there all the time. So EM/ICU was a natural fit. Then I did 3rd year and realized I am not a nice enough person to do adult medicine and not become completely jaded and cynical. And I didn't want to be jaded and cynical and have contempt/dislike for my patients. Utmost respect to people who can do adult medicine without becoming jaded and hating their patients or jobs, but I don't think I could - not after the 5th re-admission for CHF because the dude won't stop eating at McDonalds or COPD who keeps smoking. I loved pediatrics because most times parents want the best for their kids, even when they disagree with you. And when a kid gets re-admitted for the fifth time - it's never the kid's own fault (it might be the parents fault in some cases, but you always have sympathy for the kid). So I can remain invested in my patient's care, regardless of the other circumstances. That's just me though. So I chose peds, and at that point, it was going to be PICU/CICU/NICU. And I've differentiated those things in other posts.

Hmm

This post clicks with me doc. Thanks for the insight.

 

[nimbus]

Hi MEN2C, I’ve been following this thread closely. Thank you for doing this!

This is a bit more of an individual question, but maybe it could also help someone in the future. Basically, I’m finishing up peds intern year and trying to decide between NICU and PICU. I’m wondering if you think I should keep exploring neonatology given my likes/dislikes of my experience so far.

I love physiology and intensive care. I’ve done one NICU rotation in residency so far. I enjoyed acutely ill babies in the NICU, for example, seizures, hyper/hypotension, respiratory distress, sepsis, meningitis. I think vents are super interesting. I love intubations, placing lines, etc.

However, I was never crazy about deliveries. If a patient needs bag mask ventilation or intubation I thought it was interesting. But was not a fan of most deliveries, especially being called for things like shoulder dystocia. Basically I didn’t like going whenever we went and the baby was fine, which I know is dumb because you obviously never know in advance, but still. Also, the feeding/growing part killed me and adjusting O2 by 0.5 liters slowly over 1-3 days also killed me.

I do PICU in a few months. Do you think it would be worthwhile to continue to explore NICU? I have the option to do a NICU away at a busy community hospital in town, so I could get a little different perspective.

Thanks!

Have you considered anesthesia/peds anesthesia/+-PICU? Some people with similar interests have taken that route after peds residency.

 

[MEN2C]

Also....why? Just pick. That’s TEN YEARS of residencies and fellowships.

 

[MEN2C]

Hi MEN2C, I’ve been following this thread closely. Thank you for doing this!

This is a bit more of an individual question, but maybe it could also help someone in the future. Basically, I’m finishing up peds intern year and trying to decide between NICU and PICU. I’m wondering if you think I should keep exploring neonatology given my likes/dislikes of my experience so far.

I love physiology and intensive care. I’ve done one NICU rotation in residency so far. I enjoyed acutely ill babies in the NICU, for example, seizures, hyper/hypotension, respiratory distress, sepsis, meningitis. I think vents are super interesting. I love intubations, placing lines, etc.

However, I was never crazy about deliveries. If a patient needs bag mask ventilation or intubation I thought it was interesting. But was not a fan of most deliveries, especially being called for things like shoulder dystocia. Basically I didn’t like going whenever we went and the baby was fine, which I know is dumb because you obviously never know in advance, but still. Also, the feeding/growing part killed me and adjusting O2 by 0.5 liters slowly over 1-3 days also killed me.

I do PICU in a few months. Do you think it would be worthwhile to continue to explore NICU? I have the option to do a NICU away at a busy community hospital in town, so I could get a little different perspective.

Thanks!

I don’t know what you mean by “continuing to explore”. Do your PICU month and see how you feel.

One thing I’ll mention is that you have to like bread and butter and “boring” stuff of any specialty. Whether that’s RSV on high flow in the PICU, constipation/IBS in GI, asthma exacerbation as a Hospitalist or feeder/grower in the nicu. If you don’t like deliveries, NICU is probably not the specialty for you. If you’re an attending at an academic center, you would only go to the complicated deliveries which need intubations/lines/chest tubes, or with known complicated congenital anomalies. But then you would “do” less - other people would run the code and you’d just be in the background most of the time.

At community places, you might go to a lot of “boring” deliveries (assuming they don’t have NPs in house) and those hospitals also tend to have a large proportion of feeder/growers.

From your post, CICU or PICU might be more your style. But you can wait and see.

 

[Oso]

A late reply, but thanks! All your posts have been really informative and helpful. Hope to finally figure out my life soon.

How is your fellowship going?

I also just wanted to bump this thread! Feel like not enough people really know what neonatologists do, so this thread is great

 

[QissQiqSiqSQS]

Wanted to second Oso - great thread @MEN2C - curious how another year of fellowship has treated you?

 

[MEN2C]

Doing great! “Excited“ to start looking for jobs in 4-5 months!

I almost wish we had to go through the match again for the big boy jobs!

 

[yuiiuy]

Hi, I am applying for NICU fellowship this upcoming cycle. I was wondering if it really matters going to a Level 3 or a Level 4 NICU. Also, I plan on applying pretty broadly all over the country, but was wondering what are some factors that you'd consider more when looking at a program (other than the usual geographic location, research focus, etc). Thank you!

 

[EDCuddler]

Do many NICU fellows moonlight? I'd imagine during the two-ish years of research, many are itching to go out and get a job/make some money. What have you seen at your program and others?

 

[Funke]

Hey @MEN2C thanks so much for this informative thread. What was your job search like? Were good positions fairly attainable?

 

[MEN2C]

Hi, I am applying for NICU fellowship this upcoming cycle. I was wondering if it really matters going to a Level 3 or a Level 4 NICU. Also, I plan on applying pretty broadly all over the country, but was wondering what are some factors that you'd consider more when looking at a program (other than the usual geographic location, research focus, etc). Thank you!

Yes, it absolutely 100% definitely matters. GO to a level IV where they do everything even if you don't end up practicing at a place like that. It'll teach you to be comfortable with anything.

Look at the clinical experience, research, and how much you like it overall. You've been thru this before, it's the same as picking a residency.