PEM Attending Questions

[FrkyBgStok]

I am currently a peds resident preparing my application this fall for pediatric EM. I was debating whether to post this in peds or EM so I thought I would try here. I am hoping to chat with a PEM attending and ask a couple questions over PM. I am basically looking to for a reasonable PEM hourly rate, ideally in the midwest reason, but I was hoping to get some other advice specific to my situation. Thanks ahead for anyone willing to give me a little of their time.

or is anyone willing to ballpark a decent PEM hourly rate. doesn't even matter if it is academic or community, but both would be appreciated. Thanks.

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[killdevil]

My understanding is that the pay for peds EM is about the same as the pay for general EM. With that in mind, the link below leads to a pretty good ballpark summary of current rates, which are highly variable by region.

Err, SDN thinks I'm a spammer and won't let me paste a link in. So google the terms below and click the first link.

acepnow compensation report

 

[Apollyon]

Peds EM from EM makes less than general EM. Peds EM from peds makes more than general peds. So, it's a step up from peds, and a step down from EM.

 

[BoardingDoc]

My understanding is that the pay for peds EM is about the same as the pay for general EM. With that in mind, the link below leads to a pretty good ballpark summary of current rates, which are highly variable by region.

Err, SDN thinks I'm a spammer and won't let me paste a link in. So google the terms below and click the first link.

acepnow compensation report

As Apollyon noted above, PEM generally gets paid less than EM but more than peds.

 

[RoyBasch]

At my shop the PEM physicians make 10% less than the regular EM physicians. This is still an excellent salary, and given the far lower level of complexity and acuity of the average peds ER cases compared to adult cases, I think this is very fair and generous.


Edit: I have some friends from medical school who are practicing general practice pediatricians, and these peds EM salaries at my shop is about 2.5x the salary of a gen peds. So as other posters have noted, Peds EM is a huge step up compared to general practice peds, but a little bit less than adult EM.

 

[RustedFox]

At my shop the PEM physicians make 10% less than the regular EM physicians. This is still an excellent salary, and given the far lower level of complexity and acuity of the average peds ER cases compared to adult cases, I think this is very fair and generous.

Its worth it to have dedicated peds EM staffing such that you don't have to deal with the REAL problem in peds EM; the parents.

8 year old female with neck sprain. Seen yesterday here for same complaint. Not better.
Its an obvious sprain/strain of the lower end of the SCM muscle. Its the only site that's tender, and the history fits.
I explain that this type of injury typically takes days to improve. I relate a story about a similar old sports injury that I had.
"Not good enough", say the parents - and certainly not good enough for them at 2:30AM. X-rays will show us something.
I explain why x-rays are useless. I even go so far as to pull up a normal neck x-ray on google images (along with an image of the muscle that's hurting their Princess) to explain.
Fine. Then MRI her. Now.
No. I don't have MRI capabilities.
Fine. Then CAT scan her. Now.
No. I'm not irradiating your daughter's thyroid needlessly.
Then hydrate her because she's dehydrated because she's not eating or drinking because it hurts so much.
No. She's not dehydrated. At all.
Fine. We'll just take her to [Regional Children's Hospital] since you clearly don't know what your doing here.
Okay. Enjoy the hour and a half drive to be told the same thing.

Some old poster on here had a one-liner in their post signature that said: "If hate were people, I'd be China."
Well. Ni-hao, good buddy.

 

[RoyBasch]

Its worth it to have dedicated peds EM staffing such that you don't have to deal with the REAL problem in peds EM; the parents.

8 year old female with neck sprain. Seen yesterday here for same complaint. Not better.
Its an obvious sprain/strain of the lower end of the SCM muscle. Its the only site that's tender, and the history fits.
I explain that this type of injury typically takes days to improve. I relate a story about a similar old sports injury that I had.
"Not good enough", say the parents - and certainly not good enough for them at 2:30AM. X-rays will show us something.
I explain why x-rays are useless. I even go so far as to pull up a normal neck x-ray on google images (along with an image of the muscle that's hurting their Princess) to explain.
Fine. Then MRI her. Now.
No. I don't have MRI capabilities.
Fine. Then CAT scan her. Now.
No. I'm not irradiating your daughter's thyroid needlessly.
Then hydrate her because she's dehydrated because she's not eating or drinking because it hurts so much.
No. She's not dehydrated. At all.
Fine. We'll just take her to [Regional Children's Hospital] since you clearly don't know what your doing here.
Okay. Enjoy the hour and a half drive to be told the same thing.

Some old poster on here had a one-liner in their post signature that said: "If hate were people, I'd be China."
Well. Ni-hao, good buddy.

Hey I don't disagree with you, I'm definitely happy when the PEM guys are around to see the peds cases (and their parents).

 

[FrkyBgStok]

Thanks everyone. Sincerely appreciate it!

 

[emergentmd]

Its worth it to have dedicated peds EM staffing such that you don't have to deal with the REAL problem in peds EM; the parents.

8 year old female with neck sprain. Seen yesterday here for same complaint. Not better.
Its an obvious sprain/strain of the lower end of the SCM muscle. Its the only site that's tender, and the history fits.
I explain that this type of injury typically takes days to improve. I relate a story about a similar old sports injury that I had.
"Not good enough", say the parents - and certainly not good enough for them at 2:30AM. X-rays will show us something.
I explain why x-rays are useless. I even go so far as to pull up a normal neck x-ray on google images (along with an image of the muscle that's hurting their Princess) to explain.
Fine. Then MRI her. Now.
No. I don't have MRI capabilities.
Fine. Then CAT scan her. Now.
No. I'm not irradiating your daughter's thyroid needlessly.
Then hydrate her because she's dehydrated because she's not eating or drinking because it hurts so much.
No. She's not dehydrated. At all.
Fine. We'll just take her to [Regional Children's Hospital] since you clearly don't know what your doing here.
Okay. Enjoy the hour and a half drive to be told the same thing.

Some old poster on here had a one-liner in their post signature that said: "If hate were people, I'd be China."
Well. Ni-hao, good buddy.

2am? I would have done a 2 view C/S and call it a day....... No need to educated the uneducatable. If they were educated, they would have given the kid motrin and kept them home...

 

[emergentmd]

I remember when I was doing EM residency and did a Ped EM rotation at the Children's hospital with a big PEM program. I was interested in doing a fellowship (I think 2 more years) and go into PEM.... Why not I thought. I could do both and be more marketable.

Anyhow, after talking to the PEM guys they told me

1. PEM makes less than EM
2. EM can work in most PEM hospitals but obviously not the other way around
3. Its 2 more years to get paid less

Anyhow... that was the last time I ever thought about PEM.

I worked at a Children's hospital 2 yrs ago. There were EM docs and PEM docs working the site. The EM docs were paid $50/hr more and also was given a $500 bonus per shift.

If I was a PEM working in a children's hospital making alot less than the adult guys, I would be furious esp PEM docs should be better trained.

 

[RustedFox]

2am? I would have done a 2 view C/S and call it a day....... No need to educated the uneducatable. If they were educated, they would have given the kid motrin and kept them home...

I thought about doing just this; but I had many other things to do and I'm single coverage.

 

[emergentmd]

I thought about doing just this; but I had many other things to do and I'm single coverage.

2 View order, takes less time than what you went through. Plus your Press Ganey gonna really go down.

 

[RustedFox]

2 View order, takes less time than what you went through. Plus your Press Ganey gonna really go down.

Sorry, man. I like a lot of what you post; but we're gonna disagree here. I'm not irradiating a head/neck of a kid, tying up rads for too long, pissing off the nursing staff (these people were completely unreasonable), and wasting my time. They can kiss my Press-Ganey.

 

[GonnaBeADoc2222]

2 View order, takes less time than what you went through. Plus your Press Ganey gonna really go down.

Sorry, man. I like a lot of what you post; but we're gonna disagree here. I'm not irradiating a head/neck of a kid, tying up rads for too long, pissing off the nursing staff (these people were completely unreasonable), and wasting my time. They can kiss my Press-Ganey.

Nope. Children don't get punished with radiation (or unnecessary antibiotics for that matter) for misbehaving parents. Document neuro intact, no midline tenderness, neck w full range of motion, OTC meds and discharge. Byeeeeeeeee.

 

[Perrin]

Some old poster on here had a one-liner in their post signature that said: "If hate were people, I'd be China."
Well. Ni-hao, good buddy.

Hey, I have a few more months till I turn 40. Haven't started yelling at kids to get off my lawn....yet.

 

[BigRedBeta]

I remember when I was doing EM residency and did a Ped EM rotation at the Children's hospital with a big PEM program. I was interested in doing a fellowship (I think 2 more years) and go into PEM.... Why not I thought. I could do both and be more marketable.

Anyhow, after talking to the PEM guys they told me

1. PEM makes less than EM
2. EM can work in most PEM hospitals but obviously not the other way around
3. Its 2 more years to get paid less

Anyhow... that was the last time I ever thought about PEM.

I worked at a Children's hospital 2 yrs ago. There were EM docs and PEM docs working the site. The EM docs were paid $50/hr more and also was given a $500 bonus per shift.

If I was a PEM working in a children's hospital making alot less than the adult guys, I would be furious esp PEM docs should be better trained.

That's a ridiculous compensation setup.

EM to PEM doesn't make a lot of sense unless you just can't stand the adult side of things. Peds to PEM (as the OP plans to do) does result in better compensation usually compared to gen peds.

 

[emergentmd]

That's a ridiculous compensation setup.

EM to PEM doesn't make a lot of sense unless you just can't stand the adult side of things. Peds to PEM (as the OP plans to do) does result in better compensation usually compared to gen peds.

What you get paid many times is not what you know or how much experience you have. It has to do more with how scarce you are.

If a PEM makes $150/hr then getting $175/hr is great.
If an adult EM Makes 225/hr, you are not getting him/her to cover a PEM shift for less than $225/hr.

 

[deleted109597]

If I was a PEM working in a children's hospital making alot less than the adult guys, I would be furious esp PEM docs should be better trained.

Look. I like some PEM. And yes, they should be better trained. But universally the Peds=>PEM tract suck at any procedure. Literally suck hard. And there's literature showing how little they get to do. It's not part of their training like it is for us. PEM requires adult shifts at some shops because of the lack of procedures.
I get that they're better at vaccination schedules and normal for age and whatnot. I really do. And they try to portray that they're better at understanding the physiology, and some of them do as well. But usually they're PICU docs working retrieval in other countries, not PEM where they basically add 3 more years to do acute care clinic with minimal actual emergencies.
I will always take an EM doc over a peds to PEM trained person in a dying patient situation. Always.

 

[GonnaBeADoc2222]

Look. I like some PEM. And yes, they should be better trained. But universally the Peds=>PEM tract suck at any procedure. Literally suck hard. And there's literature showing how little they get to do. It's not part of their training like it is for us. PEM requires adult shifts at some shops because of the lack of procedures.
I get that they're better at vaccination schedules and normal for age and whatnot. I really do. And they try to portray that they're better at understanding the physiology, and some of them do as well. But usually they're PICU docs working retrieval in other countries, not PEM where they basically add 3 more years to do acute care clinic with minimal actual emergencies.
I will always take an EM doc over a peds to PEM trained person in a dying patient situation. Always.

This. All day long.

The move from gen peds to pem is great from a compensation/lifestyle/academic interest perspective and I think is an awesome escape hatch for some people. Not so great from a "I want to enhance my clinical expertise" perspective as any "adult EM" can handle 99% of what a PEM trained person can (they're better than me about knowing about fatty acid metabolism disorders...whatever.) I used to be amused in residency when I'd have to get vascular access when the fellow couldn't or when almost every airway intubated by the pem fellow/attending was described as "tricky." In lots of places, the PICU (aka the real peds critical care presence in the hospital) comes down to take over the management of the really sick kids.

 

[BigRedBeta]

PICU attending here...y'all aren't wrong.

The irony of PEM training is that the places considered "the best" also have the most robust PICU presence. And then the PICU fellows are more likely to come to the ED to "help out", take all the procedures and best cases in the unit when the PEM fellow is rotating through, and generally usurp the best educational opportunities.

PEM fellows coming out of the quintenary referral centers probably do better then EM people when it comes to triage and initial management for the weird s^it they've seen.

EM folks though still do stuff out in the community that drives me batty because it makes my life harder when I get the kid in the unit - think uncuffed ET tubes, inappropriate sized ET tubes, using sux in a metabolic disease kid, and insulin boluses and bicarb in DKA. There are others, but those are the ones I see most commonly.

 

[SpacemanSpifff]

PICU attending here...y'all aren't wrong.

The irony of PEM training is that the places considered "the best" also have the most robust PICU presence. And then the PICU fellows are more likely to come to the ED to "help out", take all the procedures and best cases in the unit when the PEM fellow is rotating through, and generally usurp the best educational opportunities.

PEM fellows coming out of the quintenary referral centers probably do better then EM people when it comes to triage and initial management for the weird s^it they've seen.

EM folks though still do stuff out in the community that drives me batty because it makes my life harder when I get the kid in the unit - think uncuffed ET tubes, inappropriate sized ET tubes, using sux in a metabolic disease kid, and insulin boluses and bicarb in DKA. There are others, but those are the ones I see most commonly.

This has been my experience to the t rotating through our academic peds site. The PICU owns any truly sick resuscitation as soon as it is apparent that they are actually sick. There aren't enough sick kids to go around, even in the big centers. The PEM rotation through the PICU is essentially a shadowing experience on rounds, as they are not given primary management responsibilities on any of the patients. Essentially a waste of 4 weeks of their fellowship.

 

[Hamhock]

PICU attending here...y'all aren't wrong.

The irony of PEM training is that the places considered "the best" also have the most robust PICU presence. And then the PICU fellows are more likely to come to the ED to "help out", take all the procedures and best cases in the unit when the PEM fellow is rotating through, and generally usurp the best educational opportunities.

Unfortunately, the PEM fellows at one of the biggest EM "county" programs -- a place with no PICU fellowship and no national reputation in pediatrics -- also received little real experience in the PICU and were not competent at trauma (or even truly sick medical) resuscitation.

The really sick kids were resuscitated in the PICU by the attendings and the really sick or injured kids in the ED were resuscitated by the EM residents or EM attendings with the PEM folks standing by watching.

Granted, the PEM folks would "resuscitate" some of the kids, but that was with the (kept-quiet) security of a EM PGY4 or EM attending either watching at the bedside or just a "nurse-scream" away.

Note to folks interested in PEM:
(obviously my opinion)

If you want to be a master of a sub-specialty of emergency medicine, do an emergency medicine residency. True PEM (sick kids in the ED) is not a subspecialty of pediatrics despite what the feckless EM politicians have done to it.

If you want to be a master of critically ill kids, do a PICU fellowship or one of the anesthesiology-based pediatric pathways (PICU or peds anesthesia).

HH

 

[deleted109597]

If you want to be a master of critically ill kids, do a PICU fellowship or one of the anesthesiology-based pediatric pathways (PICU or peds anesthesia).

This.
It boggled my mind when the medical director at the peds hospital told me that he a) never billed critical care and b) wanted us to call PICU immediately on anybody kinda sick. I figured out why after working a few shifts.

 

[BigRedBeta]

Unfortunately, the PEM fellows at one of the biggest EM "county" programs -- a place with no PICU fellowship and no national reputation in pediatrics -- also received little real experience in the PICU and were not competent at trauma (or even truly sick medical) resuscitation.

The really sick kids were resuscitated in the PICU by the attendings and the really sick or injured kids in the ED were resuscitated by the EM residents or EM attendings with the PEM folks standing by watching.

Granted, the PEM folks would "resuscitate" some of the kids, but that was with the (kept-quiet) security of a EM PGY4 or EM attending either watching at the bedside or just a "nurse-scream" away.

Lordy.

There are places where the Peds ED actually does care for the truly sick and where the PEM fellows aren't just an afterthought when they are on their PICU rotations...but anyone looking for a PEM fellowship has to ask the right questions. Who get's airways in the ED, how many traumas are there, who runs them, how many PICU fellows are there and what are their roles, how many shifts do I get running the ED by myself as a 2nd and 3rd year, etc, etc. The grander issue is that peds residents get less autonomy than any other group of trainees as a general rule - even less at the big name locations with tons of fellowships - and so the peds graduates don't know any better to ask for that level of responsibility.

Oh, and PEM fellows need to stick up for their own educational opportunities and not bow out when the PICU fellow comes. PICU folks tend to be a highly self selected, not very cuddly group of pediatricians, and tend to command a room, so the less forceful people give us a wide berth.

 

[emergentmd]

I am EM trained and have worked in single coverage stand along Pedi ERs. Actually somewhat scary being the only EM doc in a Pedi Er but that is another discussion.

When a Sick kids comes in such as drowning or DKA or anything with abnormal vitals, the PICU docs gets called immediately and essentially takes over care. Actually amazing support and gives me a great peace of mind. Some of the nicest, helpful, available specialty I have met.

When a sick adult comes in such as Resp arrest, DKA, hypotensive/unstable patient comes in..... there is NO ICU/pulmunologist to be found. Even when they call back, they won't come immediately or many times just see them in the ICU. So I managed these sick patients and truthfully much sicker patients than the Pedi counterparts until they leave the Er.

This is a big reason PEM docs are not as well trained as EM docs to care for critical patients - In General. Plus sick adults to Pedi is prob 20:1

 

[Perrotfish]

At my shop the PEM physicians make 10% less than the regular EM physicians. This is still an excellent salary, and given the far lower level of complexity and acuity of the average peds ER cases compared to adult cases, I think this is very fair and generous.

Keep in mind that the patients triaged to Peds EM might not actually be low complexity or acuity, depending on how the hospital staffs the ER. At every children's hospital that I rotated through the ER was staffed with a mixture of Peds EM and either regular ER docs or general Pediatricians. The patients seen by the Peds ER docs were usually onc, partially repaired congenital heart disease, CP/DD, metabolic syndromes, etc. 'Average' Peds cases saw a general Pediatrician in the next pod.

 

[FrkyBgStok]

Well this thread turned into a super motivating thread....

 

[Brigade4Radiant]

PICU attending here...y'all aren't wrong.

EM folks though still do stuff out in the community that drives me batty because it makes my life harder when I get the kid in the unit - think uncuffed ET tubes, inappropriate sized ET tubes, using sux in a metabolic disease kid, and insulin boluses and bicarb in DKA. There are others, but those are the ones I see most commonly.

That's because in the community you intubate with what you have ,they don't keep a full stock of pediatric ET tubes. The PICU can always exchange it out.

 

[deleted109597]

When a sick adult comes in such as Resp arrest, DKA, hypotensive/unstable patient comes in..... there is NO ICU/pulmunologist to be found. Even when they call back, they won't come immediately or many times just see them in the ICU. So I managed these sick patients and truthfully much sicker patients than the Pedi counterparts until they leave the Er.

I have had "they're too sick for the ICU" on more than one occasion. Always for adults. I still don't know what that actually means.

 

[BoardingDoc]

I have had "they're too sick for the ICU" on more than one occasion. Always for adults. I still don't know what that actually means.

What? I've had the "too sick for the floor, not sick enough for the ICU" issue before, (hint: tell the intensivist and the hospitalist to talk to each other and call you back with a decision), but I've never heard someone say that a patient is too sick for the ICU. That makes no sense whatsoever. Unless they simply mean that the patient is too sick for that specific ICU and they want you to transfer the patient.

 

[deleted109597]

What? I've had the "too sick for the floor, not sick enough for the ICU" issue before, (hint: tell the intensivist and the hospitalist to talk to each other and call you back with a decision), but I've never heard someone say that a patient is too sick for the ICU. That makes no sense whatsoever. Unless they simply mean that the patient is too sick for that specific ICU and they want you to transfer the patient.

Oh, the "they can go home/no they can't/they need the ICU" thing is real too. But at my one shop (stroke/cardiac centers of EXCELLENCE!) the hospitalist would admit to the ICU. And they were terrible at it. But we couldn't transfer, and if they were sick, it was not uncommon that they would expect us to manage pressors/vents on patients. It was ridiculous.

 

[BoardingDoc]

Oh, the "they can go home/no they can't/they need the ICU" thing is real too. But at my one shop (stroke/cardiac centers of EXCELLENCE!) the hospitalist would admit to the ICU. And they were terrible at it. But we couldn't transfer, and if they were sick, it was not uncommon that they would expect us to manage pressors/vents on patients. It was ridiculous.

I'm very hopeful about the fact that you're using the past tense here a lot. Because yeah, that sounds completely insane. I'm aware of hospitals where the ED doc is responsible for responding to codes / intubating people in an emergency, but this sounds like you're literally being asked to be the intensivist as well as the ED attending. F that.

 

[deleted109597]

I'm very hopeful about the fact that you're using the past tense here a lot. Because yeah, that sounds completely insane. I'm aware of hospitals where the ED doc is responsible for responding to codes / intubating people in an emergency, but this sounds like you're literally being asked to be the intensivist as well as the ED attending. F that.

Well I'm at a freestanding now, so I often have to manage them until I can find a hospital to accept. They can't just go upstairs. So it's not that different I suppose.

 

[DeadCactus]

Well this thread turned into a super motivating thread....

A reasonable expectation would be low to mid-200's going pediatrics to PEM. Less in major cities and at larger academic brands. An EM based route is the way to go if finances are a priority and is probably the optimal route unless you hate adults. Where you fall on the triage physician to emergency physician spectrum is going to vary by institution. There are adult EM jobs as well where every procedure is farmed off to a specialist because the prime directive is to churn through patients rather than actually practice medicine.

If you want motivating:
Physician career satisfaction within specialties

Pain in the ass parents or drug seekers who might swing at you or follow you to your car. Every specialty and subspecialty has it's negatives and its really cool aspects, find the specialty where the negatives bother you the least and the mundane cases are the most tolerable.

 

[MEN2C]

Less in major cities and at larger academic brands. An EM based route is the way to go if finances are a priority and is probably the optimal route unless you hate adults. Where you fall on the triage physician to emergency physician spectrum is going to vary by institution. There are adult EM jobs as well where every procedure is farmed off to a specialist because the prime directive is to churn through patients rather than actually practice medicine.

Haha. A lot of us chose Pediatrics because we don't feel we are good enough people to be able to deal with adult patients...

 

[Dr. Wexler]

As a general pediatrician it always seemed like EM docs are as good if not better at resuscitating critically ill children compared to PEM counterparts. Yes, kids are not little adult but when a kid needs to get intubated or needs a line you want someone who does it regularly (even if it is usually on adults).

Having done peds, I'd sooner go do an EM residency and be Peds + EM than go back for a fellowship and be Peds + PEM. Same amount of time. And with the former I'd be free to work in any ER, not just the possibly 1 hospital in town that has PEDs ER docs. And make more $. (Cue comment about how in X region Peds + EM is not seen as equivalent to PEM...whatever). I realize there are GME funding issues that make a 2nd residency more complicated than a fellowship.

 

[GonnaBeADoc2222]

We've pretty much derailed the original thread here, but I think all these sentiments are important for future med students and residents to read when they are planning their career path.

The term "adult EM" is a misnomer. As EM trained specialists, we are the authority on the hyper-acute resuscitation of adults and children - and we've received legitimate training in both. If I need guidance during a complex pedi resuscitation, I am going to be getting the PICU or NICU attending on the line, not PEM. In addition, we know how to manage the flow of an ED better than anyone. There is almost nothing that a PEM doc can do that I cannot do better and faster. PEM is great for academic niche building and clinical escape hatching, but don't think that the PEM pathway will make you a better or equivalent resuscitationist to an EM trained doc. Honestly, if you are wanting to be a solid pedi resuscitationist, you should really be considering PICU or NICU.

 

[FrkyBgStok]

Yeah I have read all the posts and taken what advice I feel is valuable. I think it illustrates that medicine is what you make of it. I have worked with a few PICU attendings, a couple who feel comfortable with the ultra-sick and a couple who say, "this kid needs a line, call IR." One of the PICU attendings I spoke to in depth said she went on interviews (she has been out of fellowship 2-3 years) where the program director informed her that PICU docs were there to think, not do procedures. I have also dealt with adult EM docs who call over to the Peds ED (we have a hospital with an adult ED and Peds ED and another hospital with just an adult ED) who request advice on basic cares and urgent transfers for an 8 month old on 2L nasal cannula. In our ED, the attending fully stabilizes for the PICU including line placement and securing an airway. Our program appears to be very different than other programs.

However, I do think it is important to look at generalities as you can't assume every place is the perfect setup. I also think it is important for more junior people to realize. If I could tolerate an EM residency, I may consider it. There are things that draw me to PEM other than the thought of "ultimate resuscitation badass." And there other things that draw me away from NICU and PICU regardless of being comfortable with the ultra-sick. I mean there has to be a reason that PEM is the second most competitive specialty behind pediatric sports medicine when just looking at number of applicants per spot (source: http://www.nrmp.org/wp-content/uploads/2018/02/Results-and-Data-SMS-2018.pdf). For me, there are a lot of other things there.

So for future med students and residents, I think a good take away is don't go into PEM if you think you are going to become a total stud in peds resuscitation. There are better specialties for that but know what you are getting into. And also, make sure to look into programs before you blindly think "big name, amazing experience." Ask questions on your interviews, pay attention to who does what, and gain enough information to make an educated decision.

I appreciate everyone playing devil's advocate. It is important to challenge opinions, especially the ones that I hold.

 

[Hamhock]

Yeah I have read all the posts and taken what advice I feel is valuable. I think it illustrates that medicine is what you make of it. I have worked with a few PICU attendings, a couple who feel comfortable with the ultra-sick and a couple who say, "this kid needs a line, call IR." One of the PICU attendings I spoke to in depth said she went on interviews (she has been out of fellowship 2-3 years) where the program director informed her that PICU docs were there to think, not do procedures. I have also dealt with adult EM docs who call over to the Peds ED (we have a hospital with an adult ED and Peds ED and another hospital with just an adult ED) who request advice on basic cares and urgent transfers for an 8 month old on 2L nasal cannula. In our ED, the attending fully stabilizes for the PICU including line placement and securing an airway. Our program appears to be very different than other programs.

However, I do think it is important to look at generalities as you can't assume every place is the perfect setup. I also think it is important for more junior people to realize. If I could tolerate an EM residency, I may consider it. There are things that draw me to PEM other than the thought of "ultimate resuscitation badass." And there other things that draw me away from NICU and PICU regardless of being comfortable with the ultra-sick. I mean there has to be a reason that PEM is the second most competitive specialty behind pediatric sports medicine when just looking at number of applicants per spot (source: http://www.nrmp.org/wp-content/uploads/2018/02/Results-and-Data-SMS-2018.pdf). For me, there are a lot of other things there.

So for future med students and residents, I think a good take away is don't go into PEM if you think you are going to become a total stud in peds resuscitation. There are better specialties for that but know what you are getting into. And also, make sure to look into programs before you blindly think "big name, amazing experience." Ask questions on your interviews, pay attention to who does what, and gain enough information to make an educated decision.

I appreciate everyone playing devil's advocate. It is important to challenge opinions, especially the ones that I hold.

That is a thoughtful and mature response of the kind rarely seen on SDN (especially when there are disagreements).
Kudos!
HH

 

[gamerEMdoc]

Just my 2 cents on PEM. I consider it almost another field from EM entirely, other than having EM in their name, the two types of departments run very differently.

General EM docs make more than Peds EM docs for two reasons:
- In PEM the majority of the complaints are lower RVU complaints.
- Pediatrics (and a subsequent PEM fellowship) doesn't train you to move the meat.

So while the PEM grad may be much better with that one sick crashing child that comes in every other day (or less), they don't see the volume that the general EM grad does, who trained for three years to be built for productivity. And that's what gets paid. When you don't have high acuity, then high volume pays the bills. And PEM as a specialty just doesn't tailor their training to that like EM does. At least that was my experience as a resident, and the experience my residents tell me. I remember going to CHOP and just sitting there seeing a patient and hour or less bored out of my mind, while Peds residents rotating with the same workload were going out of their mind. The fellows had less patients on their plate than most 2nd year EM residents would have in my program. And I can't imagine any of them working out in the community, because the amount of consults that were called on nearly every patient with anything wrong with them was crazy and would never fly in the real world.

Peds EM trains docs to work in Peds ED's at tertiary care Peds centers. It is what it is, and I actually do think they have a place. Those places need to exist. And their compensation is appropriately way more than a Pediatrician, and less than an ED doc.

 

[miacomet]

PICU attending here...y'all aren't wrong.

The irony of PEM training is that the places considered "the best" also have the most robust PICU presence. And then the PICU fellows are more likely to come to the ED to "help out", take all the procedures and best cases in the unit when the PEM fellow is rotating through, and generally usurp the best educational opportunities.

PEM fellows coming out of the quintenary referral centers probably do better then EM people when it comes to triage and initial management for the weird s^it they've seen.

EM folks though still do stuff out in the community that drives me batty because it makes my life harder when I get the kid in the unit - think uncuffed ET tubes, inappropriate sized ET tubes, using sux in a metabolic disease kid, and insulin boluses and bicarb in DKA. There are others, but those are the ones I see most commonly.

I think the issues is that PEM attendings in the community aren't intubating, correctly or incorrectly, cuffed or uncuffed, sux or no sux, and aren't resuscitating patients. The really sick kids in the community are seen by EM, not PEM, because their skills are not robust.

 

[miacomet]

At many Ped hospitals, the sick kids bypass the ER and go directly to the PICU/NICU. I think PEM would be better trained if we encourage more EM grads to go into it (a tall order for two reasons- PEM is often hostile to EM, and there is no incentive for EM grads to go into it) OR if PEM/PICU were actually a combined field. There just isn't enough sick for the PEM folks coming through the ED.