PICU vs. Peds ED

[Ponyboy]

Is anyone else out there trying to decide between these two specialties? The only thing that they have in common is sick children. I can't decide what I want to be when I'm done with this residency. My take on the two:

PICU:
Advantages:
- sickest children that you'll ever see
- cool procedures
- cool diseases
- relatively quick patient turnover (average PICU stay: 4 days)
- parents listen to you when you tell them their child needs something
- possibility for a sweet schedule (some PICU attendings work 8 weeks out of the year and spend the rest doing research which is pretty cush or nothing)
- when you're done fellowship, you can take care of almost anything

Disadvantages:
- you see some of the same patients (eg vented patients) again and again simply because they are vented
- rounding ad nauseum and then some more rounding
- you are chained to the unit when you're on service
- when you're on service, the call can be brutal

Peds ED:
Pros:
- shiftwork with a good schedule
- really rapid patient turnover (hours)
- no continuity of care (some of us see this as an advantage)
- some procedures
- easy bread-and-butter peds
- fast moving pace

Cons:
- shiftwork
- bronchiolitis and gastro are your bread-and-butter
- chances of having a sick patient 1:100


Does anyone else have any thoughts?

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[SoonerBJJ]

I decided on PICU for many of the reasons you have listed. There is no place where your decisions will have more immediate and obvious effects (and repercussions). This is a scary prospect to some, but others of us find it exciting and extremely rewarding.

There is great diversity within the PICU, but like any other specialty there are the bread and butter cases that pay the bills. CHI, DKA, CP/PMR, near-drownings, post-op ortho/NES, asthma, etc can get routine but the prospect of an aberration must keep you on your toes. There will be "frequent flyers" in any specialty. Who said there wasn't any continuity in PICU?

Rounds don't have to be long and tedious. It depends on where you are and the nature of your service. Are rounds really any more tedious than rounding on 20 cases of bronchiolitis, diarrhea and FTT on the floor or spending the days seeing minor sick visits and well child checks in clinic?

ER has the prospect of exciting moments but the VAST majority of patients are not sick. The bread and butter of ER is tedious and tiresome. The zebras and the critically ill are relatively rare. Most of the children could be sent home without any treatment or intervention and they would be just fine. With the critically ill you will only stabilize and possibly begin therapy before they are sent to the PICU for definitive management. Real stabilization often occurs in the PICU anyway. If you spend your time in the ER fantasizing about the next SICK patient and what you can do to save them then why not work in a place where 80% of the patients you see are critical and really need your attention.

I considered Peds ER for a short time but it didn't take long for me to find my passion.

 

[rastelli]

From my personal observations, this seems to be a common issue: CCM vs. EM, and I really don't understand why.

Of course you do have the critically ill children who present to ED's, requiring central lines, ETT's, etc. However, most of the work in the ED is routine clinical work...asthma exacerbations, pneumonias with hypoxia, acute abdomens, and TONS of fever! Also tons of gastro, diarrhea, etc.

Aside from the fairly uncommon invasive procedures in the ED, there really are few similarities from a medical and lifestyle standpoints. I love CCM, and that's what I'll be doing with my time in the future. I do not enjoy the ED simply because (most of the time) I feel like I'm in a huge clinic. It's not that I feel one is better than the other, I just hate clinic!

 

[Apollyon]

At our "high powered" place, one PedCCM 3rd year fellow commented to me (EM), "It is looking really attractive to just get a Peds EM job, 3 shifts a week, good pay, and be done".

Half of all PedsCCM fellowship spots didn't fill through the match this year (including some "big names"), so, in the ensuing time, even at "big name" places, you might not get the strongest colleagues.

In our PICU, there was a preponderance of the REALLY sick bone marrow kids (I couldn't really figure out what got a kid to move next door from BMT to PICU, beyond the kids on the oscillator), post-op hearts, and it worked like a SICU; beyond that, there is an active gene therapy program for Pompe's disease (2/16 beds currently occupied by kids with it). The "high acuity, high powered" patients were, still, not common.

As far as rounding interminably, that seems to be consistent across a broad range of attendings - especially magnified when you add CT surgeons, the BMT team, nephrology, and Peds Cards. I don't know how you can get around this until you are the attending.

Absolutely, a lot of PedEM is "clinic", but, as a friend said, "with kids, it's all or nothing, and it's usually nothing, but, when it's something, it's everything". One thing about bronchiolitis/RSV is that you'll see a lot of it in the ED, but, the sicker ones will get admitted, and a few of those will go to the PICU - and stay.

For me, it's gratifying to "treat and street" the kids; also, I learn more about sedating kids briefly, and get to do a fair amount of procedures (including a lot of good suturing and splinting/reduction). The main procedures in the PICU were the occasional to rare intubation (since few kids needed to be re-intubated), and central lines that were (at least while I was there) femoral - anything in the chest was put in by Peds surgery.

As far as ICU's go, the PICU and SICU (in my experience) have been a similar deal - a specific subset, with ~ 50% high turnover, and the other half a rock garden. For the most "bang for your buck", the MICU is where it's at (and I am anti-medicine - I thought I liked IM until I did prelim, and then said, "What was I thinking??").

EM and CCM get connected because there is the continuity of critically ill patients coming in, and being admitted. In many ED's across the US, the initial critical care is performed by the EM docs in the ED (and times are going up, with more ED visits, so more of the critical care in the first hours is being done by the EP's, until someone can be bounced out of the units).

PICUs can be in academic centers, which can become tragically boring as little happens after admission (unless titrating fentanyl and midaz drips, or the NO infusion, works for you), occasionally thrilling, and, hopefully, rarely terrifying. In large community hospitals, rounding can be much more compact, since you're not verbalizing a bunch of regurgitated numbers, and there is no dead silence as a "teaching" question is posited, and hangs in the air, the resident mute with no knowledge of the answer or guts to say something that might be wrong.

"Tragically boring, occasionally thrilling, and, hopefully, rarely terrifying" can also, honestly, be applied to the Peds ED.

Give them both a try, and do what you dig. As a peds resident, you'll (probably) get 2 months of each, and each fellowship is 3 years.

Good luck!

 

[Ponyboy]

I've tried both of these subspecialties out and still find that I waver between the two:
On one hand, Peds EM has the luxury of shiftwork, the "treat and street" philosophy, simpler "easier" patients, and no rounding. However, because it's EM, the conservative road is almost always taken and even though the ED will see the inital presentation of sick kids, they will almost never start PICU type therapies (at least at my hospital, the ED will not start central lines or pressors and they almost never intubate). Sure, they see sick kids but they never really truly are comfortable with sick kids.

On the other hand, the PICU docs are comfortable treating really sick kids, they are comfortable with PICU type therapies (naturally) and the kids there are sick (we see lots of cards and the really sick transfers). In our Picu, there are plenty or procedures to go around and there's a good variety of illnesses (DKA, sepsis, status, etc). However, it's the rounding and the chronic care kids that drive me insane.

Is there anyone who's considering a dual fellowship?

 

[J123]

There's shiftwork available in PICU, not just EM. Many larger private practice PICUs have a shift schedule the physicians work under. I guess it all depends on where you want to work in the end, academics or more private sector.

 

[SoonerBJJ]

Apollyon's PICU experience doesn't sound much like the PICU where I've trained in residency or the one in which I'll train in fellowship. Our PICU is mid-size and has a few rocks on any given day and there are the more rapid turn over kids. But there always seem to be at least a few interesting and challenging patients that don't fit any preconceived mold. This unit is less than a third of the size of the unit where I will be training in fellowship. I have friends who are there now and there is no shortage of action and challenges, both physical and intellectual.

The "big names" in PICU differ from what would be considered such in general pediatrics. I can think of a few programs specifically that are highly regarded in all the rankings (for what they are worth) and whose names are tossed around here with such reverence that have poor PICU programs. One would never know if they weren't looking into the programs in great detail.

In a very large unit intubations, chest tubes, art lines and CVLs (not only femoral) are found in great abundance. The problem I found while interviewing is that the vast majority of PICU fellowships were based in smaller and mid-size units. Most of these programs did not fill. Most of the programs with the very large units (40+ beds) filled.

To each their own though. rastelli could not have been more correct about the daily ED experience. The overwhelming majority of patients have PCP-type problems. The ED becomes a clinic.

Spend plenty of time in both and you'll find your place.

 

[Chimera]

Not to hijack the thread, but I'm very interested in a PICU fellowship and was curious as to where the top programs are?

Thanks.

 

[Ponyboy]

From what I've heard, the good PICU programs include:
CHOP, Boston Children's (naturally), Utah, Arkansas, Pittsburgh, and UT Southwestern.
Any others?

 

[SoonerBJJ]

From what I've heard, the good PICU programs include:
CHOP, Boston Children's (naturally), Utah, Arkansas, Pittsburgh, and UT Southwestern.
Any others?

Based on what I learned while on the interview trail I would say that the more highly regarded programs include (in no particular order): CHOP, Boston Pittsburg and UT Southwestern. These are the 4 largest programs in the country and all filled with high quality fellows from what I've heard. There are programs that are more prolific in terms of published papers than any of these 4 but publishing does not make a program great. I don't know much about Utah and I have a friend at Arkansas who is very happy and feels his training is good. It is a smaller program with only 1 fellow per year and they didn't fill this year. They have excellent peds cardiac surgery exposure. I believe they have a 4th year peds CICU fellowship.

 

[rastelli]

Baylor is another great program, and only getting better. We have about 6 fellows a year, tough to imagine a larger program. Not surprising though, since Texas Children's is the largest pediatric hospital and the pediatric residency program is the largest in the country.

 

[SoonerBJJ]

Baylor is another great program, and only getting better. We have about 6 fellows a year, tough to imagine a larger program. Not surprising though, since Texas Children's is the largest pediatric hospital and the pediatric residency program is the largest in the country.

I have nothing but good things to say about the people I met at Baylor but the program actually has 3 positions and filled only 1 in the recent match. Pitt is the biggest program in the country with 6 positions while UT Southwestern and CHOP are the second largest with 5 positions. Boston comes in at third with 4. All 4 programs filled this year.

TCH may be the largest pediatric hospital but it doesn't have the largest PICU in the state of Texas.

 

[Chimera]

Interesting...thanks for the info.

I have also heard of dual accrediation programs in critical care/anesthesiology and critical care/cardiology and I had a few questions regarding both.

First anesthesiology, the major arguement I've heard for this training is that it offers you significantly more flexibility in regards to working environment and pay structure. More specifically, I've been told a lot of critical care docs burn out later in their careers, and the option to push gas at that point or earlier can help alievate this potential if you don't have major research interests, in addition to the fact that this is also much more lucrative. What are your thoughts on this and the utility of the training itself?

Second cardiology, what is the true utility of this certification? Is it primarily for budding CICU intensivists or can one practice general PICU medicine and then do say cardiac clinics or interventional when not on PICU service? If it is only for the CICU is it worthwhile to go through both fellowships, or better to do one or the other with an additional year of more specific training? (ie. cardiac fellowship and then one year of CICU experience or PICU fellowship and then one year of CICU experience)

I know it's alot of questions, but I really appreciate your response.
Thanks.

 

[Ponyboy]

I've also been thinking about combined anesthesia/PICU and cards/PICU fellowships. I think that both of these fellowships add diversity and additional skills to a PICU fellowship. Both of these add an additional venue in which you can practice (the OR or the cards clinic) and give you additional skills (airway management or CICU). I think some people do cards/PICU as they would like to do both CICU and cards and would like to open their options (other places require that you be double boarded in order to practice CICU). I know of a few who are doing cards/PICU so they can do CICU and then spend the rest of their time doing research. The cards/PICU fellowship looks appealing because you can do PICU, CICU and general cards which would keep you from being bored.

I've been thinking more about his PEM vs PICU fellowship. If I do a PEM fellowship, I gain a few skills in Ortho, Derm, ENT and Plastics but still mainly refine my skills as a general pediatrician. If a do a fellowship in PICU, I learn the skills of Anesthesia, cards, and critical care and gain an entirely new skill set that a general pediatrician is only slightly familiar with.

Additionally, if I like PEM so much, and PEM is so much like a clinic, why don't I just work in an urgent care peds clinic and save myself three years of fellowship?

 

[SoonerBJJ]

Chimera and Ponyboy already hit most of the advantages of dual fellowship. I have also considered fellowship in PICU/anesthesia or PICU/cardiology. I was warned by one of my PICU attendings to think ahead and have an out for when/if I burn out on PICU. Being boarded in anesthesia or cardiology would offer alternatives.

I have only looked into 1 PICU/anesthesia program but I think they all have similiar time requirements. This program is 5 years beyond pediatrics residency (8 years total!!). You basically do 3 years of anesthesia residency which means the majority of your time is in adult anesthesia, which did not appeal to this pediatrician. If you are interested in this route it would be quicker to do a 4 year residency in anesthesia and then PICU fellowship (7 years total).

As things stand now the minimum time for dual PICU/cards is 5 years. There used to be 4 year programs, but I think those are gone now. You have to combine your research time to cover requirements for both fellowships. You would be able to practice as a cardiologist as well as an intensivist. If you are only interested in PCICU then you could do an extra year of PCICU fellowship after 3 years of either cardiology or PICU (4 years total). PCICU is not a board regulated specialty yet and they are in desparate need of cardiac intensivists. Eventually there may be more stringent board eligibility rules but these wouldn't affect anyone entering under the current system. The disadvantages of being primary PICU with 1 extra year is that you wouldn't be trained in other areas of cardiology, such as echo, cath, etc. You would still be limited to working in a unit.

 

[oldbearprofessor]

Chimera and Ponyboy already hit most of the advantages of dual fellowship. I have also considered fellowship in PICU/anesthesia or PICU/cardiology. I was warned by one of my PICU attendings to think ahead and have an out for when/if I burn out on PICU. Being boarded in anesthesia or cardiology would offer alternatives.
.

This is an interesting discussion. I certainly have nothing against double pediatric fellowships, but I want to add one small note of caution to your considerations. That is, in an academic pediatric department, it is very difficult to sit comfortably as a faculty, especially a junior faculty, in two clinical sections at the same time. Things like service and call schedules, conferences, research space, promotions and many other things are usually "section specific." Most of the double boarded pedi specialists I have known have primarily, or exclusively, practiced one of the specialties.

With regard to pedi ICU or ER, since I don't do either, I won't comment on which is better, easier, etc. I would note that there is increasing interest recently in having academic PICU faculty doing basic science research such as many of their academic NICU colleagues do. I'm not sure this is as common in ER or will likely become so in the near future. This may or may not be important to any of you, but should be considered.

Finally, I'm not sure one is more likely to burn out on PICU than pedi cardiology!

Regards

OBP

who would never want to have to take 2 sets of subspecialty boards

 

[SoonerBJJ]

obp- Interesting points about competing interests among different sections. I can see how that might become a problem. You are right about the increasing interest in research with PICU. It is becoming more of an emphasis in fellowship and is becoming more of a priority for departments hiring new faculty.

 

[Ponyboy]

Another one of my concerns is that while I like the clinical aspects of PICU, my research interests are slightly different. I'm leaning more toward clinical epi/meta-analysis for my research while I find that most PICU research is based towards bench research or individual clinical trials. I know that a few places offer an MPH during a PICU fellowship but I haven't found many programs that have active interests in clinical epi. Does anyone know of any programs that do?

BTW, does anyone know anything (good or bad) about the following PICU programs?
Cincinnati
Columbus (Ohio)
Columbia
Cornell
Denver

 

[Chimera]

Interesting point, I never really thought about academic advancement when having dual-appointments.

I know I'm pretty much set on a PICU fellowship, but I too am worried about the long term consequences of practicing in the field. I've also been warned by numerous attendings to be aware of the burnout factor in this relatively new career path.

In my experience the current working structure in the ICU is 2-4 months of service a year per attending, and then the remainder of the time dedicated to research (generally of the basic science tilt) or working in the sedation unit (not of much interest to me). So what does one do if not interested in research...? That's the void I'm concerned about filling. Or is this point moot, as more and more institutions are trending toward having an attending in house at all times, and consequently intensivist work will become more shift based?

Thoughts?

Ponyboy - Sorry not much info on the programs, but I do know a good deal about the other Ohio program in Cleveland - Rainbow

 

[rastelli]

I have nothing but good things to say about the people I met at Baylor but the program actually has 3 positions and filled only 1 in the recent match. Pitt is the biggest program in the country with 6 positions while UT Southwestern and CHOP are the second largest with 5 positions. Boston comes in at third with 4. All 4 programs filled this year.

TCH may be the largest pediatric hospital but it doesn't have the largest PICU in the state of Texas.

TCH has the largest PICU in the country. Not sure where you've gotten your info from, but it's completely incorrect. The number of fellows was 3 several years ago. That has changed. I suggest you check out the web site...Not the fellowship program site (as it is incredibly lame), but the actually PICU site at TCH.

Regarding the match, no program did well. There were tons of programs (good ones) left without filled spots....Duke didn't fill a single spot.

Pittsburgh is indeed one of the top programs in the country.

UT Southwestern is solid, but nothing like it used to be since the chief (Brett Giroir) left the program to head to DC.

 

[SoonerBJJ]

TCH has the largest PICU in the country. Not sure where you've gotten your info from, but it's completely incorrect. The number of fellows was 3 several years ago. That has changed. I suggest you check out the web site...Not the fellowship program site (as it is incredibly lame), but the actually PICU site at TCH.

Regarding the match, no program did well. There were tons of programs (good ones) left without filled spots....Duke didn't fill a single spot.

Pittsburgh is indeed one of the top programs in the country.

UT Southwestern is solid, but nothing like it used to be since the chief (Brett Giroir) left the program to head to DC.

My statistics were taken from the appointment year 2005 match data. Baylor had 3 spots in the most recent match and filled 1 in the match. I don't care to argue this as the data is very clear.

http://www.nrmp.org/fellow/match_name/ped_crit_care/ped_critcare_prev05.pdf

There were many programs that did not fill, but the 4 largest programs that I listed above DID fill. I'll refer you to my post above.

Giroir was a good chief, but those close to the program feel it is only becoming better under the current leadership. The program at UTSW is more than "solid" by any criteria you may choose to use.

 

[rastelli]

My statistics were taken from the appointment year 2005 match data. Baylor had 3 spots in the most recent match and filled 1 in the match. I don't care to argue this as the data is very clear.

http://www.nrmp.org/fellow/match_name/ped_crit_care/ped_critcare_prev05.pdf

There were many programs that did not fill, but the 4 largest programs that I listed above DID fill. I'll refer you to my post above.

Giroir was a good chief, but those close to the program feel it is only becoming better under the current leadership. The program at UTSW is more than "solid" by any criteria you may choose to use.

Relax Schooner! All friends in here! I know the Trojans whooped on your boys, but that's in the past.

As with any fellowship program, the available spots posted for the match are those not already meted out to future fellows, say within the associated residency program. Hmmmm... So yes, you are correct sir. There were three spots available for the match (available for all our viewing pleasure on the lovely link provided by Schoon).

I'm a resident at Baylor, I know the fellowship director. So just relax a bit. It's OK to be wrong every now and then. In this case, I think most folks would agree that I might have a bit more (correct) info.

And yes, all of the programs you cited did indeed fill. I didn't expect you to be so concrete about my comment about many of the good programs not filling, after all, there are more than just four.

 

[SoonerBJJ]

LOL. Football is a bit of a sore subject right now.

No worries here Rastelli. I also know the program director at Baylor and actually found her one of the most helpful people I dealt with through the whole interview process. I had some very difficult decisions to make and got to know the programs I was considering pretty well. I have a great amount of respect for everyone I met at Baylor.

I wonder what Freud would think of us arguing over the size of the respective units? Maybe it's just a Texas thing I don't understand.

According to Baylor's webpage the PICU has 32 beds, not including the PCU. I don't count the PCU as it isn't technically intensive care. The 2 main units at UTSW contain 44 beds. 22 are med/surg and 11 are dedicated to trauma. As you've said Baylor doesn't see much of the trauma (for better or worse). The additional 11 beds are intermediate care, which to my understanding is a slightly higher level of acuity than progressive care. These patients don't quite qualify for intensive care and are thus termed intermediate. I'm not quite sure here so I'm not counting these beds in my total of 33 at UTSW to the 32 at Baylor. LOL at this knitpicking. Both hospitals have dedicated pediatric CICUs, with significantly differing roles for the PICU fellows in each.

Agreed that there are more than 4 good programs. I was using those programs to illustrate my point that fellows seem to be congregating at the larger programs. Like I've said, over 25% of the matched fellows in 2005 are going to 1 of 4 programs.

Are we all friends again?

 

[rastelli]

No sweat Schooner. I very well might have ended up at UTSW myself, but my wife had other ideas. Good luck to you...

Peace and chicken grease...

PS-I was pulling for OU as well

 

[Hogwild]

Based on what I learned while on the interview trail I would say that the more highly regarded programs include (in no particular order): CHOP, Boston Pittsburg and UT Southwestern. These are the 4 largest programs in the country and all filled with high quality fellows from what I've heard. There are programs that are more prolific in terms of published papers than any of these 4 but publishing does not make a program great. I don't know much about Utah and I have a friend at Arkansas who is very happy and feels his training is good. It is a smaller program with only 1 fellow per year and they didn't fill this year. They have excellent peds cardiac surgery exposure. I believe they have a 4th year peds CICU fellowship.

Heard through the grapevine that there was some Sooner fan on here talking about a PCCM fellowship program in AR. You're right, I'm very happy here, and you will be very happy in your chosen place as well. It was a VERY DIFFICULT choice for me. I hope that all is well; only a few months left before you get to do what you really want; and IT'S GREAT!!! I'll be happy to share my experiences with anyone here if you're interested; seems like everyone is doing a great job about pros and cons, good programs, etc. Take Care and BEST OF LUCK if I don't see you again before fellowship starts.

 

[SoonerBJJ]

Heard through the grapevine that there was some Sooner fan on here talking about a PCCM fellowship program in AR. You're right, I'm very happy here, and you will be very happy in your chosen place as well. It was a VERY DIFFICULT choice for me. I hope that all is well; only a few months left before you get to do what you really want; and IT'S GREAT!!! I'll be happy to share my experiences with anyone here if you're interested; seems like everyone is doing a great job about pros and cons, good programs, etc. Take Care and BEST OF LUCK if I don't see you again before fellowship starts.

Hey Hogwild. Good to hear from you. How's life in Ar-Kansas? How's Junior? Still thinking about doing PCICU?

I'll echo what you said about deciding on a fellowship being a VERY difficult choice.

 

[Hogwild]

Absolutely love it here; couldn't be happier. So many procedures around, that I'm getting tired of doing them. Just floated a Swan this week, which was new for me - maybe I'll give you some pointers sometime .
Junior is very well; 9 months old and getting VERY BIG - have no idea where he got that from. He does seem to be developing somewhat of a stubborn personality - like his daddy I guess.
Do first of my PCICU rotations in June/July, so still keeping my options open; though I have spent a fair amount of time there so far this winter (4 ECMO runs so far). Anyway, hope all is well. Tell everyone I said hello.

Hey Hogwild. Good to hear from you. How's life in Ar-Kansas? How's Junior? Still thinking about doing PCICU?

I'll echo what you said about deciding on a fellowship being a VERY difficult choice.