The Options for Training in Pediatric Emergency Medicine

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Do you remember the “sorting hat” from Harry Potter? Plop it down on the noggin of an aspiring young student, and it mumbles and grumbles in consideration before triumphantly announcing the house that best fits the student’s personality. Recently, we happened to have a slow day on a pediatric ward service, and our team took the “Sorting Hat Quiz” online. (Come on, what do you expect? It’s peds.) Being a combined EM/peds resident, it made some sense that my sorting hat split me between two houses. The “hybrid” resident is fairly common in my institution, but for many it’s a foreign idea. Those individuals considering a career in pediatric emergency medicine may have a hard time sorting out their future. There is more than one pathway to get there, but not everyone knows the options.

It only takes one scary encounter with a pediatric patient to help us remember why there is a need for pediatric emergency specialists – the American College of Emergency Physicians (ACEP) and the American Academy of Pediatrics (AAP) agree. Pediatric training really does make a difference for these patients. Currently, there are three recognized routes to this specialty:

1)   Pediatric residency, followed by a pediatric emergency medicine (PEM) fellowship;
2)   EM residency, followed by a PEM fellowship;
3)   EM/peds combined residency.

The first two result in pediatric emergency medicine sub-board eligibility, whereas an EM/peds combined residency results in double-board eligibility.

Why consider combined training over a fellowship route? The overall number of combined training programs is on the rise. Many know about EM/IM and med/peds, but there are many others, including EM/FM and pediatrics/adult/adolescent psychiatry. Currently there are four existing EM/peds residencies: Indiana University, University of Maryland, University of Arizona, and Louisiana State University. Each program typically accepts 2-3 residents per year who commit to 5 years of training. Though the curricula vary slightly between programs, residents typically alternate EM and pediatric clinical duties every few months in such a way that they do not miss the seasonal variations inherent in some illnesses. In so doing, it is possible to rotate through extremes of training in the same season – think newborn nursery to adult multi-trauma. In fact, the constant variation in training experiences is one of the largest assets of this type of program; practice style develops from EM and pediatrics synchronously, rather than in tandem.

EM/peds combined trainees appreciate the importance of participating in continuity clinic alongside their categorical pediatric colleagues. Parents often bring their children to the emergency department for non-emergent conditions and for treatment of primary care complaints. Having a half-decade to be the primary care pediatrician for a subset of children has the benefit of reinforcing fundamentals of normal growth and development. Training in this way helps with recognition of subtle abnormal findings that might otherwise be missed in the ED, carrying massive implications for those children lost to care by their primary care doctors. Furthermore, primary care time teaches residents how to navigate the sea of resources from community, state, and federal agencies.

In addition to the MICU and SICU/trauma ICU experience of categorical EM residents, EM/peds residents spend several months in the NICU and PICU settings. They gain extra proficiency in managing the unstable pediatric population, including the ever-feared ex-premie or complex congenital disease patient.

EM/peds graduates are board-eligible in both emergency medicine and pediatrics, but what do they do with that? A recent survey of EM/peds graduates provides some insights.1 The respondents were dispersed across 20 states. They work in community EDs, freestanding children’s hospitals, and in community settings. Interestingly, many graduates have filled administrative positions in their respective practices. Similar to EM residents who elect to do a PEM fellowship, EM/peds graduates note that the two additional years of trainee income is a drawback compared to their colleagues who moved on from categorical training to attending salaries. In the end, 91% reported having a salary at the same level as their emergency medicine colleagues. Nearly 90% of graduates responded their combined training was an asset to their job search and ultimate career satisfaction. Most cited broader career options, excellent training, and unique versatility as assets of their combined background. Respondents reported using ultrasound in their adult and pediatric practice. EM/peds graduates can assist in achieving the goal of great pediatric care no matter location, time of day, or hospital.

So, what if you are a student who loves emergency medicine… but you think adults are stinky? What if you love pediatrics but would rather be tortured by “dementors” than go to a primary care clinic? Maybe you are an EM resident who just particularly enjoys playing with bubbles at work. The PEM fellowship route is a wonderful fit! Less focus on primary care means more time in the emergency department. Many PEM fellowships allow EM-trained fellows to moonlight to provide an income similar to their graduated colleagues. Unfortunately, as of 2000, the number of PEM fellowship slots filled by EM residents has continued to decline. Per the study by Murray, et al in 2007, the number of PEM fellows with an EM background as their primary training was only about 5%.2,3 Pairing a categorical pediatric or EM residency with the reciprocal PEM fellowship takes 5-6 years but has the benefit of PEM sub-board certification. EM/peds combined graduates are not PEM eligible since 1998.

In fact, in the same EM/peds graduate survey, the most commonly reported shortcoming of combined training was ineligibility for the PEM sub-board certification.1 The lack of this designation was perceived to be a detriment to securing academic positions in dedicated children’s hospitals by 81% of graduates. It is noted that only a fourth of the same respondents actually worked in freestanding children’s hospitals, and only 8% felt a freestanding children’s hospital was the ideal work setting for them. Conversely, Althouse and Stockman reported that almost 80% of surveyed PEM physicians certified by the ABP plan to practice exclusively in an academic setting, and that 3% practice in a rural setting.4

The life of a medical student might be easier if we could add a “sorting hat ceremony,” especially for those considering emergency or pediatrics. Medical students know that categorically-trained pediatricians and emergency docs are more than capable of providing excellent care to children, but for those who want to specialize in the emergent care of children, hopefully these mumblings and grumblings help them find the house that is right for them. Of course, which house just depends on who they are and what they want. Good luck sorting that out.

If you’re interested in further pediatric emergency medicine knowledge or training tracks, please see the EMRA PEM Division page for PEM blogs, twitter handles, and faculty mentorship match to help “sort” into which house you belong.

References

  1. Strobel AS, Chasm RC, Woolridge DP. A Survey of Graduates of Combined Emergency Medicine-Pediatrics Residency Programs: An Update. In submission.
  2. Woolridge DP, Lichenstein R. A survey on the graduates from the combined emergency medicine/pediatric residency programs. J Emerg Med. 2007;32:137-40.
  3. Murray ML, Woolridge DP, Colletti JE. Pediatric emergency medicine fellowships: faculty and resident training profiles. J Emerg Med. 2009;37:425-9.
  4. Althouse LA, Stockman JA. Pediatric workforce: a look at pediatric emergency medicine data from the American Board of Pediatrics. TJ Pediatr. 2006;149:600-2.
Chris Lemon, MD

Chris Lemon, MD

Emergency Medicine-Pediatrics Combined Residency, University of Maryland, Baltimore, MD
Chris Lemon, MD

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Ashley Strobel, MD

Ashley Strobel, MD

Assistant Professor of EM, Hennepin County Medical Center, University of Minnesota Masonic, Children’s Hospital, Minneapolis, MN
Ashley Strobel, MD

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