The Combined Pediatrics and Emergency Medicine Residency

Session 113

Dr. Aaron Leetch one of the program directors at the University of Arizona for a combined residency in pediatrics and emergency medicine. It’s actually a very rare residency program with only four programs in the country that offer this. Find out more about this, how it’s different and much more!

Dr. Leetch is the host of the Arizona EMCast. Also, check out all our other podcasts on Meded Media.

Listen to this podcast episode with the player above, or keep reading for the highlights and takeaway points.

[01:27] Interest in Combined Pediatrics and Emergency Medicine

Aaron has always been certain he was going to be a pediatrician as he loves working with kids. He also liked the compassion of it. It was when he started working at one of the local ERs as a scribe that he felt torn between pediatrics and emergency medicine. He loved the acuity and multitasking aspects of emergency medicine. In fact, he likens it to waiting tables which he used to do.

Then he met the program director at the University of Arizona who trained at the combined emergency medicine and pediatrics program in Baltimore and started the program there. He asked Aaron why he wanted to do both and thought it was everything he had wanted to do.

After five years of doing the training program, he still loved every minute of it and knew it was the kind of thing he wanted to do for the rest of his life.

Aaron has always been amazed at people being torn between two specialties that are very dissimilar. For some people, pediatrics and emergency medicine are not the same. But he explains that there are aspects of both sides that he really liked.

'There are aspects of both sides that I really liked. That's different from saying I'm not sure so I'll just hedge my bets.'Click To Tweet

Aaron later realized that his pediatric training would be applicable when he sees children in the emergency department. To help them navigate that system in the ED is incredibly helpful to the patient.

[06:40] Traits that Lead to Being a Good Combined EM and Pediatrics Physicians

You have to be patient considering that it’s a five-year training. Be sure that you’re willing to do five years since you can just do emergency medicine and still trained to see children.

The first thing he looks for in applicants is why they want to do both programs. He also wants to know people have considered what they want to do after they’re done with training. There are lots of EDs that can’t afford to hire somebody who’s only certified to see children and they need to see both.

'You should have a good understanding of what the training is, why you want to do it, and what you're going to do with it when you're all done.'Click To Tweet

[08:38] Getting Exposure for the Program

Considering that there are only currently four programs doing this kind of training in the country, they’re hoping to gain visibility through doing medical student podcasts. Plus, they also get the opportunity to talk to people about this.

The most common for pediatric/emergency medicine is doing a peds or emergency medicine residency and then doing a fellowship. This is great as long as this is what fits with what you want to do.

However, if you want to be a rural doctor and you want the general pediatrics knowledge or the subspecialty time with pediatric nephrology or neonatal ICU, you wouldn’t be able to get this by just doing an emergency residency and the pediatric fellowship for two years.

It would not give you the same level of intensity if you want to be a broader trained person rather than narrowing and being a specialist.

[10:50] Types of Patients

The types of patients you see depends on where you go. In Aaron’s case, he does 60% peds and 40% adults.

You have the potential to work in any emergency medicine department across the country. If you want to work in a pediatric-specific emergency department, that depends on the needs of that emergency department.

'You can work anywhere that a general emergency doctor could work and you could work anywhere that a general pediatrician could work.'Click To Tweet

You could open up your own clinic if you wanted to or work in places that need a general pediatric physician as a hospitalist. You can do a fellowship on the emergency side or on the pediatric side. Or you can do both.

In their program, they’ve had people who did fellowships in pediatric critical care, simulation and medical education, toxicology, sports medicine, and some other ones.

You’ve got a lot of opportunities when you’re done assuming you keep your options opened for geography. Make sure you’ve got a good idea of where you’re headed.

As fellowships are becoming more common after residency training, you need to be able to stand out. However, you don’t want to do this just to stand out because it’s a long chunk of your life to spend. There are better things you can do. But it does help and it gives you a different philosophy for how you’re approaching things.

[Related episode: 5 Traits Patients Want Their Doctors to Have]

[14:20] Trend in Medicine for More Specialized Specialties

If you have an idea of where to go, then you need to email that institution and ask what you need to do to get the job. That said, there are plenty of places that are still clamoring to get somebody who is a specialist and wants to take ownership of pediatrics.

There’s a lot of literature suggesting that people who have done the pediatric EM fellowship stay in large academic centers. They don’t go out into the community and work as they had hoped. In fact, many have now questioned whether centralizing everything at the children’s hospital is still the best way to go.

Aaron feels that if you’ve got extra training, you feel more comfortable seeing children. You feel more prepared to see a really sick kid out there because that’s where the majority of these kids are going to end up going.

'I think that a lot of medicine is becoming more specialized because we know a lot more... as we learn about what's out there, there's only so much you can fit in your head.'Click To Tweet

For their program, Aaron explains you have to have the pediatric experience. You’ve seen kids, especially the really chronically ill kids, and the tech-dependent kids. You’ve seen them in the clinic. You’ve seen them at the subspecialist’s office. You’ve seen them when they’re really sick in the ICU. You’ve got a background on how to take care of children that you can pull from.

And then you’ve got procedural competency and that critical care emergent time-management mindset from emergency medicine. The other five years of training just becomes a part of you.

[18:30] How to Know If You Have the Procedural Competence

If you can get any experience during medical school, you will decide very quickly whether you love procedures or you don’t. There are a handful of environments where residents and attendings tell you how they’ve walked into X environment and they knew they’re home. For some people, that’s the O.R. For some, that’s the clinic or the ICU or the ED.

If you have the opportunity to do any kind of three-week elective or some experience ahead of time, do it. Email a physician and ask if you can shadow them even just for one shift or overnight or for one time that will allow you to get the best exposure.

'Most of what we do especially in pediatric emergency medicine is to convince people that their kid is going to be okay.'Click To Tweet

A lot of what they do in pediatric emergency medicine is to convince their kids are going to be okay as well as a lot of return precautions. If you don’t like doing this then pediatric emergency medicine is probably not great for you. You’re not constantly having critical children coming in.

Regardless of what you’re considering, try to get some experience early and that will help you make your decision.

[21:00] Work/Life Balance and Taking Shifts

Aaron still gets to have a life outside of the hospital. But he believes you have to make time for it. He makes it a point to take time out apart from doing anything related to work to recuperate and refresh.

'If I just worked all the time, especially in an emergency medicine environment, it's draining. It's high highs and it's low lows. But you have to focus on what's in the middle.'Click To Tweet

With shift work, you’ve got to work 365 and somebody’s got to work the holidays. Somebody’s got to work the overnights. So you adjust to it. And if you’re considering emergency medicine of any kind, you have to determine whether you can function at 2 am. And are you somebody that someone wants to be around at 2 am? Or do you turn into a werewolf that nobody wants to work with?

You have to make it a point to do something that is not medical after work in order to restore yourself.

At their program, they’ve got a handful of people that just do nights. They’re offered a pay differential so you can make a little more. But they would usually split between mornings and evenings.

The morning shift can start as early as 6 am. They work 9-hour shifts. And it can start as late as 5 pm and you get off at 2 am. But in an emergency, you get off when everything is done, especially as a resident when you’re still trying to learn your flow and your management. But you will get better over time and things will get tolerable.

As a resident, everybody rotates through in a circadian fashion so that you do as much as you can. But you do a lot more evening shifts because that’s when the patients come in. Even if your sign out is done is at 4 and your relief comes in at 4, then you’re not done for another 30 minutes so that the transition of care is appropriate. And this is expected.

Aaron gets off when he’s supposed to probably 60% of the time. Especially in pediatrics, most of the kids they see are not critically sick. So when he works his adult shifts, he always buffers knowing that a lot more adults are going to be critically sick and they’re going to need his time. But you’re never really prepared for that stuff.

[26:45] The Training Path

If you want to do pediatric emergency medicine, you can do a three-year pediatric residency and the three-year pediatric emergency medicine fellowship. You can do a three or a four-year emergency medicine residency. Then another two or three years in pediatric emergency medicine fellowship.

At their school, they have a five-year program where you have to fulfill all of the requirements for emergency medicine and all of the requirements for general pediatrics. They’re doing this concurrently.

They do somewhere between 2 and 6 months in the emergency department doing trauma surgery, ICU at the VA, emergency medicine, anesthesia. Then you’ll flip and do 2-6 months of general pediatrics, neonatal ICU, pediatric pulmonology, inpatient wards, clinic. Then you keep flip-flop back and forth until you reach your five years.

'It's like a bilingual child, you're trying to teach two languages at once.'Click To Tweet

Aaron likens their training to children growing up in a bilingual household. They don’t necessarily keep the same verbal milestones compared to a kid growing up in a single language household. They’re learning two different words, two different idioms, and two different ways to say the same thing. But once they do, they catch up pretty quickly and they speak two languages.

With their program, they’re going to teach you how to speak pediatrician and how to speak emergency physician. Although, it takes a little bit longer.

It’s a different growth curve of how you’re going to progress along in your understanding of both specialties. But once you do, you’re going to catch up. You may even surpass some of the residents from either the emergency medicine or the pediatrics program itself because you now speak two languages.

[29:45] How to Be Competitive for This Program

The four programs that offer the combined residency include the University of Arizona, University of Maryland in Baltimore, Indiana University in Indianapolis, and LSU in Louisiana.

There are only 8 or 9 spots in country. Aaron says that you have to consider if you’re crazy enough to do five years. You have to love this enough that you want to do five years

To make yourself competitive, have a backup either in pediatrics or emergency medicine. Some people choose both.

And even if you don’t match into one of these spots, you can still do emergency medicine and a fellowship or pediatrics and a fellowship. They’ve even had several residents that graduated from one program and then re-entered the match and did the other ones. So they did six years to do the same. Well, it’s not quite the same because you’re taking it in chunks instead of intermingling it.

'To do an all-or-nothing match towards a specialty with only 9 spots is not a good idea.'Click To Tweet

Aarons recommends that you strengthen your application packet towards whichever is going to be your backup. So if your backup is emergency medicine, then strengthen your packet towards emergency medicine. Show that you’re going to be a good emergency medicine resident.

Doing away rotations is great as well as interview rotations to have a good idea of what’s there.

Do pediatric emergency medicine or pediatric ICU as they’re going to be helpful whether you do the combined EM/peds program, EM on its own, or pediatrics on its own. Both are going to intersect with peds/EM and peds-ICU. This will help strengthen your packet for the combined program and for whatever your backup is going to be.

[33:40] Applying as a DO and How to Stand Out in Rotations

Two of their residents at their program are osteopaths and they’re fantastic. If you’re applying to a place that already has unfavorable opinions set on osteopaths, go for it if you want to be the trailblazer and try to rotate there. Otherwise, consider if it’s really the best place for you if you’re not going to be viewed as an equal with the other residents.

Aaron adds that you can strengthen your application just as you would for any other place. But if you feel like that may be a hindrance for you, doing an audition rotation is a great way to show how good you are.

To stand out at these rotations, you have to show initiative and that you can work well with a team. They want to see that you’ve done some of the work on your own. There’s also the 2 am test. Are you somebody they want to be working with at 2 am? You have to be reliable.

A fit in personality is also important to consider. Their program wants to see that you fit well. So you have to consider whether you’re a good fit at a certain program and determine if you like them.

'You've got to determine, 'Is this actually a place I want to go' apart from just giving you a place that will give you good training.'Click To Tweet

[37:30] What He Wished He Knew That He Knows Now

'Residency is all-consuming. It takes a lot out of you.'Click To Tweet

Aaron wished he had done a much better job with self-care and making sure that he took time (that he now takes) for family, for friends, for hobbies, and for things that help maintain his sanity.

Although residency is not as a brain-drain that medical school can be where you feel like you’re drinking from the firehose, it is time and energy-taxing.

You have to put effort into the things that you want to be around when residency is around like family and friends. Because you can’t just push pause and come back in 3 to 5 years and feel like everything is still going to be the same.

[38:50] The Most and Least Liked Things

What Aaron likes the most about the combined residency is that they are people who like to have fun and have a broad perspective of medicine.

'I get to do more good for people in the emergency department by helping them navigate the healthcare system.'Click To Tweet

What he likes the least about the pediatric emergency medicine is that when it’s bad, it’s really bad. They deal with cases like child abuse, pediatric sexual assault, drownings, SIDS, and cancer diagnosis. Often, those will happen in the ED.

What he realized that really affected him is that they can’t help everyone. They want to take care of everybody that’s there. They want to try to help every person that comes into the emergency department. But there are so many people that come in with complaints that they can’t help.

He tries to provide hope for people in a hopeless situation when they come in at midnight on a Saturday. For him, this is frustrating when you can’t offer what they want.

[42:35] The Overlap of Pediatric Care and Adult Emergency Medicine

Especially during residency, you spend a lot of time in the clinics and on the wards. They even joke around that kids are not little adults but adults really are just big kids.

Aaron says he can do a lot of the same things that he does with children. He’s able to apply some of that to adults especially among the 20-year-old’s where the overlap is not quite there yet.

In pediatrics, one of the first questions they ask themselves is whether the patient needs an IV. In adults, before they even get their chief complaint, they’ve already gotten an IV. They’re getting a dose of antibiotics and they’re on their way to the CT scanner. All those being said, he gets to have a different perspective.

If he had to do it all over again, he’d still be a combined EM pediatric physician. And even his wife just recently told him that if he had to do it all over again, she would still support him all the way through.

[45:25] Final Words of Wisdom

To those interested in getting into this specialty, try to get experience in both emergency medicine and pediatrics because they want to train people in both. They want you to be a pediatrician. They want you to be an emergency physician. Then they’re going to train you on how to be a pediatric emergency physician.

Make sure you really want to do both because the last thing they want for somebody is to be halfway through and say they hate this. They want you to go in with eyes wide open.

'Make sure you have a good reason why you would want to do both.'Click To Tweet