A Community Based Pediatrician Talks About Her Specialty

Session 61

Dr. Catherine Mcilhany is a community-based General Pediatrician. She joined us to talk about her position and her path and what you need to know.

We’re constantly looking for guests that we can feature here in the podcast. It has been a challenge for us. Please shoot me an email at [email protected] if you know any specialists that you would like to have on the show.

Back to today’s episode, Catherine has been in practice now for 15 years. Several weeks ago, I talked with a rural General Pediatrician. So you get to hear some differences between rural medicine and a community-based, urban center general pediatrics.

[02:15] Interest in Pediatrics

It was during her third pediatric rotation that she realized she wanted to do pediatrics. She just had so much fun with the kids and that’s what she liked about it. She admires the resilience of kids despite what they’re going through.

She did consider doing OB/GYN but then she got into rotations and realized she didn’t want to be a surgeon of any type. She also thought about doing Med-Peds but she found the scope of family medicine was so broad that she was worried there would be so much to have to know all the time. She was looking for something narrower. And after doing her adult medicine rotations, she realized she wanted to stick with the kids.

That said, Catherine likes working with the parents. A big part of what they do is educating parents and sometimes, crisis management. She describes it as a little intimidating thinking that you’re taking care of the most important person in most people’s lives. Hence, you have to interact with adults as well.

[05:35] What Is Med-Peds?

Med-Peds is a combined specialty of internal medicine and pediatrics training so you would be fully qualified to do the full scope of adult internal medicine plus pediatrics care. So it’s like Family Medicine except that you’re not doing GYN procedures like Family Medicine might do. So you don’t have the OB and some of the more specific GYN type.

[06:20] Types of Patients

In a day, he will see everything from a 3-day-old to a 19-year-old. She had seen a 19-year-old having some schizophrenic break to a diagnosed cancer. She does see a lot of healthy children. She works in a population of a fair number of kids who are really struggling in school. She sees a lot of behavior issues in her office. She also sees a fair amount of contraception counseling, sexually transmitted disease testing in teenagers. So it’s an interesting scope of diseases that they see in pediatrics, which is quite opposite to what most people probably think that they’re only seeing cold cases.

Although children may have a chief complaint, the hard thing about it is that you have to be able to find the one that’s unusual. Hence, you need to be well-trained in seeing a high volume of kids and always thinking who’s going to be the “zebra out of all these horses.”

[08:12] Community versus Academic Setting

Catherine admits having worked in an academic setting. But she knew she didn’t want to do academic general pediatrics, which involves doing research since it wasn’t really her interest.

Then when she went into general pediatrics to be a regular primary care pediatrician, she thought getting her feet wet and figure out doing it before she’d teach the residents. Although now, she’s in the position where she has been doing it for four years now so she feels more comfortable.

[09:50] Typical Day and Procedures

Catherine doesn’t do any inpatient or nursery-rounding. Her typical day starts at 07:55 am with her first patient. At her clinic, their schedules are about 24 patients a day. So she’s doing any number of well visits or sick visits. But most weeks, she sends a couple of kids to the ER, or at least once a month.

In terms of doing procedures, Catherine explains the biggest opportunity is when you’re working in a little bit of a smaller area where those doctors do a lot. In her office though, they don’t do so much suturing just because of how their schedules are set up. So they don’t have as much time to do those.

But doctors in smaller areas do a lot. They do their own admissions. And if a kid needs a spinal tap, they’d do it. They’d do the inpatient side of things and go to deliveries. They stabilize infants how are newborns. So there’s that big chance of doing procedures if you’re willing to live in slightly small area. Whereas in large metro areas, it’s a little harder mostly just because of the way practice is set up. Nowadays, there a lot more hospitalists around, which is a big change compared to back when she was still training.

[12:45] Taking Calls and Work-Life Balance

Catherine only take calls a couple weeks the whole year, which means she has a very nice setup. But this may vary from place to place. As in her case, she works for a larger group. It also depends on what size of community you’re in.

Catherine says she has enough time for her family. She doesn’t work five days a week, specifically that she has a couple of kids and one of them has a lot of medical needs. So she tries to balance those things.

But for most pediatricians, they’re pretty aware that they have lives outside of medicine and they’re pretty balanced.

Primary care, just in general, sometimes is tough because you will have to figure things out. And if the specialist you send someone to hasn’t been able to figure it out, the patients go back to see you. That said, she likes primary care also because it’s challenging. But the people that go into pediatrics are pretty much looking out for each other.

[15:05] Choosing Where to Do Your Training

Catherine wanted to train at a setting with a charity-type hospital or public safety net hospital where she got to take calls and have a lot of responsibility since she badly wanted the experience. And that’s where she ended up going. Also, because where she went to medical school had a large county hospital system, for which she went through a lot of those for her rotations.

Additionally, go to a school that has a really good primary care focus and that the clinic structure is good. Sometimes, things can change so you want to make sure that you go somewhere that’s a well-rounded, strong program.

Catherine adds that you should go to where it’s going to make you happy. Think about where you’re going to be happy and where you’re going to fit in well because it’s a long three years. It’s a lot of calls and a lot of hours. Also, try not to go too far from your support network.

[17:05] Bias Against DOs and Common Pediatric Subspecialties

Catherine says she hasn’t seen any bias against DOs. And coming originally from Oklahoma which has a very large osteopathic presence and she’s from Tulsa, which has a very well-regarded osteopathic medical school, she’s not seeing it. If this was a question 25 years ago, she would have said there was a difference. But where she trained, she really doesn’t see it as an issue.

The other more common subspecialties for pediatrics are hematology, oncology, cardiology, and gastroenterology. Catherine stresses how there’s a much larger academic emphasis in pediatric specialties that in the adult world. There’s a lot fewer jobs in pediatric subspecialties that are non-academic.

If you want to do hematology-oncology in pediatrics, you’re virtually 100% looking at the academic curve. So there’s just not enough population that support that kind of complicated work that needs a huge amount of technological subspecialty support like hematology-oncology which needs ICU and al these other subspecialists with it. So if you don’t want to do academics and you desperately want to do hematology-oncology, pediatrics may not be the right choice.

[19:55] Her Message to the Future Specialists to Help Them Take Care of Patients Better

First, Catherine says that if it sounds like a really stupid referral, it may be that the parent would literally not take no for an answer. Conversely, if they’re puzzled by something or there’s a hole in the story that they can’t figure out, understand that sometimes that they know a little more. And sometimes, as primary care doctors, they can fill in some of those gaps.. Or they can sort out why this family is so anxious about x, y, or z and they can’t figure out why. So she wishes specialists to know that they can just call them. Especially that everything is on electronic medical records now.

[21:20] Working with Other Specialties

The people she works with the most are ICUs, cardiology, infectious disease, dermatology, and GI. She doesn’t use hematology too often which is good but she uses pulmonology a ton due to asthma cases. That said, they use a whole variety of specialties. But the one they need more of is developmental behavior pediatrics and mental health support. This is one part of pediatrics that Catherine thinks that they as general pediatricians end up trying to manage a lot more than they feel comfortable managing. Luckily, she gets great support from where she works but there’s a lot of people out there that don’t.

Outside of clinical work, you can do MD/PhD Peds Hema/Onc, which was what her friend did and now does drug development.

[22:33] What She Wished She Knew

Catherine wished she had known how much better she would be once she became a parent. Again, she says it’s an incredible responsibility and privilege to take care of someone’s kid.

It’s a tough job, but at the end of the day, pediatrics is great. At times, you may have to tell some bad news and it can be difficult. And she sort of knew this but she didn’t really know this until she had her own kid.

What she likes most about being a pediatrician would be her patients and her colleagues. She considers them as being each other’s tribe. Everyone she works with is very committed to population health of the children in the U.S.

On the flip side, what she likes the least is wrestling a one-year-old to see their ears. ON a serious note, she says the hardest thing is people who don’t want to vaccinate their kids. She knows they care for their child and they think they’re making the right decision.

[27:05] Major Changes in Pediatrics and Final Words of Wisdom

Catherine points out that telemedicine is a big issue right now. And she thinks some pediatricians get the “primadonna” type reputation but it’s not true. The irony is they’re the least interventionist with their own patients. So she really doesn’t see how telemedicine for pediatrics is going to work.

If she had to do it all over again, Catherine would still have chosen to become a pediatrician. Ultimately, for premeds or med students interested in getting into pediatrics, Catherine’s advice is to realize that it’s the parents and not just the kid. Also, remember that it’s always about what you’re going to be happy doing. Compare yourself to other people going into it and when you do rotations. Think about could you work with these people. You want to make sure you could sign your patients out or trust your colleagues. Or if you feel like you could enjoy working with them.

So don’t just look at the work hours, the prestige, the money, etc. But long term happiness. You need to feel like you fit. Don’t try to put a square peg in your round hole all the time even if you thought you’re only going to do one thing. Be flexible and think about where do you really fit since you’re going to work with them for a long time.

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