Career Planning, Pediatric EM

Demystifying the EM to PEM Journey: A Conversation with EM to PEM Attendings

Upon completion of residency training we are expected to be well-equipped to handle whatever walks into the ED. However, many emergency medicine graduates will feel uncomfortable caring for the critically ill pediatric patient.1

The most common reason for this is a lack of exposure to critically ill pediatric patients. A lot of us may choose to practice in an ED that sees very few pediatric cases, but it is hard to completely avoid pediatric patients, especially when they represent up to 22% of our patient population.2 Also, up to 90% of these patients are seen in non-speciality facilities without pediatric emergency medicine (PEM) trained physicians, where both adults and children are treated.3

Pursuing a fellowship in PEM can provide expertise in caring for children in a shorter time frame than practicing in the community for several years. Furthermore, studies have shown that PEM physicians have some of the highest job satisfaction in medicine.4 Despite these benefits of PEM fellowship training, most fellowship applicants come from pediatric residencies compared to emergency medicine. There are multiple reasons for this trend including perceived differences in salary compared to adult emergency medicine, duration of training, and the fact that emergency physicians can treat children without further training, among several other reasons.

To address some of these concerns, we interviewed EM to PEM attendings about their journey towards pediatric emergency medicine. Dr. Marianne Gausche-Hill (MGH) is the medical director of Los Angeles County EMS and a PEM faculty member at UCLA. Dr. Evelyn Porter (EP) is the assistant residency director and PEM faculty member at UCSF. Dr. Carolyn Holland (CH) is the Pediatric Emergency Medical Director and Division Chief at the University of Florida.

Q: Briefly tell us about your career trajectory.

MGH: While in medical school I was very interested in virtually every subject, but my heart had been set on a pediatric specialty. I had originally thought that I’d be a pediatrician but then became very interested in orthopedic surgery and applied to an orthopedic surgery residency with the thought that I’d do a pediatric fellowship. Once I had started my internship in general surgery at Harbor-UCLA Medical Center, I realized I had a real love for emergency medicine. I spent a great deal of time in the ED and decided to change my specialty in February of 1984; this was the last year that I could enter emergency medicine, having done an internship in another field. I then applied to and thankfully matched in emergency medicine at Harbor-UCLA Medical Center.
During my last year as a resident, I had worked with faculty to establish a Chief Resident year; however, there was no funding available at that time. James Seidel, MD, PhD, who was on faculty at Harbor, successfully competed for a grant with the Health Resources Services Administration on Emergency Medical Services for Children. Within that grant, he funded a fellowship position and I became his fellow in Emergency Medical Services/Pediatric Emergency Medicine, during my last year of residency. I worked on the grant as a fellow for 2 years in the Pediatric Emergency Department. At that time, there were no other fellowships that accepted emergency physicians in pediatric emergency medicine. So, after my 2-year fellowship in EMS for children/PEM, I became the first board certified, fellowship-trained emergency physician in the United States to be sub-boarded in Pediatric Emergency Medicine (1992).

EP: I started off like many medical students, with no specialty in mind. I found interest in all my rotations, but the ER seemed like home. I loved the staff, acuity, undifferentiated patients, procedures, team-centered approach, and ability to treat anyone no matter their background or status. I decided to pursue PEM  out of a commitment to providing excellent care to patients of all ages and out of a nagging fear of sick children. During PEM fellowship I was immersed in a busy pediatric ED where I became comfortable with the sickest pediatric patients. Fellowship also nurtured an interest in teaching, simulation, adult learning theory and curriculum development. Academics seemed like a great fit, affording me the opportunity to combine all my interests and easily split shifts between adult and pediatric emergency departments. Currently I am heavily involved in the development of PEM education for both EM and pediatric residents.

CH: I did my residency in EM at the University of Cincinnati and then I pursued a fellowship in PEM at Cincinnati Children's Hospital. I then stayed on the faculty there for 2 years prior to coming to my current position at UF. I have spent the past 7 years at the University of Florida in Gainesville where I was recently named the medical director of the PED and Division Chief of Pediatric Emergency Medicine.

Q: Why did you choose to train in PEM after completing EM training?

MGH: I was very much interested in improving care for pediatric patients in the emergency department. I realized during my residency that there were many gaps, in terms of quality and methodology of care, and that emergency physicians were often ill-equipped to care for critical illness in pediatric patients. During my fellowship, I was able to participate in training the first national faculty in pediatric advanced life support (PALS). Furthermore, my research during my fellowship made it clear that a lot of work was needed to improve pediatric readiness at the pre-hospital and ED settings.

EP: When I chose emergency medicine as a specialty I was fully committed to learning how to address any and all emergencies. Although I had quite a bit of exposure to PEM through my rotations in two separate pediatric emergency departments, both NICU and PICU rotations, international experiences and through critical care transports, I lacked confidence when it came to the care of the critically ill pediatric patient. I needed more volume and exposure. I chose fellowship as a means of getting the exposure and expertise in a concentrated way as opposed to having these experiences parsed out over the course of my career. I also wanted to explore academic emergency medicine and knew that fellowship would offer me that opportunity.

CH: I wanted to be as good at taking care of sick kids as I was taking care of sick adults.  The number of critically ill pediatric patients I saw in residency was significantly less than critically ill adults - even though I rotated through one of the busiest pediatric emergency departments in the country as an EM resident.

Q: How do you navigate being an EM to PEM physician when the majority of PEM trainees primarily trained in pediatrics first?

MGH: Navigation in the specialty is easy if one embraces the concept that we are all emergency physicians. Peds-PEM trained physicians have similar goals and perspectives as emergency physicians. In other words, we are more alike than we are different. I find that my PEM colleagues are problem solvers just like me, and are very much interested in improving care for children in our nation’s EDs and in the pre-hospital environment. I have been active both in AAP and ACEP and I believe that has helped create mutual trust and respect with both organizations. It also has resulted in a full career for me with exposure to PEM colleagues with a different training background and skill set, yet with a common vision.

EP: Fellowship training took into account my expertise as an emergency medicine trained physician and offered experiences to improve my blind spots. I was able to dig deeper into the pediatric subspecialties and procedures while practicing emergency medicine in a community ED to maintain my hard-earned EM skillset. I was also trained by and with pediatricians and have always found value in their perspectives and experiences. At the end of the day I’m capable of practicing in any pediatric ED alongside pediatric and EM trained physicians. My current practice houses the division of PEM within the department of emergency medicine. Additionally, I’m one of several EM trained, so I have colleagues who have traveled a similar path.

CH: The skills and knowledge that have to be acquired in fellowship are different. I had to do pediatric primary care, NICU, pediatric specialty clinics, but got to skip trauma, orthopedics and adult EM.  The programs that I had interviewed with all had plans for the pathway differences for Pediatric primary trained fellows and EM primary trained fellows.

Q: Do you still take care of adult patients? If yes, how has PEM made you a better physician when caring for adults?

MGH: I have always, throughout my career, tried to work in both the pediatric and adult EDs. I believe my sensitivity for families in the pediatric ED has helped me deal with patient’s families in the adult ED as well. My ability to learn from my patients who are non-verbal in the pediatric ED has translated to better observational skills for adults that are unable to speak or communicate with me in the adult ED. Overall, I feel the training in pediatric emergency medicine has made me a better doctor. 

EP: I still take care of adult patients, mostly on my general ED shifts but they also present to the pediatric ED for a multitude of reasons. I’ve learned to really listen to what my patients need from their visits. People communicate in a variety of ways and reading these cues is very similar in pediatric and adult emergency medicine.

CH: Yes. Some of the exam and distraction techniques that work well on pediatric patients also work well on developmentally disabled adults, adults who are intoxicated, and adults with mental illness.   

Q: How would you advise EM residents who are thinking of a PEM fellowship but are concerned about being compensated less financially throughout their career and the extra 2-3 years of fellowship when most EM fellowships are 1-2 years? 

MGH: Going into pediatric emergency medicine provides the EM trained physician additional opportunities post fellowship training. There are PEM fellowship programs that allow for a 2-year PEM fellowship versus a 3-year. I will state that many academic programs are very interested in PEM trained physicians as they can immediately lead a division of PEM, can assist in establishing pediatric EDs within academic centers and provide a niche that other faculty cannot provide. Regarding the compensation, a PEM trained EM physician would be compensated equally to his/her EM colleagues and, in fact, because of fellowship training, often could start at a higher compensation level. This can be negotiated both in private practice and in academic settings. In addition, PEM physicians, as pediatric emergency medicine specialists, can also work and have leadership in not only academic centers but also community hospitals where they are models of PEM trained individuals who can assist community hospitals in improving their pediatric emergency care service line. Finally, EM physicians who are sub-boarded in pediatric emergency medicine have the opportunity to work in children’s hospitals, unlike their EM trained colleagues. Overall, I feel PEM offers expanded opportunities for the emergency physician to contribute to the specialty.

EP: Being happy in your career is so important. At the end of the day if it’s PEM you love then you should consider fellowship training. Compensation is variable depending on, but not limited to the type of group practice, location, and position/title you hold within your department. You should also moonlight regularly in a general ED to maintain your skillset (and supplement your income) if you plan to continue caring for adults. It is a very personal choice and is a sacrifice of time and money so make a thoughtful decision that’s right for you and your family. Knowing what I do about personal finances, retirement and job satisfaction I would make the same decision if I had to do it all over again.

CH: The key in academics is to get a job under the Department of Emergency Medicine instead of the Department of Pediatrics. My fellow PEM providers and I get paid on par with the general EM providers. As for the extra time, in the big picture, another year or two is not really a big deal. I did moonlighting during my fellowship to keep up my adult EM skills and functionally doubled my salary.

Q: What strengths and contributions do you think EM trained physicians going into PEM bring into the field? 

MGH: I believe that PEM trained individuals have a unique opportunity to improve care locally, regionally and nationally. At a local level serving on committees for state chapters for ACEP as well as EMS agencies, these individuals can help improve the pediatric care services provided locally and regionally. There are data to suggest that improving pediatric readiness improves mortality within a region and a PEM trained individual is the perfect thought leader to enter these communities and begin the process of collaboration with other stakeholders to improve pediatric emergency care. Leadership can also occur at a state and national level as all states have EMS for children programs and state partnership grants. The PEM physician can get involved on that level on technical advisory committees and even as the Medical Director for these programs. Also at a national level, the PEM physician can be active in the AAP as a member of the Emergency Medicine section or on the Committee for Pediatric Emergency Medicine (COPEM). For ACEP, the PEM trained physician may wish to join the Pediatric section for ACEP as well as seek leadership opportunity on the Pediatric Emergency Medicine committee. In addition, there are lecturing opportunities both at the state and national level for ACEP. Furthermore, the emergency physician trained in PEM can develop a focus area for doing other continuing education lecture opportunities with the many providers wanting to expand their EM knowledge. There are also unique opportunities to train advanced practice providers (APPs) in the care of children. 

EP: As a minority participant you bring a different vantage point that is likely not represented. You know what it’s like to take care of sick kids without the expertise and can speak reality into any questions or concerns that lack perspective. EM trained physicians are masterful at task switching, running a department and immediately prioritizing the care of sick patients. These skills are valued in PEM. EM is also an amazing field that allows for a huge variety of niche interests which can also be useful in PEM.

CH: EM primary trained physicians bring their well-honed sick/not-sick detector from the years of training in EM. Also, as more and more "adult-type" illnesses occur in pediatric patients due to childhood obesity (like type 2 diabetes, cardiovascular disease) the expertise of the general EM trained physician is critical.

Q: What do you like best about working in PEM? What do you like least?

MGH: Well, it’s hard to say what I like least about it as I’ve enjoyed a full career of over 32 years in the field. What I like the most about working in PEM are the patients, the nurses and my colleagues. We are all joined by a singular vision to provide the best care possible to our patients and I enjoy very much working with nurses and my colleagues to achieve just that. I do love children and their very positive way of looking at the world. I love their joy, their desire to play, and admire their inherent trust of the world. For me, being around patients such as those is an honor. Lastly working with the team that I do is one of the greatest joys I have in my life.

EP: My favorite aspect of working in PEM is witnessing the resilience of sick kids. My least favorite thing about PEM is seeing how the shortcomings of our society affect kids.

CH: Best part of PEM is the kids and having the chance to help them feel better on a regular basis. My least favorite part is parents who come to the ED for evaluation of their not-ill child who may have had a fever for 60 minutes and the child has not received any antipyretics. Then, I have to spend lots of extra time convincing them that their child doesn't need any tests, blood work or x-rays. It always takes more time face to face time to disposition a well child who the parents think is sick.

Q: What’s one thing you’d like people considering PEM fellowship to know?

MGH: The one thing that I would want them to know is entering a career in PEM will provide a full career and allow the physician to feel the strength of their training in ways that they never knew possible.

EP: Fellowship is a ready-made network of experts who are invested in your success. It’s intended to develop your clinical expertise, but expose you to the variety of different interests that exist within PEM in a short period of time. This could technically be done without fellowship, but it would take a lot more time and individual footwork.

CH: While ABEM only requires 2 years of fellowship there are still some institutions that require 3 years, just like the primary Pediatric trained candidates. Keep that in mind when choosing programs to apply to.
 

Q: How can an EM resident stand out in a fellowship application?

MGH: The way they can stand out is through their personal statement and demonstration of their desire to have the training and leverage to better care for pediatric patients in emergency settings. I believe doing research, some type of scholarly work, and/or project centered around the care of children would demonstrate their sincere interest in addition to their attestation of their intent to utilize their training to better care for children. I do believe aligning themselves with current experts in the field so that these experts can get to know them and write them a strong letter for their fellowship application also would be extremely useful. However, most importantly the applicant should aim to excel in their residency.

EP: Demonstrate that you have seriously explored PEM life and be able to articulate why fellowship is of value in your career trajectory. This can be done through research, activities, curriculum development, or leadership activities. Know that your residency training is not a deficiency, but an asset. Your professional interests will likely be different from those coming from pediatrics just by virtue of the differences in training requirements. Letters of recommendation from a PEM trained physician, clinical excellence, intellectual curiosity and accomplishments are typically well received. Ultimately you want to find a program that fits your needs so be thoughtful in where you apply.

CH: Demonstrate enthusiasm for pediatric patients early in residency. Do research related to pediatric patients. Perform well in your pediatric rotations so you can get good letters of reference. Consider getting involved in pediatric emergency medicine on a regional or national level to help make connections and build your network.

References
1. Simon HK, Solomon F. Confidence in performance of pediatric emergency medicine procedures by community emergency practitioners. Pediatr Emerg Care. 1996;12(5):336-339.
2. Goto T, Hasegawa K, Faridi MK, Sullivan AF, Camargo CA Jr. Emergency Department Utilization by Children in the USA, 2010-2011. West J Emerg Med. 2017;18(6), 1042-1046.
3. Chamberlain JM, Krug S, Shaw KN. Emergency care for children in the United States. Health Affairs. 2013;32(12):2109-2115.
4. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialities. BMC Health Serv Res. 2009;9:166.

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