So You Want to Be a Pediatrician

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So you want to become a pediatrician. You love the idea of babies, children, and adolescents. Who needs adults anyway? Let’s debunk the public perception myths, and give it to you straight. This is the reality of pediatrics.

 

What is Pediatrics?

Pediatrics is the field of medicine providing care for babies, children, and adolescents from birth up to the age of 25. The age range was capped at 18, but given our new understanding of human brain development, the age range has been expanded.

Think of pediatrics as the equivalent of internal medicine, but for younger patients. That isn’t to say that children are just little adults, because they’re not. Children’s physiology is different, and certain medications you would use for adults may have dangerous side effect profiles in children. Additionally, because children are more resilient than adults, they tend to crash hard and abruptly, meaning they may seem relatively ok and stable, followed by a sudden decompensation requiring prompt intervention.

Just like internal medicine, pediatrics is a massive field with a variety of subspecialties such that it’s difficult to generalize the field. You can take care of patients in a variety of settings, from premature babies in the NICU, to healthy children at regular PCP visits, to hospitalized children for various rare genetic anomalies.

You can view pediatrics from a generalist versus a specialist lens. As a generalist, you’ll be handling a wide variety of presenting pathologies that don’t require sub-specialized care. If you practice in the inpatient setting, this translates to being a pediatric hospitalist, taking care of kiddos admitted to the hospital. This may include infectious diseases like pneumonia and cellulitis, neonatal issues like hyperbilirubinemia and failure to thrive, or metabolic problems like diabetes, among others. If you’re an outpatient generalist, you’ll be seeing patients in clinic, primarily for regular checkups, vaccinations, and less acute conditions, like allergies, eczema, constipation, or ADHD.

As a specialist, you focus on a single organ system of the body. Similar to internal medicine, this could be cardiology, gastroenterology, rheumatology, endocrinology, and others. Neonatologists specialize in the care of neonates, which are infants less than 4 weeks old.

 

Outpatient vs Inpatient

In outpatient adult medicine, the majority of your patients have comorbidities, meaning pre-existing medical conditions or risk factors. In outpatient pediatrics, the majority of your patients are well children, and you’ll primarily be focusing on health promotion to prevent rather than manage a diagnosis. You’ll build a relationship with the patient and their family over time, as you may see them for up to 25 years, through all developmental stages.

Beyond well-child visits, you’ll see the occasional asthma, eczema, or failure to thrive, meaning poor weight gain. From time to time you’ll see a rare diagnosis, like leukemia or retinoblastoma, but these are exceedingly rare in primary care outpatient settings. You’ll still need to be alert, as kids can compensate well and look healthy until they suddenly decompensate.

Outpatient pediatrics has a great work-life balance, and you’ll generally work 9 to 5 hours. It’s common to have 4 days of clinic and 1 admin day per week.

With inpatient medicine, your focus is on kids who need to be admitted to the hospital. You’ll admit patients from the emergency department, working them up with labs, diagnostics, imaging, and other tests. For certain conditions requiring specialized care, you’ll send consults to the specialists for recommendations.

In adult medicine, you often have disposition disasters, meaning a great deal of frustration in discharging the patient and getting them to a place that can take care of them, whether that’s a skilled nursing facility or someplace else. However, social situations can still be complex with kids, such as when they aren’t safe at home with their parents. In these instances, you’ll interface with social workers and child protective services.

Academic vs Community vs Private Practice

Academic pediatrics often includes 12-18 weeks of inpatient care. Beyond clinical practice, there’s a high amount of research and teaching, in addition to side projects of various types. These are wide-ranging, such as quality improvement for implementing a different electronic medical record in the hospital or partaking in advocacy and going to the capitol, lobbying for better safety protections for children.

Community pediatrics is the most common practice setting, where you’re working with a larger medical group. Private practice is the least common, as it is for other specialties, in part because hospitals are buying up small private practices.

Misconceptions About Pediatrics

Some think that pediatrics isn’t that complicated, and it’s just babysitting. That’s certainly not the case, and remember, kids actually have a unique physiology that requires careful attention and nuance. Acuity and sick kids are certainly a part of pediatrics, although it’s fair to say on average there’s a lower amount of acuity.

If you think pediatrics includes only talking to children, think again. There’s a heavy family relationship-building component, and you’ll essentially work with at least 2 patients – the kid and their parents.

Last, some think pediatrics is a woman’s field, and while the majority are certainly women, it’s not as skewed as some other specialties. Approximately 70% of pediatricians are female.

 

How to Become a Pediatrician

After medical school, pediatrics residency in the U.S. is 3 years. In residency, the focus is on inpatient, but there’s of course continuity clinic, where you’ll act as the primary pediatrician for your panel of patients. You’ll get new babies when starting residency and have them for 3 years, offering a longitudinal relationship that many enjoy.

As with most residencies, the hours are challenging, usually ranging between 60 to 80 hours on most weeks. It’s not too far off from something like internal medicine. A chief year, meaning tacking on a fourth year to your residency, is optional, and is best suited for those looking at academic positions who want to strengthen their CV and leadership experience.

In terms of competitiveness, pediatrics is in the bottom 4, with an average USMLE Step 1 of 228, USMLE Step 2CK of 245, and match rate of 98.2%. But of course, highly desirable programs are more competitive, even if the overall specialty is less so.

Stereotypically, medical students applying to pediatrics are the soft, gentle, kind-hearted students who care deeply about the community and kids. They tend to be positive, and want to come to work smiling and laughing with their patients. These medical students are stereotypically the “do-gooder” types.

 

Subspecialties within Pediatrics

After pediatrics residency, there are several subspecialties you can pursue through fellowship. All of the following are 3 years in duration.

Hematology/Oncology

Hematology/Oncology, or heme/onc for short, is focused on treating kids with blood or solid cancers, including leukemia, lymphoma, brain, and the like. You’ll also deal with non-cancerous blood disorders, like sickle cell disease. It’s primarily, but not exclusively, an outpatient specialty.

This is for the pediatricians who are a mix of brain and heart. They’re able to be there for their patients on one of the worst days of a parent’s life, while also being highly intellectual and strategic about the best approach. This also tends to be a highly academic subspecialty with many PhD’s.

Intensive Care Unit (ICU)

ICU is exclusively inpatient in nature, unlike the other fellowships listed here. You’ll be dealing with critically ill kids. Instead of focusing on diagnosing conditions, your primary aim will be to stabilize and support them for other subspecialists to take over and follow up with.

You’ll be dealing with sick kids who are intubated, meaning on breathing tubes, on pressors to maintain blood pressure, and will help with pre- and post-op surgical care. It’s primarily acute conditions, but you’ll see some frequent fliers, such as patients with cerebral palsy, who are in and out of the ICU often with infections.

This is for the pediatricians who are the masters of physiology, remembering everything from medical school and applying it the ventilator in front of them. They want to do the fun stuff of treating the physiologic abnormality and then transferring to the next level of care, without getting into the nitty-gritty of diagnosis and follow-up.

Cardiology

Cardiology is the most competitive pediatric specialty, and many do additional fellowships after to further subspecialize within cardiology, like electrophysiology.

You’ll deal with lots of congenital abnormalities, like the tetralogy of fallot. In managing these congenital conditions, you’ll work closely with cardiothoracic surgeons to determine optimal timing of repairs. Sometimes, it’s a staged repair, requiring one surgery at 6 months, another at 1 year, and so on.

Stereotypically, these are the pediatricians with a bit of a god complex who love managing complex physiology and nerding out about physics.

Gastroenterology

Gastroenterology is a highly procedural subspecialty, splitting time between inpatient, clinic, and the procedure suite for endoscopies and liver biopsies. They primarily deal with chronic diseases, like inflammatory bowel disease, thus promoting longitudinal relationships. But there’s much more to it than that, such as getting into the mind-body connection, as there’s a large overlap with psychosomatic disorders in children, such as anxious kids with abdominal pain. Nutrition is an increasingly important focus as we are in a child obesity epidemic.

Stereotypically, these are the down to earth pediatricians who enjoy joking about poop with kids and enjoy working with their hands, and maybe don’t need to be as deeply intellectual as some of the other subspecialties, although there is a growing need for research-minded gastroenterologists with the exploding knowledge of the microbiome and intestinal immunology.

Emergency Medicine

Pediatric emergency medicine can be approached in one of two ways – as a three year fellowship after pediatrics residency, or a two year fellowship after adult emergency medicine residency. There’s no outpatient time, no following up on labs, and once you get your shift done, you don’t take any work home with you. Your job is to stabilize kids and get them to the appropriate level of care. Compared to adult emergency medicine, there’s less acuity, but when it does escalate, it escalates quickly. If you want to know more about the field of emergency medicine, we did a So You Want to Be article on that.

 

What You’ll Love About Pediatrics

Pediatrics is a great specialty with lots to love.

First, and most obviously, you’re working with kids and you get to joke around with them and be silly every day at work.

It’s unique in that you can make an impact early in someone’s life that can compound to yield tremendous changes over a long period. It’s a beautiful part of the field that’s unique to working with a pediatric population. This is the most powerful form of preventative medicine for the simple fact you’re intervening early in their life.

There are subspecialties of pediatrics that don’t have great outcomes, like pediatric oncology, but for the most part, the majority of your patients will get better. There’s less death compared to adult populations, and rosier outcomes are always a good thing.

There’s a high amount of flexibility within the field, meaning it’s family friendly. After all, these are the doctors that prioritize children. Even in residency, your program will be more understanding of maternity or paternity leave than something surgical.

 

What You Won’t Love About Pediatrics

While pediatrics is a great specialty, it’s not for everyone.

Compensation for pediatrics is at the bottom of the list, averaging $232,000 per year. Part of this is the payer mix, as many children are on Medicaid, which has lower reimbursement than commercial insurance. In the fee-for-service model of U.S. healthcare, you’ll generally have fewer interventions than adults, which is another reason why adult specialties often make more.

If you love high acuity and the adrenaline rush, pediatrics has less acuity than most other specialties, since kids are usually healthy and resilient.

As with other primary care focused specialties, there’s lots of charting and computer time, and you may feel like you don’t get enough time with your patients.

Seeing child abuse and maltreatment, or seeing young children pass also never gets easier.

And finally, there’s not as much research within pediatrics compared to adult medicine, which can be frustrating since certain drugs haven’t yet been tested in kids for efficacy and safety profiles.

 

Should You Become a Pediatrician?

How can you decide if pediatrics is a good fit for you?

While you should certainly love children, you shouldn’t mind having essentially two patients – after all, you’re dealing with not only the kids but also their parents, who may be more concerned or neurotic with their child’s health than with their own.

Pediatricians also tend to think about the health of the whole child, including nutrition, living situation, families, and thinking broadly about what health means more so than just diagnosing and treating conditions.

Many pediatricians find enjoyment with the data, puzzles, and detail required of the field. They tend to be interested in public health and advocacy work, and are focused on more than just the medicine aspect, but also the context in which the child grows. In doing so, they hope to build a better system to promote children’s health.

And finally, the happiest pediatricians tend to be mission-driven. After all, it’s not a lucrative specialty, and many who go into this field do so because they love kids and want to take care of them at the end of the day.

Special thanks to Dr. Erin Elbel Mauney, current Insider at Med School Insiders, for helping me in the creation of this article.

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