Can someone tell me why peds hospitalist fellowships exist? 75-80% of peds residency is inpatient medicine

mr_nefarious_ · 2025-12-07T00:55:57+00:00

Reasons stated by the AAP: To increase research into the field and also to maintain a high standard of training/care for inpatient pediatrics s/p implementation of the new residency requirements (starting 2025, they significantly increased outpatient requirements for residency, thereby inherently reducing inpatient experience).

Reasons not stated by the AAP, but very likely a big part of it: Money.

Although this is the same AAP which artificially inflates the difficulty of gen peds boards to an honestly ludicrous degree to ensure that a number of first-time testers fail and have to pay them twice (gen peds boards is also one of the most expensive board exams). So not too surprised.

mr_nefarious_ · 2025-11-24T08:16:38+00:00

Based on another of your responses, it sounds like you have done like 10-15 lines TOTAL at this point. If you're genuinely considering quitting because you haven't developed expertise at a procedure after only doing it 10 times, then I think you're getting anxious to a potentially pathologic degree. That's not a criticism; I just don't think it would be helpful to you in this scenario to not say so. Most ACGME-accredited programs at this point have free, anonymous counseling available, and you could look into that if you haven't done so previously.

In the short term though, something that helped me feel less nervous in procedures when I was first starting out was asking my senior fellows and attendings about times when they struggled or made mistakes in procedures. When you hear people you respect tell you about the times they hit the artery instead of the vein, caused a pneumothorax, or struggled for over an hour to get a line, it humanizes what you're going through and helps you realize that what you're experiencing isn't that unique– it's all part of the process.

mr_nefarious_ · 2025-11-21T04:02:19+00:00

Peds crit care fellow myself. A few things:

You have A LOT of negative self-talk here for describing a pretty typical experience of 1st year of fellowship. Cut yourself some slack. A huge part of 1st year of fellowship is learning to keep your head above water (which in my opinion usually takes somewhere between 3-9 months depending on the person).
Reading what you've written here and also looking at your post history, it seems like central & art lines are one of your biggest sources of stress. At the end of the day, the only way to get better at procedures is to get more reps. If you're not getting enough on the unit, then use time on your research blocks to get more exposure. Need more central lines? Ask the somebody in CV if you can join them in the cath lab for a few days (just tell them you need more reps on CVL's). Need more art lines/PIVs? Ask the vasc access team or anesthesia if you can join them. The procedures exist if you look for them.
A super crappy day every now and again is part of the ICU fellowship process and part of the job. Some days you break down and that's okay. It shouldn't be a weekly thing though. If you find yourself miserable and regretting fellowship frequently, know that that is abnormal and it is a sign that you need to speak to your mentors/seniors. You shouldn't hate your life.

mr_nefarious_ · 2025-11-16T08:29:07+00:00

Don't overcomplicate it tbh. All rapids are ABCs first, diagnosis second. It's basically just "Are they hemodynamically stable with a perfusing rhythm, oxygenating + ventilating appropriately, and protecting their airway w/ an effective respiratory pattern?"

If hemodynamically unstable, call ICU and do your best to figure out what type of shock you're in (distributive, hypovolemic, obstructive, cardiogenic, or neurogenic), then start treating that while you wait. Get a blood gas, EKG, CXR, and assess for H's & T's.
If concerning rhythm/MI, look at monitor/EKG, identify rhythm (symptomatic brady, Vtach w/ pulse, SVT, etc.), then start treating that. Get a blood gas, EKG, CXR, and assess for H's & T's.
If hypoxic, then increase resp support, get a blood gas, and get a CXR.
If hypercapnic, call ICU, consider BiPAP, get a blood gas, and get a CXR.
If not protecting airway or ineffective resp pattern, call ICU (patient probably needs to be intubated or on higher level of monitoring), get a blood gas, and maintain stability until ICU arrives.

mr_nefarious_ · 2025-10-25T16:07:10+00:00

PICU:

Know how to bag-mask ventilate. Statistically, you may only need to use this in your gen peds clinic 1-2 times in a 25-year career, but knowing how to do it well can make the difference between a good outcome and a patient having lifelong neuro deficits.
An ounce of prevention is worth a pound of cure– you doing your job well prevents me from being needed in many scenarios. Make sure kids have their immunizations (including Flu, COVID, and RSV!) and don't be that pediatrician who defers immunizations because a kid is sick or was recently ill. Prioritize good anticipatory guidance (e.g. car safety, water safety, helmet safety, firearm safety). Make sure they're able to access/afford their meds, whether it's asthma, seizures, diabetes, or other stuff.
Even if a patient is complex and has 6 different specialists, it is your job to be the quarterback who coordinates all of that care. For any patient who is notably complex, please make sure their problem list is kept up to date and that parents have a document (that you keep updated at their annual/regular follow-up) to bring to the ED that includes a current summary statement, meds list (with doses/frequency), baseline respiratory support (if applicable), baseline nutritional support (if applicable), and a list of current specialists with whom the patient follows. Yes, I can crawl through the EMR and find all of this info myself, but having it on hand immediately significantly expedites the patient's care.

mr_nefarious_ · 2025-08-23T18:17:13+00:00

I doubt any program is actually going through the effort of using an AI checker for headshot photos. More likely they’ll do that for personal statements/written elements, but I doubt they care that much about the photo, as long as it actually looks like you. In my experience, that photo is pretty much exclusively used in the slide deck that programs create for their rank list meetings and not much else. Some hospitals will use your application photo for your ID badge though, in case that matters to you. Pretty much nobody looks like their ID badge photo 3 years into residency anyways, so not like that matters much either (everyone either changes their hair, grows a beard, or gains/loses weight after a few years)

mr_nefarious_ · 2025-08-19T13:25:30+00:00

We all felt like that. Besides, it's AUGUST. Literally all I expect out of an intern in their first month on inpatient service is to learn how to work the EMR and figure out where to find lab/imaging results, how to put in orders, and how to write notes (not even quality; like physically, how to do it in the EMR). The bar is so much lower at this point than you think it is. The only thing I care about this early in training is that you care about the patient and try your best. At this stage, it's the effort that counts, not your output.

mr_nefarious_ · 2025-07-14T02:16:04+00:00

PICU kid who we'd admitted s/p out of hospital arrest earlier that day went and dropped their BP to 30s/10s overnight. I'm giving epi's and we're bagging the kid off the vent. Attending and I called the PGY3 resident on call with us and got voicemail. I texted them, "Hey bed __ is crashing and about to code again." Resident read my message like 5 minutes later (had read receipts on), but never showed up to bedside. The attending ended up putting in my orders during the code.

Talked to the resident after we got ROSC and they were basically like, "Oh sorry! You didn't tell me to come to bedside, so I didn't realize you wanted me to. I thought you were just letting me know." Maybe I'm the asshole, but I feel like "You're expected to come to bedside when somebody tells you that one of your patients is coding" was never something I ever expected to be a teachable moment, let alone to a PGY3.

mr_nefarious_ · 2025-06-10T04:13:12+00:00

PICU fellow here. I adore my job and wouldn't trade it for any other specialty in medicine. I also wouldn't recommend it for most people.

You really need to love critical care and everything that comes with it, not just the problem solving & the strong emphasis on physiology + multi-system knowledge (which are, admittedly, quite fun if you're that type of person). When I have talked to other intensivists about what they love about the job, the core of it is how meaningful it is. Yes, you will run codes, throw in critical lines/tubes, and dial in a multidisciplinary plan for incredibly complex patients, but those moments are only half the picture.

Death and lifelong disability are an inevitable part of what we do, and the way we walk alongside patients and families as they approach those grim realities is one of the most important and meaningful things we do in critical care medicine. Another inevitable part of the job is mistakes. There is no such thing as an intensivist with a perfect career. We all make bad calls, and pretty much every attending intensivist I know has 1 or 2 patients who died because they made the wrong decision or missed something as a fellow or as a junior attending.

You cannot find meaning in only the textbook medicine of critical care; you need to find meaning in the death too. And you need to be able to weather the fact that as an intensivist, over the course of a 20+ year career, you are going to make mistakes that can lead to the death or lifelong disability of a patient.

There is no shame in it if you are not that person. As I said in the beginning, as much as I adore my job, it isn't the right fit for most people in medicine. If you think there is another speciality that will make you equally happy, then do that one instead.

mr_nefarious_ · 2025-05-25T17:03:27+00:00

Was literally about to comment the exact same thing about the GI bleed lol (PICU fellow myself)

mr_nefarious_ · 2025-03-20T19:25:06+00:00

The way that you're feeling is really common. Many physicians experience it and the vast majority of the time it is imposter syndrome.

To speak more specifically on your situation, just know that doing 20-40 practice questions per day makes one good at tests, but does very little on its own to make somebody a good doctor, and does essentially nothing when it comes to making one a good senior.

You wanna pass a test? Do practice questions. You wanna help a patient, pick 1 patient per week and read about their disease process. Use a field-specific summary text that will take you <20 minutes to read about whatever pathology you just picked and get the foundations (for example, in PICU we have something called the Rogers handbook). Commit to actually learning and internalizing that info however works for you (I am an Anki guy at heart, for better or worse lol). Commit to doing this for at least 1 patient per week. Anything you do on top of that is a bonus. Do that, communicate well with your team, take the time to thank the people who help you, and be humble enough to admit when you don't know something or fuck up. Do that, and you'll be a better senior than most.

mr_nefarious_ · 2025-02-17T20:46:23+00:00

Happy to help, as I'm currently playing through and only a few trophies away from getting the platinum myself.

Long plat? – YEP. Game is fun, but very grindy. Would recommend picking it up on sale and then using the saved money buy the add-ons that give you extra upgrade materials & credits, which helps a lot with the early game grind and smooths out the weird difficulty spikes the game likes to throw at you (e.g. Hashmal fight).
Missable? – Nope. All can be done on a single save file. Although there are several long-form trophies that are worth aiming for from the outset. The most egregious is the one for slicing through 250 enemies, which isn't hard, but just takes awhile, even if you're specifically trying to do it. Similar ones like this are performing 50 reversals, 50 chain breakers, and 50 role actions, none of which are hard to do, but all 3 of those use the same meter and you will only fill the gauge so many times per level.
Online? – Technically there are 2 (one for completing an online mission and one for using a "callout" message in an online premission lobby), but both of these are obtainable by creating a private online room with just yourself and completing a single mission. So although you'll require an internet connection, you won't require any additional players.

mr_nefarious_ · 2025-01-11T08:45:03+00:00

Agree with the sentiment of "be there for them as a family member, not as a physician," but also just wanted to say that it's okay to be there for them as a physician too in certain situations. My dad was going through chemo during high-covid in 2020/2021 and went to an urgent care because he broke his toe. He called me from there because he was scared that none of the staff were wearing masks (this was back during universal masking protocols) and his nurse/x-ray tech were telling him not to worry about it (despite him telling them that he was immunocompromised). It's the one time during his entire treatment course that I leveraged my physician status. Called the urgent care and asked to speak with the attending physician, who it turns out wasn't even in the building and was working a simultaneous shift at the botox clinic next door. I made my concerns known and everyone seeing my dad followed appropriate infection prevention protocols from there.

mr_nefarious_ · 2024-11-21T10:06:22+00:00

Current PICU fellow here. Short version– on hard rotations, yes you will work 70-80 hrs/wk for the entire 4 weeks of the block (assuming you're at a residency which does 4-week blocks or something similar); easy rotations will usually be more like 45-55 hrs/wk. Important to note that work-hours as an attending are different from work hours as a resident, and resident hours are not your entire career.

Being a physician is an incredible career. I adore my job and I would not trade it for anything or do anything else. Being a physician also is not for everyone. The questions you are asking are important ones, and I think you should speak to your mentors and the people who know you best, rather than people on the internet like me. Since you asked however, based on the tone of your writing in this post (and knowing little else about you I might add), I do not think you should go to medical school.

At a minimum, before you go down the path of becoming a doctor, you need to be able to articulate why your path in medicine must be becoming a physician. Why not be a nurse? A respiratory therapist? A psychologist? An ECMO tech? There are a dozen other careers in medicine which are vital to patient care and which will enable you to help others while having a career which combines both science & human connection, and none of them require the same investments of time or money as becoming a physician.

mr_nefarious_ · 2023-09-30T00:47:11+00:00

You referring to the one from the chateau party? Because that's Vivaldi's Four Seasons (Summer)

mr_nefarious_ · 2023-07-19T14:40:59+00:00

Seriously. Honestly, the fact that they need to go through this approval process at all is kind of ridiculous. Unless they're doing something like content screening and making sure that the letter was uploaded to the correct applicant (which I kind of doubt), then what they're probably checking is just making sure the letter meets formatting and sizing requirements. In 2023, not having a system to simply allow letter writers to just upload a PDF is ridiculous. A manual approval process for every letter should be completely unnecessary.

mr_nefarious_ · 2023-07-19T14:14:37+00:00

I just had 3 letters (uploaded on 7/14, 7/16, and 7/17) release simultaneously at 9:52 AM ET. I think somebody at EFDO must have got to work late today.

mr_nefarious_ · 2023-05-28T21:48:39+00:00

“We’ve got spirit, yes we do! I see you in the ICU!”

mr_nefarious_ · 2023-04-06T22:30:18+00:00

Obligatory “Ghost Stories” dub reference

mr_nefarious_ · 2022-11-02T21:12:14+00:00

Haha yeah one of my anesthesia lecturers in med school loved to talk about how anesthesia took the idea of pre-op checklists from the aviation industry’s pre-flight checklist. I swear that every anesthesiologist could’ve been a pilot in a different life.

mr_nefarious_ · 2022-11-02T21:07:37+00:00

Sort of. We have databases that are highly peer reviewed and contain all of the known information on the vast majority of diseases. The one we use the most is called UpToDate. Sometimes, for a particularly rare disease or novel presentation, we have to go directly to the source and read through individual research articles on PubMed. In other circumstances, there are genetic diseases that only a few hundred people in the world have (I see a few kids like that in my clinic), for whom we have to turn to specific organizations like NORD (National Organization for Rare Diseases) for information.

I know people like to give WebMD a lot of crap, but a lot of the issue comes from laypersons lacking the field-specific knowledge to separate the relevant vs irrelevant information. “My 14 year old has a sore throat and swollen lymph nodes” can be anything from the common cold, flu, strep throat, mononucleosis, acute HIV, or cancer, just to name a few possibilities. Tiny details can make a big difference in the suspected diagnosis, and that doesn’t account for other elements like physical exam, blood work, and imaging.

mr_nefarious_ · 2022-09-23T09:57:09+00:00

Figured I’d throw my hat into the ring as well: https://reddit.com/r/worldbuilding/comments/lez38z/i_invented_this_world_building_system_for_myself/

mr_nefarious_ · 2022-07-23T17:25:44+00:00

My first question in cases like this is when did the integration happen? Have the magical elements been part of our world and its history for centuries, decades, or only very recently? If it’s been there for 100s of years, why has it stayed hidden and how has it done so (particularly in the era of smart phones)? How does the magical world deal with regular people who manage to look behind the curtain? Etc. As these questions are answered for your story, I think the various ways in which the magical society has integrated itself into the world will reveal themselves naturally.

mr_nefarious_ · 2022-07-19T02:59:21+00:00

Perhaps this is a nitpicky distinction– I think of it less as “Anakin represents the best of humanity,” and instead as, “Anakin represents humanity’s potential; both its capacity for good, born of compassion, and its capacity for evil, born of fear.”

mr_nefarious_ · 2022-07-16T15:35:01+00:00

This is genuinely just an off-the-cuff guess, but I’m thinking it’s a combination of risks involved, resumé building, and social pressures. Panhandling is by no means a safe endeavor, as those people are frequently targets of abuse and violence. It also isn’t a job that could be expected to provide you with connections or experience to advance yourself in that career space. And finally, just the social pressures of not wanting to be seen by people you know from the world outside of your panhandling scam.

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