Bright Outlook

Child’s play? Pediatrics requires patience, empathy … playfulness

“You can’t be cocky as a pediatrician,” says Ronald V. Marino, DO, MPH. “Plus, you’re going to get peed on and spit up on anyway.”

As retired pediatrician Arnold Melnick, DO, observes, anyone interested in a career in pediatrics needs to have “real concern and empathy and love for kids.” These traits are intrinsic to individuals; they can’t be developed during training, he says.

“If screaming babies disturb you or you get angry when kids seem to be obnoxious, you don’t belong in pediatrics,” insists Dr. Melnick, a former president of the American College of Osteopathic Pediatricians (ACOP). “Pediatricians have to be accepting of children. They must listen to kids without contempt or ridicule, understanding that children think and speak at a different level than we do.”

Pediatricians have to be meticulous because medication doses must be calculated so carefully, points out Robert W. Hostoffer Jr., DO, another former ACOP president. Because they deal with smaller bodies and anatomical parts, physicians in this specialty require excellent fine motor skills and hand-eye coordination, he says.

“As a pediatrician, you need great patience and great humility,” adds Ronald V. Marino, DO, MPH, who directs the AOA-approved pediatrics residency at Good Samaritan Hospital in West Islip, N.Y. “If you have to start an IV on a pudgy 18-month-old, a lot of times you’re sweating bullets because it’s so hard to find a vein. You can’t be cocky as a pediatrician. Plus, you’re going to get peed on and spit up on anyway.”

Because they interact with both kids and their parents, pediatricians need especially strong interpersonal skills. “You need to bond not only with the child but also with the child’s family,” says Eileen L. Hug, DO, the director of the AOA-approved pediatrics residency at Henry Ford Macomb Hospitals in Warren, Mich. “This is challenging because when a child is sick, the family is under a lot of stress.”

Playfulness and imagination help pediatricians establish rapport with wary or frightened young children.

“My residents laugh, but I have a large repertoire of animal sounds,” Dr. Marino says. “I can laugh like a duck, honk like a goose and make elephant sounds. Kids love this. You’ve got to be a little goofy.”

But pediatrics is far from being all fun and games. From a clinical standpoint, the field is as intellectually demanding as internal medicine, Dr. Hug says. And as infants and young toddlers cannot describe their symptoms, diagnosing childhood illnesses can be particularly challenging.

What sets pediatrics apart from other specialties, however, is the huge education and advocacy role pediatricians play. On the front lines of preventive medicine, pediatricians champion immunizations, healthful eating and exercise, as well as safety precautions, such as wearing a helmet while bike riding and knowing what to do in a house fire. This often means asking difficult questions that may seem intrusive to parents.

“Because I’m in Oklahoma, where many people own guns, I ask if there are guns in the home,” says Tulsa, Okla., pediatrician Scott S. Cyrus, DO, the ACOP’s vice president. “I just stress to the parent the child safety responsibilities inherent in gun ownership. ‘If you have guns in the house, lock them up.’ ”

Pediatricians also need the courage to confront parents who exhibit poor judgment, such as not feeding their children well or letting them watch too much television. “We give parents guidance and try to increase their confidence,” Dr. Cyrus says. “But we can’t be afraid to challenge a mother and father when their parenting skills are not adequate. Many times they don’t realize that what they’re doing is not best for the child.”

With an average annual income of $156,000 a year, according to a Medscape survey, general pediatricians make less money than other medical specialists. Thus, passion rather than pay draws individuals to this field. As with internal medicine, pediatricians can increase their earnings by pursuing fellowships in subspecialties such as hematology and oncology, allergy and immunology, neonatal intensive care, and endocrinology.

Today, 14 of the 18 AOA-approved residency programs in pediatrics are also accredited by the Accreditation Council for Graduate Medical Education (ACGME). Trainees in dually accredited residencies can apply to either AOA-approved or ACGME-accredited fellowship programs. Pediatric residency and fellowship opportunities will likely increase in a couple of years, with the AOA and the ACGME working toward a common accreditation system by 2015.

Students match into pediatric residencies, which are three-year programs, in their fourth year of medical school. Not all of the 208 funded osteopathic positions fill, but some residencies are highly competitive, with dozens of applicants per opening.

Ideal applicants

The new Osteopathic GME Match Report by the American Association of Colleges of Osteopathic Medicine provides a glimpse of 2011 graduates who matched into pediatrics as their first-choice specialty. These graduates had an average score of 486 on Level 1 of the Comprehensive Osteopathic Medical Licensing Examination—USA (COMLEX-USA) and 498 on Level 2-Cognitive Evaluation (CE), while 100% passed Level 2-Performance Evaluation (PE) on the first attempt.

Of those pediatric candidates who matched into their first-choice program, 98% had volunteer experience, 79% had work experience and 63% had research experience.

The program directors of competitive pediatric residencies emphasize the importance of strong COMLEX scores but say that several other factors are crucial as well.

“We like candidates to have passed each component of COMLEX on the first attempt and with a solidly good score, not just by the skin of their teeth,” says Dr. Marino, who receives more than 10 applications for each of five available positions a year. “Our programs have to develop competent, credentialed pediatricians who can pass the pediatric board-certification examinations. An applicant’s COMLEX scores are a good indicator of how well he or she will do on the pediatric boards.”

With approximately 250 applications for six openings a year, the AOA-approved pediatric residency at Geisinger Health System in Danville, Pa., is very selective, says program director Michael E. Ryan, DO. He requires candidates to have scored at least in the 80th percentile on both Level 1 and Level 2-CE of COMLEX and to have passed all parts of the exam on the first attempt.

“We also look for volunteer experience related to medicine. We value this even more than research experience,” Dr. Ryan says. “But if candidates have done some research as well, that gets our attention.”

Because audition rotations are difficult to come by at Geisinger, Dr. Ryan does not require candidates to have rotated with him. Approximately half of the candidates he interviews have done a pediatrics rotation in Danville. “This gives us a chance to look at these candidates closely, but outstanding applicants are outstanding applicants, whether we’ve seen them before or not.”

In general, though, candidates who are known to program directors have an advantage over those who are not.

“You can learn a lot about candidates during elective rotations,” Dr. Marino says. “Are they team players? Do they follow through? Are they responsible? These are not traits you can gauge easily in an interview alone.”

Dr. Hostoffer, who directs an AOA-approved pediatrics residency, prefers students who have completed an intense audition rotation, known as an “acting internship,” in his program at University Hospitals Richmond Medical Center in Richmond Heights, Ohio. This allows him to observe how a student interacts with patients and their parents, as well as assess the candidate’s work ethic and clinical knowledge.

Dr. Hostoffer also favors candidates who have been involved in the ACOP’s Student Chapter, which has more than 2,000 members. Students who attend ACOP conferences have the opportunity to meet with program directors to learn more about various residencies and the availability of elective and audition rotations. Students also have the chance to do poster presentations on research they’ve done or clinical topics.

Dr. Hug, who receives approximately 100 applications for four openings a year, says she finds audition rotations helpful in narrowing down the list of candidates. But she cautions students against excelling just on specific pediatric rotations while not taking other rotations seriously.

“Sometimes students are misguided,” she says. “They think, ‘I did super on this rotation and impressed Dr. Hug, so it doesn’t matter that I messed up during my general surgery rotation at the same hospital.’ Well, guess what. There is a good chance that the surgery attending will come and talk to me.

“Students should do their best on every rotation.”

The director of the AOA-approved pediatrics residency at Doctors Hospital and Nationwide Children’s Hospital in Columbus, Ohio, Carl R. Backes, DO, is impressed by students who have research experience and exposure to rural medicine and international medicine. “We’re looking for someone who is above the routine—someone who shined either during the academic part of class or during some of the rotations they had,” says Dr. Backes, who receives more than 100 applications for four positions each year.

A member of the ACOP Board of Trustees, Dr. Backes also places a lot of weight on letters of recommendation and a candidate’s personal statement. Reference letters from pediatricians who know the student well should detail why the candidate would make a top-notch pediatrician and would be well-suited to the particular residency.

“Candidates for our program must be able to handle the stresses and strains of working in a huge hospital in a large dually accredited academic program,” says Dr. Backes, noting that MD pediatric residents in the program outnumber DOs by more than 6 to 1.

“Sometimes I get letters and phone calls from graduates of my program who ask me to consider superb students who were unable to rotate at Doctors,” Dr. Backes says. “I always welcome such recommendations.”

In candidates’ personal statements, Dr. Backes looks for inspirational stories of how the students became passionate about pediatrics, not vague expressions of mild interest in the specialty. “Often something happened in their lives that turned them on to our field,” he says.

Dr. Backes himself decided to specialize in pediatrics after a heartbreaking personal experience as an intern in the early 1970s. He had been planning on pursuing a general surgery residency when one day he was called to revive a boy who had stopped breathing. “He died of epiglottitis when I was trying to resuscitate him,” Dr. Backes remembers. “I was convinced that I could have saved his life if I had known more. That day, I changed my career path.”

Dr. Marino agrees that moving personal statements can make a difference. “A personal statement can give you some insight as to who this person is,” he says. “What is their degree of maturity? What kind of life experiences have they had? And where do they put medicine in their life’s values?”

After vetting each candidate’s package of credentials, program directors decide whom to interview—often an intense daylong process in which students meet with a number of individuals, including current residents.

“During an interview, you can tell very quickly when someone really wants to do pediatrics,” says Dr. Backes, noting that genuine enthusiasm always shines through.

Dr. Hug typically interviews about a third of the students who apply to her residency program, frequently struggling to choose among the best candidates.

“Most of the individuals who apply to our residency are good people. And those who get interviews are exceptional,” says Dr. Hug, whose program is integrated with an ACGME-accredited residency at Children’s Hospital of Michigan in Detroit. “It’s difficult to decide between an exceptional and an exceptional. Often there are 15 people I’d like to take on as residents, but I can’t. It comes down to splitting hairs.”

Outlook

Career prospects for both general pediatricians and subspecialists are bright, with the demand for primary care pediatricians particularly strong in rural areas.

Approximately half of the pediatric residents at Geisinger end in up rural primary care and half enter subspecialty programs, according to Dr. Ryan. Recent graduates have entered fellowships in hematology and oncology, neonatal and pediatric intensive care, infectious diseases and nephrology.

At University Hospitals Richmond Medical Center, approximately one-third of pediatric residents go into primary care, while two-thirds enter fellowship programs, says Dr. Hostoffer.

The field’s most striking trend, more than 70% of pediatric residents today are women, Dr. Ryan says. Previously, most general pediatricians new to practice would work long hours in both the office and the hospital, but today’s graduates are insisting on work-life balance, he notes.

“Because many young women have husbands and children, they are looking for defined and predictable schedules, even though they are committed to pediatrics,” Dr. Ryan says. One career path involves practicing entirely in an office environment, from 8 a.m. to 5 p.m. or 8 a.m. to 6 p.m., for example. Many other new pediatricians become hospitalists or work in urgent care settings, with some women practicing part time, he observes.

Whatever one’s practice arrangement, pediatrics is a deeply satisfying though sometimes stressful profession, Dr. Hug maintains. “It has been a great privilege being a pediatrician,” she says. “I can’t imagine doing anything else.”

This article has been updated to note that Dr. Backes is the director of the pediatrics residency program at Doctors Hospital and Nationwide Children’s Hospital, not just Doctors Hospital. Also, MD pediatric residents outnumber DOs by more than 6 to 1 in the entire program, not just at Doctors Hospital, as previously reported.

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