Pediatric Emergency Medicine encompasses the spectrum of care of all acutely ill and injured children who are seen in the emergency department (ED) setting. The specialty of PEM has many dimensions: clinical, administrative, education, research, advocacy, injury prevention, and public health. It attracts candidates who have a wide variety of career goals and aspirations. PEM specialists undergo concentrated training on the evaluation and management of a wide array of emergent problems that can occur in children. They have an expanded knowledge base in many areas beyond those which are covered in an emergency medicine (EM) or pediatrics residency. This includes procedural expertise, pathophysiology of emergent pediatric disorders, differential diagnosis of acute and emergent symptoms in children, emergent congenital and neonatal disorders, and management of complex and life-threatening pediatric disorders.

 

To date, most candidates entering a PEM fellowship have had primary residency training in pediatrics, but now most available fellowships are accepting and actively interested in training EM residency graduates. The career opportunities for EM/PEM trained individuals are many and include academic and clinical positions. Most academic positions are located within tertiary care children’s hospitals but are often affiliated with EM residency programs. In addition, many EM residency training sites see patients of all ages in their EDs; therefore there is a need for EM/PEM trained EM faculty. Dual academic appointments in Emergency Medicine and Pediatrics are often possible. Many community hospitals have recently created pediatric specialty EDs within their larger EDs and are actively seeking EM/PEM trained individuals. Such a person can be an invaluable resource for a private EM group as well.

 

There is a very active research community within the subspecialty of PEM with several collaborative, multicenter, federally funded research networks. Many diseases and emergent problems that are unique to children are being studied through these venues. Some of the topics include pediatric cardiac arrest, head injury, bronchiolitis, and child abuse. A PEM fellowship can provide advanced research training as well as exposure to others in the field who are working on these and other important pediatric diseases. PEM specialists are also often involved in other areas which affect the health care or delivery of health care to children such as child advocacy and injury prevention. There are opportunities to work with large national organizations on policies and programs which affect children in this manner.

In 1992, PEM became the first official subspecialty approved by the American Board of Emergency Medicine (ABEM) and since that time almost 200 ABEM diplomates have received subspecialty certification. Although some of these diplomates received certification by the practice route, this is no longer an option; to obtain subspecialty certification, one must complete an accredited fellowship in PEM. Eligibility for subspecialty certification depends on the candidate’s primary certification. Post-graduate training in PEM may be two or three years depending on the candidate’s primary certification (EM or Pediatrics) and the individual fellowship program. Graduates of an EM residency are eligible to take the subspecialty certification exam in PEM after 2 years of fellowship training however, some fellowship training programs mandate a three year commitment regardless of the candidate’s residency training. This may be due to specific issues with the curriculum, clinical responsibilities, or research requirements.

Clinical training in PEM takes place predominantly in a Pediatric ED but other rotations may include Pediatric Intensive Care Unit, Pediatric Anesthesia, Child Abuse, EMS/Transport, Toxicology, Neonatal Intensive Care Unit, and other pediatric medical and surgical subspecialties. Most fellowships have protected time for research and many offer the opportunity to obtain an advanced degree through course work in public health or epidemiology or non-degree course work in epidemiology and biostatistics. A major part of most PEM fellowships is the opportunity to teach residents and medical students the unique aspects of PEM. Fellows often organize didactic lecture series, mock codes, journal clubs, morbidity and mortality conferences and other specialty conferences, in addition to the enormous amount of bedside teaching that is done.

Things to Investigate Prior to Selecting a Fellowship in Pediatric Emergency Medicine:

1. Graduates of EM residency programs should discuss flexibility in the curriculum with the program director. Many established fellowships will be designed to meet the educational and experiential needs of graduates from pediatric residencies. Ask about previous EM trained fellows and the adaptations made during their training. For example, pediatric residency graduates are required to have 3 months of adult EM experience during the fellowship. This would not be necessary for the EM residency graduate and could be used to obtain other important experience in areas of deficiency. Get in touch with other EM/PEM trained individuals to see if those modifications were important and helpful in overall training.

2. Graduates of EM programs will also want to discuss a mechanism for maintaining their general emergency medicine skills during the fellowship period. Many PEM fellowships are associated with EM residencies and there is an opportunity for clinical work in this setting. In addition, there may be moonlighting opportunities in affiliated academic or community hospitals. Discuss if the income earned from these opportunities will be used to either offset or supplement the fellowship salary.

3. Ask about opportunities to participate in the didactic curriculum of an affiliated EM residency particularly if the ultimate goal is to secure an EM faculty position.

4. Discuss with the program director whether you will be able to complete the fellowship within 2 years required of EM graduates, or whether you will be expected to complete 3 years. The decision to enter a two or three-year fellowship is highly individualized and should be carefully thought out and based on both present circumstances and future career goals.

5. Ask in detail about the clinical role of the fellow in the PED. EM graduates will already be familiar with the logistics of managing an ED through their residency training and need to focus more on the nuances of pediatric diseases.

6. Make sure the fellowship faculty can appreciate the unique needs of a graduate of an EM program. Your skill set and educational needs will be different. Training together with graduates of pediatric residencies and being taught by faculty with both backgrounds is advantageous as it provides perspective and deepens your knowledge.

7. Discuss what your role will be in rotations like Toxicology, EMS, or Orthopedics as EM graduates will already have some knowledge in these areas from residency training. Assure that you will have ample opportunity to focus specifically on the pediatric content of these rotations.