What it’s like in pediatric critical care: Shadowing Dr. Kuppy

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As a medical student, do you ever wonder what it’s like to specialize in pediatric critical care? Meet Joanna Kuppy, MD, a critical care pediatrician and assistant professor of pediatrics at Rush University Medical Center, and a featured physician in the AMA “Shadow Me” Specialty Series, which offers advice directly from physicians about life in their specialties. Check out her insights to help determine whether a career in pediatric critical care medicine might be a good fit for you.


“Shadowing” Dr. Kuppy

Specialty: Pediatric critical care medicine.

Practice setting: Hospital and academic.

Employment type: Employed by a hospital.

Years in practice: 7.

A typical day and week in my practice: It depends whether I am on service or not. I don’t really have a typical day, which is something I like about this job. It gives me a more flexibility in my life. When I am on clinical service, my days are generally 7 a.m. to 5 p.m., and a minimum of 75 hours for the week. I pre-round with the overnight attending, then run team rounds on the patients, then juggle other issues that include procedures, evaluate any changes in clinical course, talking to families and other subspecialists, and, (my favorite) teaching. I sign-out to an on-call attending in the early evening who covers the unit overnight. A service week in our group consists of five weekdays of clinical service in sequence and associated weekend calls, which are 24 hours long. As an intensivist, we are here in the hospital when on-service or call, regardless of acuity. Since working 75 hours in a week is not sustainable for every week, our schedule allows for off-service time to attend to other academic responsibilities.

Approximately half of my time is spent in our medical college developing the curriculum, serving as a faculty advisor, and teaching. For instance, this week my schedule is more of a function of what work needs to be done for the school and our curriculum, associated meetings, and student mentoring. 

Hospitals and institutions have tried to address burnout in critical care, since it is well-known to have a high burnout rate. One of the strategies is to stagger clinical service such that you are not on service every week—there is no way you can do this job every day of the week. Because it is “intensive” intellectually, physically, and often emotionally, there are a lot of life and death issues. You have to be “all in” and present for the patients and the team. Ultimately, having a strong team to work with allows for a reasonable clinical load and leads to better patient care.

In my group that includes 11 intensivists, we cover two hospitals and three different service teams. This also includes 24/7 in-house coverage for one hospital and “at-home” overnight coverage for the other hospital. In addition to clinical coverage, we have monthly division meetings, monthly department meetings, and addressing other academic responsibilities.  

The most challenging and rewarding aspects of pediatric critical care: For me, the most challenging part is when things aren’t going the way we would like. You can’t fix everybody, no matter how hard you try. Having those tough conversations with families and gently introducing that reality is a necessary part of this job. What constitutes bad news can be something as routine as needing to put in a new peripheral IV for a child, all the way to telling families that their child is dying. It is very challenging to break bad news, and that happens frequently in this line of work. It is a skill, and you become more sophisticated with it over time.   

One of my favorite parts of being an ICU attending is the acuity, clinical reasoning and tying clinical care back to basic physiology and pathophysiology. When I teach trainees, I relay that many parts of the clinically relevant topics are actually very close to some of their first-and second-year medical student materials.

My absolute favorite thing is when we have what we call “graduates” who return to the PICU. These are kids who were in the PICU—sometimes for a very long time—who come back after recovery, and they are doing better. That is so much fun. It is just wonderful. They come in and do their “victory lap.’ I love it.

Three adjectives to describe the typical critical care pediatrician: Mentally agile, dedicated and hopeful. You’ve got to think on your feet. You’re dedicated to the cause when you’re on service. If you lose hope, this can be a very soul-crushing specialty very quickly.

How my lifestyle matches, or differs from, what I had envisioned: In medical school, I knew I was going to go into pediatrics, but I thought I was going to be an outpatient physician. The reality of in-house calls on nights and weekends is hard, but it is becoming a necessary part of the equation to ensure quality care. Nobody likes to be in the hospital at night, but ultimately, I believe—and many others do as well—that it is best for the patients in this setting.

At the same time, I have a lot of flexibility in my schedule because of where I have chosen to work, what I have chosen to do and how I have chosen to explore my nonclinical interests. As a medical student I never understood that I would have that kind of choice. I don’t know if it’s because no one told me or that I didn’t accept that these would be decisions that I could make.

I work in a medium-sized PICU that has reasonably high acuity and I get to do all the things I love. Our group also covers the county hospital across the street, so I get to see a wide variety of patients with a wide variety of conditions. I have been very lucky.

Skills every physician in training should have for pediatric critical care but won’t be tested for on the board exam: The thing that we try to teach, but I don’t know if we assess well enough, is interpersonal communication.

ICU medicine is a team sport. There is nobody that is more important than anyone else. I don’t care if you’re the attending, the family, the nurse, the resident, the respiratory therapist—everyone has something important to contribute. Everyone has a role to play and every role is vital to ensure good patient care.

Professional behavior and interpersonal communication are huge and it is important to remember that our team relies on us to model professional behavior. I think families are comforted and teams function better when they see that their leader delivers great care and models a strong work ethic.    

Curiosity. I don’t know how we test for curiosity but there are many times in the ICU that things in front of you appear one way, but the reality is something entirely different. You’ve got to have that natural intellectual curiosity with you at all times to examine the information in front of you and make sure that that you’re not prematurely reaching a diagnosis and take note of rapid changes in clinical status.

One question physicians in training should ask themselves before pursuing pediatric critical care: Am I OK with the nights and weekends? In general, every specialty has nights and weekends, but am I OK doing those in the hospital? If not, then it can be very challenging. In general, most students and residents should ask themselves: Do I love this? Because if you don’t love it, you’re not going to be happy. That’s true for anything.

A book every medical student interested in pediatric critical care should be reading: There are certain things that are always good to read, like When Breath Becomes Air, by Paul Kalanithi, MD. It is a wonderful book about a physician’s journey toward death. It is a hopeful book in its own way. That’s one of the books in recent years that has stood out to me as one that perhaps we should make required reading for all of our students.

The online resource students interested in pediatric critical care should follow: I don’t really “follow” this, but the resource I use the most is PubMed. I am always searching for literature to answer both clinical and educational questions. Learning how to effectively navigate your way through PubMed is an invaluable skill. I just learned it as an attending. Doing a real search of that database will give you what you need.

Quick insights I would give students who are considering pediatric critical care medicine: It is a great way to practice medicine. If you think you like it, don’t be scared of the lifestyle. Spend time talking to people who practice it and ask them what they do.

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