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Pediatric Emergency Medicine

Authors

Jessica Wall, MD, MPH
Pediatric Emergency Medicine Fellow, Children's Hospital of Philadelphia
Attending Emergency Medicine Physician, Penn Presbyterian Medical Center
Clinical Instructor in Pediatrics, University of Pennsylvania 
Clinical Associate Faculty in Emergency Medicine, University of Pennsylvania

Christopher J. Ford, MD
HealthPartners-Emergency Medicine Physician
Children's Minnesota Pediatric EM Fellow

Faculty Editors

Megan Lavoie, MD 
Attending Pediatric Emergency Medicine Physician, Children’s Hospital of Philadelphia
Associate Professor of Clinical Pediatrics, Perelman School of Medicine at the University of Pennsylvania
Co-Director, PEM Fellowship, Children’s Hospital of Philadelphia

Paul Ishimine, MD
Director, Pediatric Emergency Medicine
Department of Emergency Medicine, UC San Diego Health 
Director, Pediatric Emergency Medicine Fellowship Training Program
UC San Diego / Rady Children’s Hospital, San Diego
Clinical Professor of Emergency Medicine and Pediatrics
University of California, San Diego School of Medicine

Special thanks to our 1st edition writing team 

Jessica Wall, MD, MPH
Ashley Strobel, MD
Neil Jain, MD

INTRODUCTION

Description of the specialty
Pediatric emergency medicine (PEM) is an ACGME-accredited clinical subspecialty that focuses on caring for the acutely ill and injured pediatric patient in the emergency department. Subspecialty training is available to graduates of either pediatrics or emergency medicine residencies, and completion of PEM training and examination results in board certification in pediatric emergency medicine.

History of the specialty/fellowship pathway
In 1990, the American Board of Emergency Medicine (ABEM) and the American Board of Pediatrics (ABP) applied for approval to offer subspecialty certification in pediatric emergency medicine. Once approved, the first board examination for PEM was offered in 1992, and it has been offered biennially since that time. The longest running PEM fellowship was established in 1980 at Children’s Hospital of Philadelphia, and since that time, more than 70 fellowships have been developed in the United States.

Why residents choose to follow this career path
PEM combines principles of emergency medicine with general pediatrics and pediatric critical care. This subspecialty allows the emergency physician to expand his/her knowledge of pediatrics in the acute care setting. In addition to advanced clinical training, pediatric emergency medicine fellows develop skills in pediatric emergency care protocol and guideline development, pediatric emergency care infrastructure, pediatric emergency medicine education, practice in a pediatric emergency setting, and advancing emergency medicine research in the pediatric population.

How do I know if this path is right for me?
This fellowship is ideal for those who love the emergency department setting and also have an interest in pediatric care. By taking the pathway of emergency medicine to PEM fellowship, you have already developed strong resuscitation and acute care skills in residency and will expand your skills with diagnostics and management of pediatric patients in fellowship.

Career options after fellowship
PEM fellowship will expand your employment options and practice settings. Those boarded in emergency medicine and pediatric emergency medicine are qualified to work in any emergency department (pediatric or adult) in the country. Some physicians choose to practice exclusively in the pediatric emergency department; however, many either practice in a combined emergency department (pediatric and adult patients seen in the same care setting) or dual pediatric/adult emergency department (pediatric and adult patients seen in parallel departments in the same hospital) or in multiple care settings (adult and pediatric hospitals). Additionally, those who practice in general emergency departments often become the pediatric care coordinator, or “pediatric champion,” for the department and establish protocols and quality improvement practices for the care of pediatric patients.

Splitting time between departments
Given variability in practice settings, some EM/PEM physicians split time between the general adult emergency department and pediatric emergency department or practice in a combined pediatric and adult emergency department. Many institutions will help with setting up your contract and establishing the division of labor between these two departments.  This split of your time will be highly variable.  Positions may entail a relatively even split between time seeing adult and pediatric patients, or they may be constructed so that you see predominantly children or adults. Some institutions will have one department chair for both departments, which will make contract negotiation easier, whereas others have two separate department chairs whom must both agree to hire you. It is not uncommon that when two separate department chairs are involved, one chair will take the lead for contract negotiations.

Academic vs. community positions
There are both academic and community positions for the EM/PEM physician, depending on the type of practice environment you seek. The majority of pediatric hospitals are academic centers, therefore practicing exclusively in the pediatric emergency department setting will often have a teaching/supervisory component. Furthermore, pediatric academic hospitals often utilize residents, nurse practitioners and physician assistants, leading to a different practice environment than many emergency physicians have encountered in residency. These settings offer rich experiences in teaching and mentoring, but may lead to less direct patient care or use of one’s own procedural skills.

IN-DEPTH FELLOWSHIP INFORMATION

Number of programs
To date, there are more than 70 PEM fellowship opportunities. Programs are added to the EMRA Match database and the AMA Residency & Fellowship Database as they become available. 

Differences between programs
PEM fellowships vary widely in departmental structure. The majority are situated within tertiary care pediatric hospitals, while some function within combined adult and pediatric centers. As with emergency medicine, there is a spectrum from highly academic to more community-oriented fellowships. The fellow role varies between programs, with many having the fellow as an intermediary role between the resident and attending, while others have the fellows see patients in an attending capacity primarily with supervision. There is also variability in curriculum with regards to the incorporation of graduate classes, research, and elective opportunities. 

Length of time required to complete fellowship
To be eligible to sit for the PEM subspecialty boards, emergency medicine physicians must complete an accredited 2-year fellowship. However, given that pediatricians must complete a 3-year fellowship, there are both 2- and 3-year programs. For some programs, the third year is strongly recommended of all EM-trained fellows. It is best to find out by contacting them directly. However, this year may include additional certifications or graduate educational opportunities.

Skills acquired during fellowship 
All programs will train you in trauma and medical resuscitation of the critically ill pediatric patient. You will also gain skills and knowledge in dealing with pediatric specific complaints and pediatric subspecialty areas such as neonatal and infant care, genetic syndromes and metabolic disorders, congenital heart disease, endocrinopathies, transplant medicine, and neurologic disorders. Some programs will offer various rotations in specialties not often encountered in traditional EM training but pertinent to a career in PEM such as Child Abuse/Child Protective Services.  EM graduates are required to have training experiences in primary care, as well as pediatric and neonatal critical care. 

Typical rotations/curriculum
Because this is a clinical fellowship, the majority of your time will be spent in the pediatric emergency department with direct patient care. Curriculum varies between programs; however, exposure to the pediatric intensive care unit, pediatric anesthesia and specific pediatric subspecialties are typically included. Many programs include rotations in child abuse, sports medicine/orthopedics, transport medicine, neonatal ICU, burn/trauma, and pediatric primary care. Many programs include opportunities for obtaining advanced degrees in research, public health or medical education, among others. 

Board certification afterwards?
Yes, you will be board-eligible in pediatric emergency medicine after the completion of an ACGME accredited pediatric emergency medicine fellowship. Similar to EM residency, you will take in training examinations (ITEs) for PEM boards once a year. These ITEs, similar to EM training, are geared to help you prepare for PEM boards and guide your studying.

Average salary during fellowship 
The majority of programs have a salary consistent with that of a PGY-4,5,6, which will vary by location. Some programs will offer or allow moonlighting opportunities. It is important to note if your intent is to return to adult practice following fellowship, moonlighting (in a mostly adult ED) should be a strong consideration to maintain your adult skills. Inquire regarding moonlighting opportunities during your interview. Once matched, reach out to your program once again regarding moonlighting, as the credentialing process can be lengthy, even taking up to six months in some cases.

PREPARING TO APPLY

How competitive is the fellowship application process?
The application process is strongly competitive for fellowship applicants. Given the multiple paths to this fellowship and the variable training years, some programs are more open to emergency medicine applicants than others; however, as the specialty matures this gap is closing.

Requirements to apply
The only requirement for application is completion or projected completion of an emergency medicine or pediatric residency. 

Research requirements
Research, while not a requirement for applications, is strongly encouraged, as is experience in quality improvement. While pediatric emergency medicine-related research is encouraged, fellowship programs are seeking applicants who show a track record of success in research and an applicant who will be able to “see a project through”, even if prior research is not related to the pediatric population. 

Suggested elective rotations to take during residency
Given the unique educational environment of the PEM fellowship, it is important to obtain letters of recommendation from PEM faculty, as well as some experience in a pediatric emergency department prior to your application. Depending on the program in which you are training, you may not have access to a pediatric emergency department beyond the minimum rotation requirement. In this case, we recommend completing an away rotation at a site where you are interested in applying. Additional rotations you may find helpful in preparation for applying to fellowship include the pediatric intensive care unit, the neonatal intensive care unit, transport medicine, sports medicine, and pediatric anesthesia.

Suggestions on how to excel during these elective rotations
Read the pediatric chapters of whichever emergency medicine textbook you use in residency prior to a pediatric rotation. Many pediatric emergency departments have developed treatment protocols for common complaints such as asthma, bronchiolitis, neonatal fever, button battery ingestions, and appendicitis diagnosis. Contact the department in advance to find out if you can access them online so you will be familiar with their treatment algorithms prior to your arrival. Remember that pediatric emergency departments have a structure and flow model that is often different from general emergency departments, so go into these rotations with an open mind. Finally, skim through some of the pediatric blogs, podcasts, and online review articles such as Evidence-Based Medicine and Pediatric Emergency Medicine to get a sense of current topics in pediatric care. 

Should I complete an away rotation?
If your home institution does not have a dedicated pediatric emergency department either on-site or closely affiliated with the residency, then you should strongly consider an away rotation for letters of recommendation and exposure to the practice of pediatric emergency medicine during your elective time.

What can I do to stand out from the crowd?
Show that you are interested in pediatrics! Look for and participate in pediatric emergency medicine opportunities offered by pediatric organizations. Join a pediatrics based quality improvement committee at your institution, write a pediatrics article for EM Resident or another emergency medicine magazine, join the EMRA Pediatric Division, the ACEP Pediatric Section or the American Academy of Pediatrics Section on Emergency Medicine and get involved. With regard to research, PEM fellowship includes a research requirement. Thus, being involved in research will put you a step ahead of other applicants. Consider submitting a case report or interesting clinical image during residency in addition to your research. 

Should I join a hospital committee?
If your hospital provides pediatric care, then consider joining a committee or quality improvement project relating to pediatrics. Many emergency departments have a committee dedicated to pediatric care protocols, which would be an excellent learning opportunity and way to be involved. 

Publications other than research        
Any publication that you can include in your CV relating to pediatric care will bolster your application. You may consider working on a book chapter or writing an article for an emergency medicine magazine. You may also consider writing an article for EM Resident or the ACEP Pediatric Section Blog.

How many recommendations should I get? Who should write these recommendations?
You should provide 3 letters of recommendation, 1 from your program director and 1-2 from PEM attendings who have worked with you. If you need a third letter, consider a research or QI mentor who can speak to your non-clinical leadership qualities. 

What if I decide to work as an attending before applying? Can I still be competitive when I apply for fellowship?
Yes! Just as in any fellowship application, you will need to explain your decision to work as an attending prior to applying for fellowship, but this is not uncommon among PEM fellowship applicants. You will strengthen your application if you demonstrate an ongoing commitment to PEM (e.g., PEM research, participation on PEM-related committees) during your time as an attending. 

What if I’m a DO applicant?
If you have completed a residency in emergency medicine and are eligible to sit for the AOBEM/ABEM boards, then you may apply for PEM fellowship. 

What if I am an international applicant?
The same requirements are necessary for PEM fellowship as prior for an ACGME residency. If you are a U.S. citizen applying as an international medical school graduate, and you have completed a residency in pediatrics or emergency medicine making you eligible for ABP or ABEM, then you may apply for PEM fellowship. Many programs are able to support a visa, but international applicants are less common. Thus we recommend that you contact individual programs prior to applying. 

APPLICATION PROCESS

How many applications should I submit?
There is no firm guideline for the number of places to apply for fellowship. A general recommendation is to send applications to 10 programs; however, this should be tailored to your desired location, program qualities, and the strength of your application. 

How do I pick the right program for me?
When selecting a program, look at the number of EM trained fellows they have taken in the past, as EM applicants start fellowship with a different skill set than their pediatric peers. It is helpful to have a program that understands that the educational goals of an EM trained fellow are different from those of a pediatric trained fellow. Assess the clinical experience you will get in each program. Also, look at opportunities for fellows including research, electives, supervisory roles, graduate school, and international rotations. Finally, look at where the program’s fellows go after they complete fellowship: academic vs. community, local vs. national, and combined vs. pediatric specific sites, and consider whether this mirrors your anticipated career path. 

Common mistakes during the application process
ERAS opens for PEM in the late spring, so send in your application as early as possible. Approach your letter writers early so they have enough time to write your letters of recommendation and upload them for your application. When writing your personal statement, explain your interest in PEM and then use your application and CV to support this. Be honest in your application, remember to spell-check, and have a colleague review and proofread it.

Application deadlines
The application season opens in June, and programs are able to start viewing applications in July, until the end of August. Interviews are from September to November, and the match occurs in December. The application timeline can be found on the ERAS site

Tips for writing your personal statement
Your personal statement should discuss the reasons you are interested in PEM, and any specific examples you might have to support this. If there is anything unique about your application, or anything important about you that is not conveyed in other parts of your application, the personal statement is the chance to include it. The EMRA Pediatric EM Committee page contains an applicant toolkit and sample personal statements for EM residents applying into PEM fellowship. 

Is this a match process?
Yes. There is an NRMP match for PEM fellowships

What happens if I don’t obtain a fellowship position?
If you do not match, remember you are still a trained emergency medicine physician who can see both adults and children in practice. Consider if you would like to re-apply, which is not uncommon for pediatric trained applicants in PEM. Review your application with a mentor, your program director, and possibly your letter writers. Reach out to programs you applied to and ask them how you could strengthen your application. Look for deficiencies in your applications and work towards improving those areas in your application the next year. 

INTERVIEW PROCESS

How do I stand out from the crowd?
As with all interviews, your goal is to present yourself as competent, professional, respectful, and enthusiastic about the pediatric emergency medicine fellowship. Review the program and faculty on their website prior to your interview so you may ask insightful and appropriate questions. Know your reasons for applying to fellowship and your goals for what you would like to learn and achieve in fellowship.  Be prepared to highlight how your EM training will bring a fresh perspective to a program. 

What types of questions are typically asked?
Programs will typically ask about your reasons for applying to PEM fellowship, especially because few emergency medicine residents apply for PEM fellowship. You will likely be asked to describe your residency training experience, especially when interviewing with programs that are not as familiar with your specific residency.  You may be asked about your research and prior publications, thus consider anything on your CV a potential topic of conversation. Finally, remember that the PEM fellowship interviews are an opportunity for the program to get to know you as a person, so you may be asked about your interests, etc. 

How many interviews should I accept?
There is no standard number of interviews, but a general rule would be to go to any interview you are offered.

PREPARING FOR FELLOWSHIP

Textbooks to consider reading

  • Shaw K, Bachur R. Fleisher & Ludwig’s Textbook of Pediatric Emergency Medicine, 7th ed. St. Louis, MO: Wolters Kluwer; 2016.

Important skills to practice while in residency to prepare for fellowship

  • Resuscitation leadership
  • Ultrasound – you may be the expert in fellowship
  • Procedural skills including ultrasound guided IV placement, intraosseous placement, intubation, procedural sedation, laceration repair techniques, splinting and casting
  • Child life – practice communicating with pediatric patients at their developmental levels and providing coping mechanisms during exams and procedures
  • Emergency department flow

Tips on how to succeed as a fellow

  • Keep an open mind
  • Be aware that institutions have differing protocols based on local resources
  • Work hard on shift and seek feedback from faculty
  • Get involved in projects within your department
  • Understand that your training background will be different than many of your co-fellows and your learning needs will be different; learn from each other

CONCLUSION

Additional resources

Blogs/Podcasts:

National organizations

  • EMRA Pediatric EM Committee
  • ACEP Pediatric Emergency Medicine Section
  • PEM Database – email listserv
  • AAP Section on Emergency Medicine

Conferences

  • ACEP Scientific Assembly
  • ACEP Advanced Pediatric Emergency Medicine Assembly
  • Pediatric Academic Societies Meeting (PAS)
  • AAP National Conference
  • SAEM Annual Meeting

How to find a mentor
Look within your home institution for PEM faculty to guide you in your consideration of fellowship. Outside of your program, consider applying for a mentor through the EMRA Mentor Match program on the EMRA PEM Division website or through the EMRA Medical Student Council, which will match you with a PEM faculty member nationally.