Why and How to be a Neonatologist?

In the world of medicine, you don't have Hogwart's sorting hat which magically decides which student goes to which house. You are not Harry Potter or Hermione Granger and you will have to choose it manually in the real world. However, you still can create magic by matching your trait with that of your subspecialty.

Going forward from the previous post on Pediatric Hematology and Oncology, let us move on to choosing Neonatology as your specialty training.

Its a pleasure to have Anurag here to share his thought on this platform. He had pursued DNB in Neonatology after his graduation. So let's start with our usual question-answer round.

After your PG in Pediatrics, why did you decided to go for Neonatology in the first place?

To be very honest my story is not very typical. But it was clear that I definitely want to pursue further training in one of the pediatric sub-specialty. I got a good rank in the entrance. I am not sure why but at that time, I choose Neonatology. It was not a planned decision but fortunately turned out to be the right one.

I gradually started loving what I choose, sounds like a happy arranged marriage! and nothing is more satisfying for me than being around neonates now.

Even though my unplanned decision turned out to be correct, this may not be the case with everyone and therefore it is very important to choose smartly knowing all pros and cons regarding a particular specialty.

Fortunately, the guidance for such decision-making is slowly building up with blogs like this, and the PG,s from different places are now, in better touch with each other due to social media and connectivity.

What are the options after doing MD or DNB to pursue further training in neonatology?

There are three basic routes> for training in Neonatology in India. Fellowship courses, DNB super-specialty, and DM in Neonatology.

The Neonatology fellowships are offered by both IAP (Indian Academy of Pediatrics)and the National Neonatology Forum. These fellowships do not have any entrance exams as of now and usually follow institution-based interviews for selection. These courses have a formal exit exam to award a fellowship. There are some institute based fellowship programs as well but they are less well known and not uniform.

On the other hand, Degree courses are offered by various state medical colleges under MCI as DM and DNB by the National Board of examination. The usual routes are obtaining a decent rank in the NEET SS exam or institution-specific exam.

The fellowships are for a shorter period of time 1 or 2 years. While DM and DNB in neonatology have a 3 years curriculum.

What do you feel, which one should be preferred over the other?

Well, this is a difficult question to answer. What is rather important is choosing the right place and right course from the available options.

The deciding factors are usually personal preferences, circumstances (options available), and the time you can afford for further training. The names don't matter, be it a fellowship program, DNB, or DM, what matters is the structure and quality of training.

Longer training periods in DM/DNB provide good hands-on experience, better cumulative knowledge, and rationality in decision making over complex and tricky issues that often arise in neonatal care.

This also provides better job opportunities. But in the end, it's a personal decision and mainly depends on how much time you would like or can afford to invest.

Short term training programs are also important in high volume branches like Neonatology. The relatively good number of neonatal intensivists every year helps optimize NICU management at various levels and ensure better outcomes. In a big country like India, this is really important. Branch specific practices definitely help in strengthening healthcare.

What are the things one must look for, before choosing the training institute for Neonatology in India?

If I had to make a list, of things I should focus on for choosing a particular place for training, It would be like this.

The senior trainees can be quite helpful to provide the factual details about these things. Just remember, asking for all this information over the phone may not be always possible and might even require a face to face visit.

Is the training uniform across all courses?

No. Unfortunately not. The training program formats in Neonatology across these courses are not the same. They vary a lot between the institute and also at the program level. ( fellowships, DNB and DM).

Doing a fellowship or a course is not working as a reg in a particular specialty but formal and structured learning in that specialty. This needs to be very clear.

Formal training, teaching, and hands-on are very important, and until the process is more centralized, It is on us to make smart choices on where we want to pursue the courses. Doesn't matter which courses but the place should have psychology to train you rather than just getting a registrar to do work.

Can you name some good institutes for training in Neonatal medicine in India?

I can mention a few, but this is limited to my knowledge and there may be good places which I may miss.

In Northern India AIIMS, Sir Ganga Ram hospital, New Delhi, PGIMER in Chandigarh, LHMC, and MAMC in Delhi are few good places.

KEM, Surya Hospital, Sion Hospital in Mumbai, and Bharti Vidyapeeth, Surya Hospital in Pune are good training centers in the west part.

Fernandez Hospital, Hyderabad, CMC Vellore, KKCTH Chennai, St John Medical College, Bengaluru, and KIMS in Trivandrum are good institutions in sound India. I am not really sure about places in the Eastern part.

The institutes I mentioned are not in any sort of order.

What about training abroad? Are there any other areas for further subspecialty after neonatology?

There is always an option for further training. Learning is a never-ending task. One can obtain GMC registration and work across NICU in the UK for more exposure and know how things are done differently.

Canada and Australia too offer various fellowship and training programs.

One can specialize further in sub-specialties like Neonatal ECMO, Newborn specific transport, Perinatal, and fetal medicine. This can help initiate better neonatal infrastructure in our country. The trained people can expand the existing teaching programs in India further.

Did you face any difficulties at the start of your training? This might help beginners.

Yes of course I did. I had my training at one of the busiest level 3 NICU in India. Honestly, I was overwhelmed due to the amount of work. Residents were expected to be in NICU for very long hours. I had never worked before for such a stretch of time.

The second issue was communication with parents in NICU, It is very tricky. The most important thing which I learned in beginning was communication, liaising with multiple departments for management of baby. This was new as during PG it's more of unit-based management strategies but here you must liaise with others.

In addition to work hours, there were multiple transport calls of sick babies which I felt challenging in the beginning. It was new for me.

The majority of my day was spent in NICU work. On top of that. You must finish your research (thesis) work and academic activities. Initially, it feels a bit harsh routine but it settles down eventually as you become more and more work efficient.

Neonatology is intensive care-based branch so it's obvious that you need to be thorough during rounds. And this needs time and practice and eventually, you get there. There is no substitute for hard work and no place for procrastination and excuses. You have to be mentally resilient.

So, What’s is a typical day in the life of a Neonatology trainee/fellow?

Well. this may differ here and there but for us, this is what it was like.

The day starts with morning rounds with consultants. In our unit, the routine discussion during rounds included overall clinical condition, review of investigations, and Imaging. This was followed by questions on a related clinical condition, differential diagnoses, and the justifying that, emerging evidence on NICU practices, etc. And finally formulating daily plans for the patients.

This was followed by counseling the parents. Then comes executing daily tasks which included planned procedures, sampling, informing the obstetricians and liaising with other departments etc.

The Impromptu services included LSCS/NVD deliveries, Neonatal Transport (air, rail, road).

In the afternoon there use to be academic activities like seminars, journal clubs, case presentations, interdepartmental meetings. The day concludes with evening rounds with follow up of a plan for baby and handover to fellow night resident/consultant.

I felt night duties give a unique opportunity to have independence in the decision-making in NICU But this does not mean you break the chain of communication and have to seek help whenever necessary. Supervised training is very important and learning from a mistake is not a way of practice in ICUs, being an ICU guy you know this.

Rest other activities include data keeping for various planned projects, monitoring QI indicators, the teaching of nursing staff, PGs, etc.

What are the overall challenges for Neonatologist in India?

In India, the formal training for neonatology started more than 25 years ago but due to the paucity of the seats in past, there have been a handful of Neonatologist and thus their role never came into the limelight until a few years back.

As with the other branches, neonatology is also practiced by general pediatricians and no doubt they must be doing a fantastic job but I feel formal training provides a more focused approach toward newborn care especially the sick ones.

Since the number of seats has surged there has been better recognition of Neonatology, especially in bigger cities. The trend has been set now and it is spreading to even smaller cities.

Do you think Neonatology is a more secure branch than other subspecialties?

Yes, I do, I feel there are definite perks of being a neonatologist. You can practice almost anywhere. There are no restrictions. The awareness of Neonate specific physicians and demand for Neonatologist in India is rising and this provides more opportunities and more flexibility with places to practice.

Even if you are in a smaller setup with less infrastructure, with the backup of a stronger referral system you can actually practice neonatology very well. So having a particular level of setup is also not a limitation.

Even though you always need support from other sub-specialties, In my view Neonatology is a relatively independent practice.

Does Neonatologist make good money?

Yes, a neonatologist makes a decent sum. Though don’t expect to earn hefty from day one.

Being labeled as a neonatologist doesn’t mean you are not a pediatrician that’s where your roots are. So if someone wants to diversify his interest into Pediatrics rather than just practicing Neonatology alone, he or she can also ensure a better additional income.

What carrier options the training in neonatology opens for you, especially in India?

There are multiple options to choose from after you are done with specialty training.

Start your own NICU

Pros: You’re your own boss. A good outcome will speak for itself in a community. You can liaise with fellow Neonatologists to make a bigger setup and divide the workload.

Cons: dependent on flow from fellow ObGy consultants, cost constraints while managing patients, and billing issues. It involves lots of effort and stress to run a successful NICU.

Work with Corporate Hospital

Pros: fixed work hours, better setups, better outcomes, good for learning and developing communication skills, logistics of a hospital, and progressive clinical knowledge.

Cons: You have to climb a ladder that mostly depends on departmental dynamics and hospital policy which may or may not suit you. You are dependent on the institute.

Help establish a Unit

The other thing you can do is a midway between these two. Start a Unit from scratch in a corporate hospital or small setups in tier 2 cities. There is a lot of room there. The pros and cons are a mixed bag of the above two.

Enter in Government sector

Be a part of Govt Medical College and develop upcoming units or be part of established units. Help the community! Fixed hours, shared responsibilities, and the joy of teaching altogether.

learn more - Know how things are done differently around the world

Further training and fine-tuning of skills outside India in countries like the UK, Canada, Australia is another option. Pays are good so you won't regret missing that part as well.

There is a good demand for Neonatologists in middle eastern countries with handsome salaries, where You can spend few years or may want to settle down.

I feel there are many options after Neonatology training in India with good and constant demand.

1.  BMJ - Career in Neonatology
2. Pediatric Residency Graduates Preparedness for Neonatal-Perinatal Medicine Fellowship: The Perspective of First-Year Fellows. Am J Perinatol. 2020 Apr;37(5):511-518. doi: 10.1055/s-0039-1683887
3. What Are Some Disadvantages of Being a Neonatologist? 

Author

Anurag Fursule | DNB (Pediatrics), DNB (Neonatology)

Anurag has done DNB in Neonatology from Sir Ganga Ram Hospital (SGRH), New Delhi and is urrently working as associate consultant in Surya Mother and Child Care Hospital, Pune.