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Internal Medicine-Pediatrics 101

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BACKGROUND AND HISTORY
Combined Internal Medicine and Pediatrics (Med-Peds) celebrated its 40th anniversary as a formal training option in 2007. 

The concept of combined Med-Peds training had its origins from 1949 to 1961 in the form of a two-year rotating internship.  These two year internships gradually lost faculty and resident support and were replaced by one year post graduate options combining Medicine-Pediatrics, Medicine-Surgery, and Medicine-OB/GYN. Only the Med-Peds option survived and in 1967 the American Board of Internal Medicine and the American Board of Pediatrics endorsed the concept of combined training leading to dual board eligibility.

Med-Peds training programs began to sprout in the 1960s and grew significantly beginning in the mid-1980s.  Currently there are approximately 1400 Med-Peds residents were in training and approximately 6300 Med-Peds physicians in practice who have completed Med-Peds residency training.  Med-Peds has proven to be a primary care specialty with the majority of recent graduates pursuing primary care paths(1),  approximately three-quarters who are graduates of US Medical Schools(2).  Over the last few years, there has been increased interest in subspecialization, reflecting the changing interests of students and residents nationally.

GENERAL PEDIATRICS
Pediatricians focus on the physical, emotional, and social health of infants, children, adolescents, and young adults from birth to age 21. A developmental orientation is integral to their practice.

General pediatrics is a multifaceted primary care specialty. The general pediatrician's responsibilities include:

  • Management of serious and life-threatening illnesses

  • Referral of more complex conditions as needed

  • Consultative partnerships with other care providers, such as family practitioners, nurse practitioners, and surgeons

  • Health supervision (health promotion and disease prevention activities to enable each child to reach full potential)

  • Anticipatory guidance (advice and education for patients and parents regarding appropriate preparation for predictable developmental challenges)

  • Monitoring physical and psycho social growth and development

  • Age-appropriate screening

  • Diagnosis and treatment of acute and chronic disorders

  • Community-based activities in sports medicine, school health, and public health.

 

Pediatricians diagnose and treat infections, injuries, and many types of organic disease and dysfunction. They work to reduce infant and child mortality, foster healthy lifestyles, and ease the day-to-day difficulties of those with chronic conditions. With structured evaluation and early intervention, pediatricians identify and address developmental and behavioral problems that result from exposure to psychosocial stressors. They appreciate the vulnerability of childhood and adolescence, and actively advocate for measures to protect their health and safety.

The ability to communicate effectively in a culturally competent way with patients, families, teachers and social service professionals is a key to effective family-centered pediatric care. Pediatricians collaborate with pediatric subspecialists and other medical and surgical specialists in the treatment of complex diseases and disorders. They work closely with other health professionals concerned with the emotional needs of children. They advise educators and child care professionals. They are major advocates for access to care and a medical home for all children.

Pediatrics is a highly flexible specialty offering an extraordinary number of career options. Pediatricians are free to choose one or more practice settings and styles; they may pursue a wide variety of interests. Pediatrics is also the specialty with the highest proportion of members (26%) who have elected part-time practice at some point in their careers.(3)  Pediatricians consistently score amongst the highest of all medical fields in career satisfaction.(4, 5)

GENERAL INTERNAL MEDICINE
General Internal Medicine covers the breadth and depth of the primary and consultative general care of adult patients, both in the inpatient and outpatient settings.(6)  Internists provide comprehensive, continuous, and coordinated care managing both common and complex illness of adolescents, adults, and the elderly. Comprehensive health care includes health promotion and maintenance, prevention of illness and disability, and application of a holistic healthcare model which addresses both protective factors and risk factors affecting the health and wellbeing of patients.  The general internist is a diagnostician, a therapist, a counselor, and a coordinator of care. Continuity of care means a long-term commitment to the patient in health and illness. Chronic disease management skills are utilized to provide a team-based, patient-centered approach to the planned care of chronic conditions with the goals of maximizing quality of life and health care.  Coordination means that the general internist is trained to integrate the services of other physicians and health providers to meet the needs of the patient. The primary care internist knows when to refer patients, how to interact with consultants and other health care professionals, and when to manage the patient without the assistance of others. General internal medicine combines the intellectual rigor of traditional internal medicine with the personal rewards of enduring relationships with patients.(7)

Internists are trained in the diagnosis and treatment of cancer, infections, and diseases affecting the internal organs.  They are also trained in the essentials of primary care internal medicine which incorporates an understanding of disease prevention, wellness, substance abuse, mental health, and effective approach to both health beliefs and comprehensive care needs of patients.  Primary care internal medicine integrates such disciplines as geriatrics, emergency care, adolescent medicine, clinical pharmacology, and clinical epidemiology, and focuses on ethical considerations increasingly at issue in today's health care environment.

INTERNAL MEDICINE-PEDIATRICS
Internal Medicine-Pediatrics trained physicians embody the skills, wisdom, and dedication of pediatricians and internists in a single physician. Med-Peds training and practice synthesizes two complex disciplines into a whole greater than the sum of its parts. Capitalizing on the focus, depth, and evidence base incumbent to training in and practicing the two disciplines, Med-Peds physicians bring a unique insight and scope to the care of patients throughout their patients’ life span. Caring for multiple generations of the same family lends them intrinsic comprehension of family dynamics, epidemiology and the impact of acute or chronic illness at all ages, all in the context of family systems. Coupled with this special continuity are the tremendous rewards of durable relationships as the health mentor for families over several decades.

Med-Peds physicians draw from the rich repertoire of knowledge and skills of pediatricians and internists to bring great flexibility in their approach to clinical medicine. The same adaptability provides a special versatility to follow many paths throughout their career, including patient care as generalist, hospitalist, emergency room physician or subspecialist; research; administration; public health; and education. Increasingly they occupy special niches within the medical community, such as the care of adults with transitional illnesses like cystic fibrosis, diabetes, congenital heart disease, etc. Capable of emphasizing whichever component of their skill set an individual patient or community requires, they enjoy popularity amongst patients, colleagues, and recruiters in a vast array of practice styles and locales.

EDUCATION AND TRAINING
Following graduation from medical school, Med-Peds physicians complete 4 years of integrated education in an accredited combined internal medicine-pediatrics residency program.  In 2008, there are approximately 80 Med-Peds programs offering more than 350 first-year resident positions.  These positions make up almost 9 percent of internal medicine and about 14 percent of all pediatric residency positions.  Program sites include university, children's, and community hospitals.

Med-Peds residency training is distinguished by the breadth and depth of emphasis on care of the whole patient, be they infant, child, adolescent, adult or geriatric, in the context of their family. The curriculum affords physicians the opportunity to acquire the knowledge, skills, and attitudes required for comprehensive, longitudinal, and patient-centered health care. Med-Peds residents learn by lecture, reading, interacting with senior internists or pediatricians, and especially by caring for children and adults who are acutely or chronically ill, as well as by providing preventive care and health promotion for those in excellent health. They acquire hands-on experience with newborns, children, adolescents, adults, and the aging in both outpatient and inpatient settings. In all of this, the assessment of growth and development across the lifespan is a critically important aspect of a Med-Peds physician's education.

The 4-year residency contains 24 months of training in each specialty, with residents rotating between departments every three to six months. The curriculum includes rotations in general internal medicine and pediatrics (outpatient and inpatient); normal newborn care; neonatal, pediatric and adult intensive care; emergency care; behavioral pediatrics; adolescent medicine; geriatrics; and time in selected subspecialty areas. Subspecialty rotations are selected from options in allergy/immunology, cardiology, endocrinology/metabolism, gastroenterology, hematology/oncology, immunology, infectious disease, nephrology, neurology, pulmonology, rheumatology, and sports medicine. Experiences may focus on a single age range, or may be combined experiences, providing exposure to adults and children.  Med-Peds programs provide experience and guidance in topics such as child advocacy, risk management, cost effective care, quality improvement, evidence based practice, substance use disorders, medical informatics, medical genetics, health care financing, ethics, end of life care, and practice management.  In addition, subspecialty work in psychiatry, dermatology, ophthalmology, and gynecology are included in our programs.

The curriculum includes extensive ambulatory components, including a longitudinal ambulatory experience providing comprehensive care of children and adults. During the 48 months of training in internal medicine and pediatrics, residents have experience and instruction in health maintenance, in the prevention, detection, and treatment of illness, in the rehabilitation of patients, as well as in the socioeconomics of illness, the ethical care of patients, and the team approach to the provision of medical care.

Med-Peds programs are accredited by the Accreditation Council of Graduate Medical Education (ACGME), similar to categorical internal medicine and categorical pediatrics programs.  Accreditation allows for minimum standards across all Med-Peds residency programs, facilitates licensure in all 50 states, and provides a separate voice for Med-Peds residents about their training.(8)

HOW IS IT POSSIBLE TO LEARN TWO DISCIPLINES?
At first glance, the concept of training in two broad and deep disciplines such as pediatrics and internal medicine can seem daunting. Though rigorous, many similarities between the two areas make dual training feasible. Fundamental clinical skills are similar in the two disciplines. Though it requires special skills honed with practice to adeptly acquire a good history and perform a physical exam, there are similarities across age groups, communication skills are core, and the organization of information recording is fairly uniform. Advanced clinical skills -- those reflecting information processing, reasoning, hypothesis testing, deduction, applied statistics, and epidemiology -- are fundamentally the same in the two specialties. Pathophysiology is more similar than dissimilar across the disciplines, with the biggest difference being the manifestations of the same condition at different ages, the incidence/prevalence of conditions at different ages, and nuances in treatments at different ages.

Learning weight-based pediatric pharmacology and fluid therapy can make adult pharmacology and fluid therapy simpler, though the range of commonly used drugs is broader as patients age. There are clear areas of physiologic overlap in adolescence. The fundamentals of performing and interpreting a developmental evaluation are similar in pediatrics and geriatrics.

There are subspecialty areas, such as infectious disease, with a substantial range of diseases that are more similar than dissimilar in the two disciplines. The principles of preventive health care are similar, particularly from a systems/process perspective, though the focus and specifics are different. There is no better way to appreciate the impact of illness on a family than to take care of the whole family.

There are areas that are fairly unique and overlap less. Paramount among them in pediatrics is neonatology and the first two years of life in general. Mastery in those areas comes from the intensity of the exposure to patients of that age on any pediatric service. On the adult side, areas of less overlap include coronary artery disease, cerebrovascular disease, lipid disorders, Type II diabetes (until recently), and other inpatient-intense diseases. Oncology is quite different in the two disciples, but the primary care physician's role remains similar across the age spectrum.

Achieving the greatest competence in any discipline begins with learning from those who have mastered it. Pediatricians and internists are those masters. They have defined the care of children and adults through decades of research synthesized into a meaningful whole. They have developed cogent guides for application of this wealth of information and practical tools for its implementation. They model relentless advocacy promoting its utilization to optimize the care of patients across the age spectrum.

Growth in competence stems from partnership with masters throughout one's career, a characteristic of internists, pediatricians, and Med-Peds physicians that facilitates the exploration of new frontiers and the osmosis of new developments. Mastery by the learner evolves from continued nurturing through access to the highest quality continuing medical education. The general and subspecialty societies of pediatricians and internists are without peer in the world of medicine. They support a rich network that promotes partnership, collaboration, and growth throughout their careers amongst physicians of like mind.

SUBSPECIALTIES
Currently, approximately 20-25% of Med-Peds graduates pursue subspecialty training in either pediatrics, internal medicine or both.(1,10, 11)  Single and dual discipline fellowships generally range from 3 to 4 years in length.  Choices include traditional board-certified specialties including adolescent medicine, allergy and immunology, cardiology, critical care, endocrinology, gastroenterology, genetics, geriatrics, hematology-oncology (may be separated), infectious disease, nephrology, neonatology, neurodevelopmental and behavior pediatrics, pulmonary medicine, rheumatology, sleep medicine, sports medicine, and toxicology.(1, 11, 14, 15)  A significant portion of those Med-Peds physicians who pursue additional training after residency also complete non-board-certified fellowships in such areas as general internal medicine and pediatrics, hepatology, HIV medicine, international health, medical informatics, palliative care, outcomes research, and quality improvement.

PRACTICE OPTIONS
In 2007, 55% of Med-Peds graduates were pursing primary care practice, 18% subspecialty training, 17% hospital medicine, and 10% other careers.(1)  The primary activity of Med-Peds physicians is direct patient care.  Practice location, practice type, work hours, night call, after-hours coverage, continuing education, and personal time vary dramatically from one practice situation to the next. The average Med-Peds physician spends 75% of his/her time in direct patient care, and the remainder in other professional activities.(14)  Those activities include teaching, administration, research, and public health.

Med-Peds physicians are found in rural to urban/suburban areas.(1)  Some Med-Peds physicians elect solo, group, or partnership practices; others are hospital-based.  Some work in emergency departments or urgent care centers.  Partners include other Med-Peds physicians, internists, pediatricians, and family practice physicians. Some are employed/salaried directly by an HMO or hospital; others are in fee-for-service practices. They serve as academic faculty or work in community health centers, military, government, or public health service. Opportunities are almost unlimited in direct patient care, advocacy, clinical research, hospital staff positions, teaching, and/or administration.

PRACTICE PATTERNS
Starting in 2000, the National Ambulatory Medical Care Survey (NAMCs) began separately identifying Med-Peds physicians within their survey.  This survey provided the first nationally representative snapshot of Med-Peds practice patterns which could easily be compared to other primary care provider care patters.  This data showed that 43% of visits of Med-Peds physicians surveyed were by children 18 years or younger.  Compared to family physicians, Med-Peds physicians had a higher proportion of infants and toddlers £ 2 years of age (20.5% vs. 3.8%; P < 0.001) and from children £ 18 years of age (42.8% vs. 15.6%; P < 0.001), but treated fewer adults age 65 or older (11.3% vs. 21.3%; P < 0.001).   Pediatric visits to Med-Peds physicians included a similar percentage of infants and toddlers as visits to pediatricians (47.8% vs. 42.4%; P=0.08). When compared with internists, Med-Peds physicians saw a greater percentage of visits from adults 19-64 years of age (80.2% vs. 60.1%; P<0.01) and proportionately fewer patients age 65 or older (19.8% vs. 39.9%; P<0.01).  Patient continuity with Med-Peds physicians was comparable to pediatric providers and greater than continuity with internists or family physicians.(13)  

INCOME
Mean income for Med-Peds physicians have only started to be collected recently by the Medical Group Management Association (MGMA).  Currently this data is based on small Med-Peds sample size (106 physicians in 44 practices).  In 2006, the median Med-Peds salary was reported as $168,985 and the mean Med-Peds salary was reported as $180,008.  This compares to median (mean) salary of $177,059 ($191,525) for general internists, $174,353 ($188,496) for general pediatricians, and $164,021 ($178,859) for family physicians without OB.(14)  Median net income for all physicians tends to vary with geographic location within the United States. 

The average starting salaries reported by Med-Peds graduating residents going into practice was $118,892 in 2003 and 2004(1).

PERSONAL AND PROFESSIONAL SATISFACTION IN INTERNAL MEDICINE-PEDIATRICS
Med-Peds is a specialty of remarkable scope, flexibility, and diversity. Dual-trained physicians enjoy the ability to work with children as they grow and develop from infants to young adults, the multi-dimensionality of their patients in mid-life, and the wisdom of the aging. The intellectual stimulation of working with the very young to the very old is both challenging and fun. The in-depth training in two disciplines lends Med-Peds physicians broad skills in managing patients with simple to complex needs, while serving as their advocate and mentor for even more subspecialized care. Comprehensive longitudinal care offers the opportunity to participate in the life of a family for an extended period of time, and to serve as a role model and advisor. Pediatrics encourages optimism.  Although pediatricians care for a variety of significant illnesses and medical problems, the majority of their patients are generally healthy or, with their help, soon become so. Internal medicine brings a group of patients that on average are sicker and have more chronic illness, promoting cognitive skills practiced through diligence and thoroughness. The combination of disciplines, of optimism and cognitive exercise, brings great joy and sustenance to the Med-Peds physician.  A recent survey of Med-Peds graduates showed that 89% would choose Med-Peds again and that they felt equally prepared to care for adults and children.(11)

Med-Peds physicians enjoy unlimited professional horizons. They have the freedom to pursue whatever interests present throughout their career. These may be nurtured in the context of a single practice, or involve a sequence of career paths. That latitude promotes enthusiasm and professional growth. 

WORKFORCE ISSUES
It is difficult to speculate with a high degree of certainty about the future workforce needs in the United States. Disparity between areas of physician shortage and surplus are likely to remain, or even grow. The broad and comprehensive training of Med-Peds physicians and their ability to emphasize whichever component of their skill set is most needed in a community suggest they will be the last to be economically challenged in competitive environments.  The same skill set makes them desirable participants in addressing the broad health care needs of underserved patients, and those seeking a highly qualified generalist in any locale.  “Med-Peds graduates are well positioned to adapt to a changing medical landscaping.”(15)  

WEBSITES FOR MORE INFORMATION

Accreditation Council for Graduate Medical Educations (ACGME) Requirements for Combined Programs in Medicine-Pediatrics

American Medical Association Fellowship and Residency Electronic Interactive Database (FREIDA)

Med-Peds Program Director’s Association

Med-Peds Section

Med-Peds Programs

National Med-Peds Residents’ Association.

REFERENCES

  • Chamberlain J, Cull W, Melgar T, Kaelber D, Kan B.  The effect of dual training in internal medicine and pediatrics on the career path and job search experience of pediatric graduates.  J Pediatrics.  2007, 151:419-24.  Epub 2007 Aug 23.
  • National Resident Matching Program (NRMP) 2008 at http://www.nrmp.org accessed August 23, 2008.
  • AAP Department of Health Policy Research. Pediatrics leads specialties in number of part-time physicians. AAPNews. 2002;21(3)126.
  • Leigh JP, et al. Physician Career Satisfaction Across Specialties. Arch Intern Med. 2002;162:1577-84.
  • Lanon BE, Reschovsky J, and Blumenthal D. Changes in career satisfaction among primary care and specialist physicians, 1997-2001. JAMA. 2003;289:442-9.
  • American College of Physicians - American Society of Internal Medicine. Career paths. 2002.
  • Society of General Internal Medicine. Primary Care (General) Internal Medicine: The Career and the Residency Training Programs. 2002
  • Accreditation Council of Graduate Medical Education.  Requirement for Combined Programs in Medicine-Pediatrics at http://www.acgme.org/acWebsite/RRC_sharedDocs/sh_medPedReq.pdf  accessed August 23, 2008.
  • Frohna J, Melgar T, Mueller C, and Borden S.  Internal Medicine-Pediatrics Residency Training: Current Trends and Outcomes.  Academic Medicine.  2004; 79:591-596.
  • Meglar T, Chamberlain JK, Cull WL, Kaelber DC, and Kan BD.  Training Experiences of Combined Internal Medicine-Pediatric Residents.  Academic Medicine.  2006:81:440-446.
  • American Board of Internal Medicine at http://www.abim.org accessed August 23, 2008.
  • American Board of Pediatrics at http://www.abp.org/ABPwebsite/certinfo/subspec/subintro.htm accessed August 23, 2008.
  • Fortuna RJ, Ting DY, Kaelber DC, Simon SR.  Characteristics of Medicine-Pediatrics Practices: Results from the National Ambulatory Medical Care Survey.  Academic Medicine (accepted). 
  • Medical Group Management Association.  Physician Compensation and Production Survey – 2007 Report (Based on 2006 data). 2007.
  • Frohna J.  The Role of the Med-Peds Physician in a Changing Medical World.  J Pediatrics.  2007; 151:338-339.

Original authors: John Chamberlain and John Frohna

Revision editors (2008): David Kaelber and Jacqueline Meeks

The document is maintained by the Internal Medicine and Pediatrics Section of the American Academy of Pediatrics in consultation with the Med-Peds Program Directors Association and the National Med-Peds Residents’ Association.