Saturday, November 5, 2011

"Have you thought about med-peds?"

It is not uncommon for medical students who express interest in primary care to be asked: "have you thought about med-peds?" Not only are these programs popular for medical students but, over the past decade or two, there has also been a plethora of new and expanding med-peds programs. So, you may ask, what exactly is a med-peds program? An internal medicine-pediatrics combined residency program is a 4-year long program with 2 years spent doing pediatrics and 2 years spent doing internal medicine with the end result that residency graduates are board eligible for both pediatrics and internal medicine.

These programs have become increasingly popular with US medical students. In 2011, there were 77 med-peds programs in the US with 365 slots of which 84.7% were filled by US medical graduates. In contrast, there were 453 family medicine programs in the US with 2708 slots of which 48.0% were filled by US medical graduates (1).

Sounds great, right? Isn't this the new solution for primary care?

Well, there are several problems with this point of view:
  1. Only approximately 50% of med-peds graduates end up practicing primary care (2). The other residency graduates end up entering internal med or pediatric fellowships to sub-specialize.
  2. FM residents spend significantly more time in outpatient primary care work than med-peds residents during residency training. As a result, FM residents become more confident in outpatient work and are more likely to practice primary care when they leave residency.
  3. Family medicine residency training encompasses (in most cases) a holistic perspective of families, looking at children, pregnant women and adults together. There may be specific adult and pediatric medicine rotations but these are more or less integrated into a holistic training vision. Meanwhile, med-peds residents spend 50% of their time with the peds dept and 50% of their time with the internal medicine dept. If not done appropriately, this training has the potential to become fragmented.
  4. Med-peds doctors are not trained in maternity care or surgical care. Okay - I realize most family docs don't end up doing maternity or surgical care anyways but the training helps keep the broader, comprehensive perspective in mind, makes family docs more competent in basic procedures, and makes family docs a better fit in rural areas where they may be the only doctor.
Med-peds as residency training programs and as a specialty have existed for decades now and do serve important roles in patient care. For example, those with chronic diseases diagnosed with childhood, such as cystic fibrosis or congenital heart disease, can often be best served by a med-peds subspecialist who can bridge the continuity gap often found between the pediatric specialist and the adult specialist. Furthermore, students unsure if they want to practice primary care or subspecialize often choose med-peds. Med-peds programs are also appropriate for students who are interested in primary care but want to spend a significant portion of their time providing care to children (the argument being that med-peds residents spend 50% doing pediatrics while FM residents spend significantly less time... although this can be changed by pediatric tracks or electives depending on the program).

I argue not that med-peds doctors cannot do primary care. I only ask that before diving straight into med-peds, students consider the pros and cons of the two specialties and honestly evaluate what type of training they are seeking from residency and what they want to practice in the future. If your school doesn't have a family medicine rotation or has a weak family medicine presence, seek out an elective at another school to see how family medicine is practiced elsewhere in the country.

With its holistic and comprehensive vision of caring for patients, family medicine is naturally the specialty for primary care. Is med-peds also? With only 50% of med-peds grads vs. virtually all FM grads choosing to practice primary care, it doesn't quite seem so.

The real question then is: "have you thought about family medicine?"

(1) National Resident Matching Program. "Results and Data. 2011 Main Residency Match."
(2) Freed GL, Fant KE, Nahra TA, Wheeler JR. Internal medicine-pediatrics physicians: their care of children versus care of adults. Academic Medicine. 2005;80:858-64.


  1. Thanks Sebastian!

    I did think about Med-Peds, but I'm also interested in returning home to the west coast. There are 4 programs in the states I'm looking at, all of which are in southern California. I'm also looking to do rural medicine, and have not found a rural, community-based Med-Peds program in an area I want to practice.

  2. Good post. I thought about Med-Peds when I was a med student. Now that I'm finished, I'm glad I didn't do it. Med-Peds is in depth training into internal medicine and pediatrics, which is generally hospital based and focuses on the old and children. I think it's great for hospitalists. I think the Med-Peds have better pediatrics training because most Med-Peds are hosted in specialty teritiary academic centers while most FM programs are community based, but most very sick kids go to tertiary care centers anyways and aren't managed in most general community hospitals anyways. If you're interested in having privileges at a children's hospital, you should be pediatrics trained, but nowadays most primary care pediatricians use hospitalists and neonatologists.

    I was advised that when evaluating Med-Peds programs, you need to ask whether the programs are integrated or if the programs are basically 2 stand-alone. Like the poster said, it can be a mess.

    Because Med-Peds don't have the outpatient focus as FM, Med-Peds residents need to make a special effort to get orthopedic, ENT, urology, ophtho, and gynecologic experience that are essentially built into a standard FM program. You're going to see a lot of these cases in ambulatory care, so while FM doesn't make you an expert in these areas, it gives you a foundation and a starting point to learn and expand your skills.

    Lastly, students need to understand that to be truly Med-Peds, you need to take 2 board certifications and maintain enough CME hours to satisfy 2 boards, from graduation until you retire. This requirement may become a burden after a while, which is why (I think) some Med-Peds only become board certified in either Med or Peds.

  3. Only 20% of those entering Med-Peds before 1990 can still be found as Med-Peds in the AMA Masterfile 2005 and recent departures are likely to mean even fewer remaining.

    Interestingly, the characteristics of the remaining med-peds stalwarts were most similar to family medicine in terms of birth origins, medical schools of graduation, and practice locations.

    The Med-Peds resident site is always interesting. Usually there is something such as a promotion of med-peds as primary care (to keep funding support), but there are also promotions of med-peds as vehicles for various fellowships and subspecializations.

    Med-peds also is costly training for the yield of primary care over a career. One year longer training is a 3% reduction of workforce. The additional $120,000 for GME plus a year cost of living during training is a 10% increase in the cost of training. With less than 50% primary care retention this insures high cost per yield of primary care and not the most efficient $30,000 to $40,000 per year of primary care for family medicine. FM grads are half the cost of PD and PA, three times less cost than NP and MPD, and 5 times less cost per unit of primary care delivery for a career compared to IM.