Specialist and Primary Care

[hlancaster]

Hi everyone, apologies for a potentially silly question. I am a peds resident considering future job options. There are a few specialties I really enjoy but I also like my primary care clinic. Do people ever specialize in something like cardiology or pulmonology but then also maintain a small panel of primary care patients? Anyone know any examples of this? I was thinking maybe in more rural settings it might be possible?

I imagine it's not very common and that there are downsides to it. Aside from making less revenue and having to deal with primary care topics, what are other downsides of this type of practice?

Thanks all for your thoughts.

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[SurfingDoctor]

Hi everyone, apologies for a potentially silly question. I am a peds resident considering future job options. There are a few specialties I really enjoy but I also like my primary care clinic. Do people ever specialize in something like cardiology or pulmonology but then also maintain a small panel of primary care patients? Anyone know any examples of this? I was thinking maybe in more rural settings it might be possible?

I imagine it's not very common and that there are downsides to it. Aside from making less revenue and having to deal with primary care topics, what are other downsides of this type of practice?

Thanks all for your thoughts.

I have seen some a while back, but it uncommon. Those practitioners were in private practice. But the general problem with that model is that if you sub-specialize, you typically need to be to a larger academic center. I mean, if you have a person with long QT who needs a pacemaker, you have to refer them somewhere where they can receive the operation and be followed afterwards. But if you are in private practice, then the referral pattern is by word of mouth because no academic center that diagnoses anything related to a heart condition is going to call some private, independent specialist. Thus you kinda need to belong to an organization. But there’s the rub, because now you are working for someone else. If you want to do Cardiology clinic and primary care, now you have to appease two different division heads both of which could careless about your commitment to the other division.

All this being said, I suppose it’s possible, but specialists tend to be near centers which makes the possibility of running your own private sub-specialistic clinic all the more challenging.

 

[mvenus929]

Its gonna be easier with non-procedure specialties, like ID, Endo. Which, coincidentally, make less on average than general pediatricians. You could maybe do it with NICU in private practice, but it’s harder.

I know of some ID docs that still do gen Peds, because unless you find a niche in ID and make yourself indispensable, it’s hard to justify 1 FTE in Peds ID.

 

[BigRedBeta]

There are a few large metros that have children's hospitals with less enmeshed academic affiliations (Dallas, Denver, and Atlanta for example - though each of those situations are unique in their own way), you might be able to get a set up like this. Of the 4 such individuals I've seen doing this, 2 have been PEM (makes sense given the shift work nature and types of complaints seen) and 2 have been ID.

Additionally, every city I've been in during training and as an attending has had independent GI practices not part of the academic machinery and so I think that would also be a potential avenue towards this idea. Not sure what it is, but GI seems to draw those with a greater independent streak I guess.

I'd think you could also do it in Peds Neuro, but most neurologists are already so busy that it may not work very well.

Lastly, I think there's a possibility in some smaller communities to make it happen. What many trainees don't necessarily recognize is that moderate volume NICU's with even just mid-level acuity can attract a constellation of pediatric subspecialists (GI, Neuro, Cardiologists, Endocrinology) simply to serve the needs of the NICU. It may only be one or two physicians per practice/specialty, but it can sustain some people especially if the cost of living is low. I've done locums in a couple different places where I've been surprised by the variety of specialists available to me, far away from the ivory towers. So in such a location you may be able to augment your subspecialty patient panel with some general pediatrics.



Now, all that said...If you are looking at entering a fellowship, you should recognize that probably 90%+ of the available jobs out there will not allow you to do anything remotely like what I've described. If you can't see yourself following the more typical path into academic medicine sans primary care, then you probably should stick with primary care.

The choice is somewhat similar to what I tell medical students considering Med/Peds...will your professional soul have a hole in it if you don't get to do both? Or is one just a "nice to have"? In this case, which one do you really need to fulfill yourself professionally?

 

[oldbearprofessor]

Hi everyone, apologies for a potentially silly question. I am a peds resident considering future job options. There are a few specialties I really enjoy but I also like my primary care clinic. Do people ever specialize in something like cardiology or pulmonology but then also maintain a small panel of primary care patients? Anyone know any examples of this? I was thinking maybe in more rural settings it might be possible?

I imagine it's not very common and that there are downsides to it. Aside from making less revenue and having to deal with primary care topics, what are other downsides of this type of practice?

Thanks all for your thoughts.

Interestingly, this model is extremely common in Latin America where neonatologists and others often work in the (public hospital) NICU by morning and go off to private pediatric practices (where they make more money) in the late afternoon.

One model for this is the (rapidly vanishing) neonatologist who also runs a developmental follow-up clinic which has some cross-over with gen peds. There are also a variety of specialists who spend some time in complex care clinics handling complex patients in a gen pedi way.

Generally however, the answer is no, once you do a fellowship in the current era, you are very likely to either 1) practice only that specialty for your whole career or 2) never or only briefly practice it and go back to primary care (this isn't all that uncommon for a variety of personal reasons)