Adolescent Medicine

[deleted407021]

This peds/IM/FM sub specialty seems very under-discussed on SDN. Since the peds and IM forums seem dead and FM is running slow, I reckoned I'd plonk this here, so med students and any lurking residents/attendings might share some experiences or perspectives on the field.

I'm interested because I have enjoyed tutoring middle/high school kids and I like working with the population, at least in that capacity. From what little I can find, there appear to be many issues unique to the patient pop., i.e. puberty and sex/gender identity issues and sociopsychological considerations. Also, an educational conponent, opportunities for advocacy and a broad set of patients, from "kids" around 12 to emerging adults in the early 20s.

I'd appreciate anyone who could shed more light on this specialty and add to the little bit there is on the forums.

Thanks!

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[mvenus929]

The peds forum isn't dead. It's just quiet.

Adolescent medicine is the primary care for adolescents. It is run differently at different places, and can be done by general pediatricians. However, most pediatricians don't get the same amount of training for adolescents as they do for younger children, primarily because there are fewer scheduled well checks. Sports medicine is an important component to the curriculum, as is sex education. There is a lot of psychosocial issues that you would have to deal with, and a lot of legal issues that will vary depending on the state you practice in.

From peds, adolescent is a 3 year fellowship, which is why many of the people who actually do it are general pediatricians with an interest in adolescents, rather than being formally trained.

 

[deleted407021]

The peds forum isn't dead. It's just quiet.

Adolescent medicine is the primary care for adolescents. It is run differently at different places, and can be done by general pediatricians. However, most pediatricians don't get the same amount of training for adolescents as they do for younger children, primarily because there are fewer scheduled well checks. Sports medicine is an important component to the curriculum, as is sex education. There is a lot of psychosocial issues that you would have to deal with, and a lot of legal issues that will vary depending on the state you practice in.

From peds, adolescent is a 3 year fellowship, which is why many of the people who actually do it are general pediatricians with an interest in adolescents, rather than being formally trained.

Thanks for the input! Is this an unpopular focus for physicians? I've read elsewhere that they'd have a lot of patients, since most peds doc wouldn't want to work with pts 12+.

 

[togaedere]

If you are interested in adolescents you should definitely consider doing a med/peds residency. 4 years to do it as opposed to 3 but you may like the extra training/focus in transitions as well as opportunity to do more in adolescent clinic. I'm a fourth year med student who applied to med/peds so don't have a clear handle on the resident side of things yet but there are a ton of adolescent-focused med peds physicians and a lot of applicants who are interested in this as well.

Thanks for the input! Is this an unpopular focus for physicians? I've read elsewhere that they'd have a lot of patients, since most peds doc wouldn't want to work with pts 12+.

 

[deleted407021]

If you are interested in adolescents you should definitely consider doing a med/peds residency. 4 years to do it as opposed to 3 but you may like the extra training/focus in transitions as well as opportunity to do more in adolescent clinic. I'm a fourth year med student who applied to med/peds so don't have a clear handle on the resident side of things yet but there are a ton of adolescent-focused med peds physicians and a lot of applicants who are interested in this as well.

That's neat! Aside from being able to bridge the divide between child and adult, what's the concept behind the peds/IM combined residency? I'm applying to med school at the moment, so I don't have much exposure to th system.

Are good med/peds residencies generally within reach of DO grads?

 

[togaedere]

There are definitely some programs that are DO friendly and many that have multiple DOs per year. They are smaller programs (typically around 5 residents per year or even smaller, but some programs have around 10 and I think the largest is 16) typically but work closely with the categorical (internal medicine, pediatrics) residents at that same program. Some DOs I met on the trail definitely said they avoided some programs cus those specific ones weren't open to osteopathic residents (for whatever reason) but that may very well change by the time for you to apply.

The benefit for me specifically with med/peds and adolescents is that teens can benefit from the knowledge you'd be learning from both sides, especially if they have a congenital illness. Med peds folks get both MICU and PICU training so see some pretty sick adults and kids and get a depth of training I think can help in the outpatient setting. Something else to consider is that if you only see adolescents, you would only see patients for a handful of years and then pass them off to an internist or FM doc who sees adults. Whereas if you had adolescent training thru med peds you could see any patients you felt like following deep in their adult years as well. Or get at them before they were teens and be particularly good with your peds background.

In any event I just think it's something to think about, another avenue to see this population. I'm all about whatever works for everyone so don't mean any disrespect at all to categorical peds followed by adolescent fellowship if that's what you end up choosing (but you have some time 😉)

That's neat! Aside from being able to bridge the divide between child and adult, what's the concept behind the peds/IM combined residency? I'm applying to med school at the moment, so I don't have much exposure to th system.

Are good med/peds residencies generally within reach of DO grads?

 

[deleted407021]

There are definitely some programs that are DO friendly and many that have multiple DOs per year. They are smaller programs (typically around 5 residents per year or even smaller, but some programs have around 10 and I think the largest is 16) typically but work closely with the categorical (internal medicine, pediatrics) residents at that same program. Some DOs I met on the trail definitely said they avoided some programs cus those specific ones weren't open to osteopathic residents (for whatever reason) but that may very well change by the time for you to apply.

The benefit for me specifically with med/peds and adolescents is that teens can benefit from the knowledge you'd be learning from both sides, especially if they have a congenital illness. Med peds folks get both MICU and PICU training so see some pretty sick adults and kids and get a depth of training I think can help in the outpatient setting. Something else to consider is that if you only see adolescents, you would only see patients for a handful of years and then pass them off to an internist or FM doc who sees adults. Whereas if you had adolescent training thru med peds you could see any patients you felt like following deep in their adult years as well. Or get at them before they were teens and be particularly good with your peds background.

In any event I just think it's something to think about, another avenue to see this population. I'm all about whatever works for everyone so don't mean any disrespect at all to categorical peds followed by adolescent fellowship if that's what you end up choosing (but you have some time 😉)

Thanks for the input! Good luck, yourself.

 

[deleted407021]

Anyone else with some insight or experience in adolescent medicine?

 

[mvenus929]

Thanks for the input! Is this an unpopular focus for physicians? I've read elsewhere that they'd have a lot of patients, since most peds doc wouldn't want to work with pts 12+.

I can't speak to all physicians, just the pediatricians I have exposure to. We don't have a board certified Adolescent Medicine physician at our program--we have lots of general pediatricians who are interested in adolescents. Many of our residents are working on a 'teen-tot' clinic for teen moms, so they can take care of both the parent and the child. Most people I've seen go back and forth between actually completing a fellowship, because it is an additional three years of training (and loss of attending salary) for something that you could almost entirely do as a general pediatrician. I do know some people who have chosen to go through the fellowship, though, for various reasons.

I'm not going to stay in gen peds (going into peds endo), but will likely end up being like a PCP for a number of adolescent patients, because I will see my adolescent patients at least twice, if not 3-4 times per year, far more than they would go to a general pediatrician. I will also have some expertise in birth control, since I will use it as treatment for some of my patients.

 

[deleted407021]

I can't speak to all physicians, just the pediatricians I have exposure to. We don't have a board certified Adolescent Medicine physician at our program--we have lots of general pediatricians who are interested in adolescents. Many of our residents are working on a 'teen-tot' clinic for teen moms, so they can take care of both the parent and the child. Most people I've seen go back and forth between actually completing a fellowship, because it is an additional three years of training (and loss of attending salary) for something that you could almost entirely do as a general pediatrician. I do know some people who have chosen to go through the fellowship, though, for various reasons.

I'm not going to stay in gen peds (going into peds endo), but will likely end up being like a PCP for a number of adolescent patients, because I will see my adolescent patients at least twice, if not 3-4 times per year, far more than they would go to a general pediatrician. I will also have some expertise in birth control, since I will use it as treatment for some of my patients.

So, there appears to be some overlap between and among (sub)specialties.

Do you like adolescent patients, personally? Why might many peds docs avoid them?

 

[CubsFan314]

From what I understand, it is difficult to sustain a purely adolescent medicine practice outside of an academic setting. The patients who need to see an adolescent specialist are generally the same ones who are unlikely to show up to appointments. It's tough to maintain a practice like that, unless there is someone to subsidize your salary through programmatic or education work.

 

[PL198]

The peds forum isn't dead. It's just quiet.

Adolescent medicine is the primary care for adolescents. It is run differently at different places, and can be done by general pediatricians. However, most pediatricians don't get the same amount of training for adolescents as they do for younger children, primarily because there are fewer scheduled well checks. Sports medicine is an important component to the curriculum, as is sex education. There is a lot of psychosocial issues that you would have to deal with, and a lot of legal issues that will vary depending on the state you practice in.

From peds, adolescent is a 3 year fellowship, which is why many of the people who actually do it are general pediatricians with an interest in adolescents, rather than being formally trained.

a 3 yr fellowship? are you joking

 

[CubsFan314]

Which is why few people go into it. The salary is relatively small and you need to do a 3 year fellowship. Tough pitch for most people.

 

[deleted407021]

From what I understand, it is difficult to sustain a purely adolescent medicine practice outside of an academic setting. The patients who need to see an adolescent specialist are generally the same ones who are unlikely to show up to appointments. It's tough to maintain a practice like that, unless there is someone to subsidize your salary through programmatic or education work.

Can anyone corroborate this? Despite there being only a small amount of discussion on adolescent medicine on the forums, I haven't read this before.

 

[619959]

Can anyone corroborate this? Despite there being only a small amount of discussion on adolescent medicine on the forums, I haven't read this before.

I was seen by an adolescent medicine practitioner (for 5 years of my life) and I can tell that I never missed an appointment and the doctor was SO BUSY with appointments (so clearly, no one missed her appointments.) And she did not hold an academic position nor she practiced in an academic setting. (She was so warm and nice though; but not so cuddly like some pediatricians are.)
Sometimes, teens (like I used to be) like that the previous patient that his/her physician had seen was a teen also, not a 2 years old.

 

[mvenus929]

Can anyone corroborate this? Despite there being only a small amount of discussion on adolescent medicine on the forums, I haven't read this before.

The patients who tend to be cared for in an academic practice are low socioeconomic status. These patients are by nature more likely to no show appointments, for a variety of reasons. So it would make sense that adolescent medicine pracitioners in academic settings are more likely to have no showed appointments. That said, the teen clinic I rotated through in med school (which was run by the OB department, as they took care of a lot of teen pregnancies) had relatively few no shows, and in our adolescent clinic, we have relatively few no shows. So, I think it varies depending on where the practice is actually located and what population it seeks to serve.

 

[619959]

...low socioeconomic status...patients are by nature more likely to no show appointments, for a variety of reasons...That said...had relatively few no shows, and in our adolescent clinic, we have relatively few no shows. So, I think it varies depending on where the practice is actually located and what population it seeks to serve.

ditto to this... I come from a low socioeconomic status background

 

[BigRedBeta]

Adolescent is also a really great spot to do a lot of advocacy work. Working with school districts on things like safe sex campaigns, concussion testing and drugs/alcohol education is a huge opportunity. Further, you can also do a lot of government advocacy as well as things like graduated drivers licences, medical/decriminalized/legal marijuana, and other public health concerns have unique impacts on teenagers. And LGBT issues are also a huge area in need of physician insight and guidance.

In my opinion, to have a purely adolescent practice environment, where you see no one other than 11 and up, you have to be in one of two different scenarios - 1) Academic medicine, which may require fellowship training to get hired (more on that later) or 2) joining a big pediatric group practice with lots of other physicians and being their go to ado person. You may still get called into doing some sick visits for little kids because of schedule, but in the right setting with enough pediatricians who don't want to talk about sex, drugs, and vaginal discharge, you can have a big enough pipeline to make it work. I have one friend doing this and his practice lets him run his schedule from 2pm to 8pm four days a week plus a Saturday morning clinic. He does work with nearby school districts that takes up some mornings, but there's some sort of stipend he gets from them.

As for the three year fellowship, no one actually thinks that it takes three years to garner the knowledge necessary to become an ado specialist. But in the late 80's/early 90's the American Board of Pediatrics sought to standardize pediatric fellowships and the decision was made that all fellowships had to be 3 years. Part of this is because the ABP also requires a scholarship project to be completed during fellowship in order to be Board Eligible, and so there is research time built in to all peds fellowships as well. Even with that, most people still think that 3 years is excessive for something like Ado Med. There are some rumblings about a review of pediatric fellowships, but any change is going to be years away.

 

[deleted407021]

Adolescent is also a really great spot to do a lot of advocacy work. Working with school districts on things like safe sex campaigns, concussion testing and drugs/alcohol education is a huge opportunity. Further, you can also do a lot of government advocacy as well as things like graduated drivers licences, medical/decriminalized/legal marijuana, and other public health concerns have unique impacts on teenagers. And LGBT issues are also a huge area in need of physician insight and guidance.

In my opinion, to have a purely adolescent practice environment, where you see no one other than 11 and up, you have to be in one of two different scenarios - 1) Academic medicine, which may require fellowship training to get hired (more on that later) or 2) joining a big pediatric group practice with lots of other physicians and being their go to ado person. You may still get called into doing some sick visits for little kids because of schedule, but in the right setting with enough pediatricians who don't want to talk about sex, drugs, and vaginal discharge, you can have a big enough pipeline to make it work. I have one friend doing this and his practice lets him run his schedule from 2pm to 8pm four days a week plus a Saturday morning clinic. He does work with nearby school districts that takes up some mornings, but there's some sort of stipend he gets from them.

As for the three year fellowship, no one actually thinks that it takes three years to garner the knowledge necessary to become an ado specialist. But in the late 80's/early 90's the American Board of Pediatrics sought to standardize pediatric fellowships and the decision was made that all fellowships had to be 3 years. Part of this is because the ABP also requires a scholarship project to be completed during fellowship in order to be Board Eligible, and so there is research time built in to all peds fellowships as well. Even with that, most people still think that 3 years is excessive for something like Ado Med. There are some rumblings about a review of pediatric fellowships, but any change is going to be years away.

I'm very interested in patient education and advocacy. I do a lot of that, already. The opportunity for this kind of thing drew interest from me. Additionally, I think this age group is one of the most important at any given time and needs as many positive influences as possible.

I've heard it described as "social work with a stethoscope", and that's appealing, based on my limited experience.

A previous poster mentioned combined peds/med residencies. Might such training qualify one to specialize in this population, comparable to fellowship training -- minus the formal certification?

Thanks for the input! Much appreciated.

 

[tantacles]

If you are interested in adolescents you should definitely consider doing a med/peds residency. 4 years to do it as opposed to 3 but you may like the extra training/focus in transitions as well as opportunity to do more in adolescent clinic. I'm a fourth year med student who applied to med/peds so don't have a clear handle on the resident side of things yet but there are a ton of adolescent-focused med peds physicians and a lot of applicants who are interested in this as well.

Med-peds applicant #2 chiming in to say absolutely consider med-peds for the reasons stated above.

 

[deleted407021]

Med-peds applicant #2 chiming in to say absolutely consider med-peds for the reasons stated above.

Why did you choose a combined residency, personally?

 

[tantacles]

Why did you choose a combined residency, personally?

I have an interest in transitional care for patients with chronic diseases as well as lgbtq and adolescent health.

Also, you save two years by doing med-peds - it's only a 4 year residency.

 

[deleted407021]

I have an interest in transitional care for patients with chronic diseases as well as lgbtq and adolescent health.

Also, you save two years by doing med-peds - it's only a 4 year residency.

Do you mind sharing how you developed those interests?

 

[BigRedBeta]

I'm a huge fan of med/peds residencies (if they made me king of the ACGME for a day, my first move would be to eliminate all Family Medicine programs in favor of med/peds and then create an OB fellowship for anyone who wanted to do a traditional FM practice).

Given that med/peds makes you board certified in both, and ado is mostly part of peds, I don't think there's any added benefit from a "I'm qualified to see these patients" over a peds residency. However, practically, the knowledge about adult diseases is undoubtedly useful. Particularly for a lot of those chronic diseases that can show up in adolescence but usually show up slightly later (lots pediatricians struggle mightily with rheumatology issues for example).

The question about fellowship and how it matters for an academic appointment is much more complex. The market for adolescent specialists is probably in a lot of flux as pediatrics, just like every other specialty, is seeing a trend towards greater and greater subspecialization. The children's hospitals where this trend is more advanced, the CHOP's/Cincinnati's/Texas Children's of the world's are going to want that fellowship training because of the research training that is part of the fellowship and the presumption that you're going to be far more academically productive which is important to those institutions. Children's hospitals with smaller academic footprints may still be okay with non-fellowship trained physicians who are simply willing to see these patients and take part in the advocacy missions of the institution. Going med/peds I don't think gets you in the door at the first group, and doesn't do much benefit at the second in terms of getting the job. The trajectory of pediatric subspecialization in 4-7 years time will probably increase the importance of fellowship with more institutions wanting it, but I don't think we're going to see quite the speed of uptake that's been seen in fields like peds critical care where specialized cardiac intensivists and neurocritical care specialists are on the wishlist of every Division of Pediatric Critical Care.

The last layer is of course the option for private practice and what possibilities exist. There are a lot of what if's that come out in terms of location, practice size, history of the group, what the partners think is worth it, and so on. Med/peds is practically useful, and may help you make the case to certain groups, but again is not a necessary aspect. It all depends.

 

[deleted407021]

I'm a huge fan of med/peds residencies (if they made me king of the ACGME for a day, my first move would be to eliminate all Family Medicine programs in favor of med/peds and then create an OB fellowship for anyone who wanted to do a traditional FM practice).

Given that med/peds makes you board certified in both, and ado is mostly part of peds, I don't think there's any added benefit from a "I'm qualified to see these patients" over a peds residency. However, practically, the knowledge about adult diseases is undoubtedly useful. Particularly for a lot of those chronic diseases that can show up in adolescence but usually show up slightly later (lots pediatricians struggle mightily with rheumatology issues for example).

The question about fellowship and how it matters for an academic appointment is much more complex. The market for adolescent specialists is probably in a lot of flux as pediatrics, just like every other specialty, is seeing a trend towards greater and greater subspecialization. The children's hospitals where this trend is more advanced, the CHOP's/Cincinnati's/Texas Children's of the world's are going to want that fellowship training because of the research training that is part of the fellowship and the presumption that you're going to be far more academically productive which is important to those institutions. Children's hospitals with smaller academic footprints may still be okay with non-fellowship trained physicians who are simply willing to see these patients and take part in the advocacy missions of the institution. Going med/peds I don't think gets you in the door at the first group, and doesn't do much benefit at the second in terms of getting the job. The trajectory of pediatric subspecialization in 4-7 years time will probably increase the importance of fellowship with more institutions wanting it, but I don't think we're going to see quite the speed of uptake that's been seen in fields like peds critical care where specialized cardiac intensivists and neurocritical care specialists are on the wishlist of every Division of Pediatric Critical Care.

The last layer is of course the option for private practice and what possibilities exist. There are a lot of what if's that come out in terms of location, practice size, history of the group, what the partners think is worth it, and so on. Med/peds is practically useful, and may help you make the case to certain groups, but again is not a necessary aspect. It all depends.

Thanks, doc!
Would you say most adolescent medicine is practiced in academic settings? Why might that be?

 

[Perrotfish]

Thanks, doc!
Would you say most adolescent medicine is practiced in academic settings? Why might that be?

This wasn't addressed to me but I'll try to answer anyway

Adolescent medicine is not the most financially viable field of medicine. An adolescent appointment doesn't pay much more than a normal office visit, but involves a dramatically larger time investment in each patient to do it well.

I see a somewhat larger adolescent panel than most outpatient Pediatricians and had more adolescent medicine forced on me in residency than most Pediatricians. Even with the extra training each appointment painfully slow. A theoretically healthy adolescent takes me 40 minutes in the room, vs. no more than 15 minutes for a well child check or 10 minutes for a 'sick' child. Adolescents also almost universally leave with no less than 3 new medications and/or consults. If it was any more of my panel than it is now I would just never leave on time. You also can't just break it up into multiple appointments because patients so rarely return to clinic. If you don't take care of it that visit you likely won't ever see that patient again.

Because adolescent medicine is so friggin slow, I've really only seen two models of how it can work as a full time job. The first is an outpatient academic adolescent clinic where its allowed to be slow because its educational. The residents have 1 hour appointments, you have 30 minutes appointments with each patients and you don't need to write the notes. The second is an inpatient adolescent team, which basically focuses almost exclusively on a subset of adolescent medicine like eating disorders. If you go into general practice in order to make the numbers work chances are you're going to need to cut back so that teenagers are no more than 20-30% of your actual panel, unless you can find a large enough group of Pediatricians who are willing to let you take their entire adolescent practice.

BTW if your goal is just to practice a lot of adolescent medicine without the fellowship, I would personally not recommend a med/peds residency. Adolescents don't, in my experience, have much internal medicine pathology. They have a combination of routine Pediatric pathology, sexual health problems, sports medicine injuries, Devo problems (ADHD/school failure), and psych issues. A pediatrics or family program with judicious use of electives would be a much better fit than a med/peds program that robs of the electives you need to learn Gyn, devo, sports med, and psych. IM is about really sick adults. There aren't a lot of really sick adolescents, and the ones I've worked with all had sick kid problems (CF, congenital hearts, Seizure disorder, etc) rather than sick adult problems (severe T2DM, cirrhosis, kidney failure, severe HTN, polypharmacy, etc) .

 

[deleted407021]

This wasn't addressed to me but I'll try to answer anyway

Adolescent medicine is not the most financially viable field of medicine. An adolescent appointment doesn't pay much more than a normal office visit, but involves a dramatically larger time investment in each patient to do it well.

I see a somewhat larger adolescent panel than most outpatient Pediatricians and had more adolescent medicine forced on me in residency than most Pediatricians. Even with the extra training each appointment painfully slow. A theoretically healthy adolescent takes me 40 minutes in the room, vs. no more than 15 minutes for a well child check or 10 minutes for a 'sick' child. Adolescents also almost universally leave with no less than 3 new medications and/or consults. If it was any more of my panel than it is now I would just never leave on time. You also can't just break it up into multiple appointments because patients so rarely return to clinic. If you don't take care of it that visit you likely won't ever see that patient again.

Because adolescent medicine is so friggin slow, I've really only seen two models of how it can work as a full time job. The first is an outpatient academic adolescent clinic where its allowed to be slow because its educational. The residents have 1 hour appointments, you have 30 minutes appointments with each patients and you don't need to write the notes. The second is an inpatient adolescent team, which basically focuses almost exclusively on a subset of adolescent medicine like eating disorders. If you go into general practice in order to make the numbers work chances are you're going to need to cut back so that teenagers are no more than 20-30% of your actual panel, unless you can find a large enough group of Pediatricians who are willing to let you take their entire adolescent practice.

BTW if your goal is just to practice a lot of adolescent medicine without the fellowship, I would personally not recommend a med/peds residency. Adolescents don't, in my experience, have much internal medicine pathology. They have a combination of routine Pediatric pathology, sexual health problems, sports medicine injuries, Devo problems (ADHD/school failure), and psych issues. A pediatrics or family program with judicious use of electives would be a much better fit than a med/peds program that robs of the electives you need to learn Gyn, devo, sports med, and psych. IM is about really sick adults. There aren't a lot of really sick adolescents, and the ones I've worked with all had sick kid problems (CF, congenital hearts, Seizure disorder, etc) rather than sick adult problems (severe T2DM, cirrhosis, kidney failure, severe HTN, polypharmacy, etc) .

Thanks for the input, doc. Do you know of any other routes to working with this age group -- perhaps adolescent psych?

Lots of opinions -- some conflicting, but each coming from a unique perspective. I'm learning more about the subject and adding to what's on the forum, which is what I'm looking for.

 

[tantacles]

Do you mind sharing how you developed those interests?

It was a combination of having a chronic disease leading to interests in transition of care along with loving the challenge of softening a hard shell in an adolescent who is stone cold towards you.

 

[deleted407021]

It was a combination of having a chronic disease leading to interests in transition of care along with loving the challenge of softening a hard shell in an adolescent who is stone cold towards you.

A good, supportive physician in my younger life, when I dealt with a specific condition, would have been great.

To what degree do you plan on specializing in adolescents?

 

[styphon]

Thanks for the input, doc. Do you know of any other routes to working with this age group -- perhaps adolescent psych?

Lots of opinions -- some conflicting, but each coming from a unique perspective. I'm learning more about the subject and adding to what's on the forum, which is what I'm looking for.

Since no one else has talked about family medicine...

Family medicine residency is what you make of it, most residencies have lots of electives, and of course it is up to you to be proactive. For example: I was very interested in womens health/OB - so I ended up with lots of experience on OB care, GYN outpatient procedures, and contraceptive management. I am comfortable inserting IUDs and nexplanons - both of which have a role in adolescent medicine.

Family medicine can apply to the same adolescent fellowship that is mentioned above.

 

[BigRedBeta]

This wasn't addressed to me but I'll try to answer anyway

Adolescent medicine is not the most financially viable field of medicine. An adolescent appointment doesn't pay much more than a normal office visit, but involves a dramatically larger time investment in each patient to do it well.

I see a somewhat larger adolescent panel than most outpatient Pediatricians and had more adolescent medicine forced on me in residency than most Pediatricians. Even with the extra training each appointment painfully slow. A theoretically healthy adolescent takes me 40 minutes in the room, vs. no more than 15 minutes for a well child check or 10 minutes for a 'sick' child. Adolescents also almost universally leave with no less than 3 new medications and/or consults. If it was any more of my panel than it is now I would just never leave on time. You also can't just break it up into multiple appointments because patients so rarely return to clinic. If you don't take care of it that visit you likely won't ever see that patient again.

Because adolescent medicine is so friggin slow, I've really only seen two models of how it can work as a full time job. The first is an outpatient academic adolescent clinic where its allowed to be slow because its educational. The residents have 1 hour appointments, you have 30 minutes appointments with each patients and you don't need to write the notes. The second is an inpatient adolescent team, which basically focuses almost exclusively on a subset of adolescent medicine like eating disorders. If you go into general practice in order to make the numbers work chances are you're going to need to cut back so that teenagers are no more than 20-30% of your actual panel, unless you can find a large enough group of Pediatricians who are willing to let you take their entire adolescent practice.

BTW if your goal is just to practice a lot of adolescent medicine without the fellowship, I would personally not recommend a med/peds residency. Adolescents don't, in my experience, have much internal medicine pathology. They have a combination of routine Pediatric pathology, sexual health problems, sports medicine injuries, Devo problems (ADHD/school failure), and psych issues. A pediatrics or family program with judicious use of electives would be a much better fit than a med/peds program that robs of the electives you need to learn Gyn, devo, sports med, and psych. IM is about really sick adults. There aren't a lot of really sick adolescents, and the ones I've worked with all had sick kid problems (CF, congenital hearts, Seizure disorder, etc) rather than sick adult problems (severe T2DM, cirrhosis, kidney failure, severe HTN, polypharmacy, etc) .

Good point about the complexity of a good portion of adolescent medicine. Upon reflection of my experiences in residency, they really were at the extremes - lots of really quick birth control refill visits or minor sports medicine sort of stuff...or rather complex psychosocial nightmares like you mention.

As for other ideas about why academic medicine tends to have a hold on strict adolescent practice for the OP, and I think it's because it's a degree of subspecialization that doesn't stand out as "necessary" for a lot of people. I imagine that there is probably 10-15% of pediatricians who would give up their adolescent patients in a heartbeat if given the opportunity, a 1/3 that wouldn't mind handing them off but are otherwise okay seeing teens, another 1/3 who feel like teenagers are part of pediatrics and enjoy the change of pace (but maybe would consider handing off some of them if there was someone in their group who specialized), and the remaining 20% or so who feel strongly that they should keep their patients until they really are adults. Some of that is certainly due to the length of relationships one can have with these kids and their families. Again going back to the idea that the adolescent medicine fellowship doesn't need to be three years, there's not so much unique specialized knowledge in Ado that precludes general pediatricians from managing these patients, that's obviously quite different than other subspecialties.

 

[deleted407021]

Good point about the complexity of a good portion of adolescent medicine. Upon reflection of my experiences in residency, they really were at the extremes - lots of really quick birth control refill visits or minor sports medicine sort of stuff...or rather complex psychosocial nightmares like you mention.

As for other ideas about why academic medicine tends to have a hold on strict adolescent practice for the OP, and I think it's because it's a degree of subspecialization that doesn't stand out as "necessary" for a lot of people. I imagine that there is probably 10-15% of pediatricians who would give up their adolescent patients in a heartbeat if given the opportunity, a 1/3 that wouldn't mind handing them off but are otherwise okay seeing teens, another 1/3 who feel like teenagers are part of pediatrics and enjoy the change of pace (but maybe would consider handing off some of them if there was someone in their group who specialized), and the remaining 20% or so who feel strongly that they should keep their patients until they really are adults. Some of that is certainly due to the length of relationships one can have with these kids and their families. Again going back to the idea that the adolescent medicine fellowship doesn't need to be three years, there's not so much unique specialized knowledge in Ado that precludes general pediatricians from managing these patients, that's obviously quite different than other subspecialties.

Maybe the field will grow as more people get coverage and we learn more about emerging adulthood, etc.

 

[tantacles]

A good, supportive physician in my younger life, when I dealt with a specific condition, would have been great.

To what degree do you plan on specializing in adolescents?

My hope is to do an ID or GI fellowship (either adult or combined), which would put me squarely in a position to deal with patients who both are clearly in the pediatric and adult populations and also those ready to transition out, either based on age or level of autonomy.

 

[deleted407021]

My hope is to do an ID or GI fellowship (either adult or combined), which would put me squarely in a position to deal with patients who both are clearly in the pediatric and adult populations and also those ready to transition out, either based on age or level of autonomy.

Why those fields specifically, if you don't mind?

 

[tantacles]

Why those fields specifically, if you don't mind?

For ID, HIV. For GI, IBD.

 

[deleted407021]

For ID, HIV. For GI, IBD.

Good luck!

 

[deleted407021]

Thanks for the responses, everyone! I think they've been beneficial to myself and the forums.

 

[619959]

This thread is on SDN's FB page! #ThreadoftheDay

 

[deleted407021]

This thread is on SDN's FB page! #ThreadoftheDay

Really? How's that determined?

 

[Perrotfish]

Family medicine can apply to the same adolescent fellowship that is mentioned above.

Just so you're aware they're not actually the same fellowship. Peds goes into 3 year Peds adolescent fellowships, Family does a 2 year FP adolescent fellowship.

Both options are crazy, in my opinion. I would never consider doing more than a one year fellowship in a field of medicine I can already practice in its entirety without a fellowship.

 

[619959]

Really? How's that determined?

IDK lol

 

[deleted407021]

Is Transitional Medicine a larger and more accessible field than Adolescent Medicine?

 

[deleted407021]

Meep.