Originally posted by Ponyboy
"The interesting thing with Med-Peds is that the two fields while very different can complement each other well at times. In our program Med-Peds PGY2s are often much more comfortable with the critical care and EM aspects of peds than the categorical PGY3s. It's at times like this that I look more fondly at all those open ICU months on the medicine side. I agree that it is more challenging to complete a Med-Peds residency than a categorical program in either medicine or pediatrics. I knew this going into residency and most of the program directors at programs I applied made that very clear. It's what I wanted to do though and I am happy with my choice. "
Again, this argument is pulling an characteristic unique to one program. While at this one program, med-peds residents may be more comfortable with ICU/EM aspects of peds, I could also argue that by doing categorical peds, my program allows me to have roughly two-three times as much experience in the PICU and Peds Emerg than many other med-peds residents. I think that this added time would more than compensate for time not spent in adult ICU's. Additionally, the extra time in peds only ICU's and Emerg's will give me a better grasp of the nuances both pediatric disease and management.
I recognize that I can only comment on the training that occurs at our institution. That said, when I interviewed with the categorical Peds program directors at the Med-Peds programs I applied to the consensus basically was that the Med-Peds residents were viewed as the some of their top residents (in comparison with the peds categorical residents). As far as having 3 times the amount of PICU and ED experience unless the Med-Peds residents at your institution have none (and the RRC won't allow that) or you have done all of your electives in these areas I'm having difficulty seeing how this can be true.
Perhaps the point I didn't make very well in my earlier post was that successful Med-Peds residents don't attempt to do Medicine and Pediatrics in a vacuum flipping back and forth between the two disciplines every few months. Instead their is a comparative approach to the anatomy and physiology of the two disciplines. The Peds resident insists that children aren't just little adults. The Meds-Peds resident looks at how and why children are managed differently than adults and in what cases the management is the same. If the adult literature supports a certain management and the pediatrics literature on that topic doesn't exist the Med-Peds resident will ask does the anatomy and physiology support considering this management approach in this child. Sometimes it does. Sometimes it doesn't.
"Again I think it depends on the program, and the residents. I think with the shift to focus on competencies by ACGME we may get a better idea of what really works in residency and what doesn't. One thing I would say is that if you look at the non elective rotations by the categorical and Meds-Peds residents at our institution they fall in line pretty closely. What we lose are extra electives and some of the non clinical months of the program."
Again, this is specific to your program. I have seen other med-peds programs that skimp on PICU, NICU and ED months when compared to the categorical program. Regarding less elective time, I believe that the basis for a good general pediatrician is a strong background in all the subspecialties. Without spending time in all of the organ-system subspecialites (nephro, cardio, etc), residents miss the opportunity to learn proper outpatient/inpatient management of specific diseases from specialists in each field. Instead, they are left with what they have read in books or picked up on the wards from others. This leads them to fall into an algorithm/clinical reflex approach to medicine instead of thinking and asking why. At this point, there is little that separates an MD from a PA or NP. If you're not going to think about a problem, why did you learn so much about it to begin with? I didn't go through four years of medical school to follow a little algorithm. That is why I think that electives are of extreme importance to any residency and should not be regarded as a dispensable part of training.
The RRC has specific guidelines for subspecialty exposure, therefore in our program they are not considered optional or elective. At the end of this educational year I will have completed full pediatric months of Cardiology (with fun PICU/CCU call), Heme-Onc/Stem Cell (with Stem Cell Unit call), Pulmonary, and Gastroenterology. I still have another full year of pediatric months in my program and am sure that additional opportunities for subspecialty exposure will exist. Additionally I've completed 2 ED months (1 with trauma team responsibilities), 1PICU, 2 NICU (both with delivery resuscitation responsibilities) 1 Nursery month (with night delivery resuscitation call), and an Anesthesia/Critical Care month. Perhaps I am at a great program (it was my first choice after all), however, as our program director likes to remind us the ACGME and RRC have guidelines, rules, and standards. Our program needs to meet them. I'm wondering how the Med-Peds program you are describing meets those requirements.
As far as algorithms are concerned I think that the literature supports certain practice guidelines and standards of care. Competent physicians follow these while staying abreast of the literature as it changes, changing practices as warranted. Additionally there are times when the literature does not fit the situation or your patient (or both) and at that point as a physician you must combine you clinical training with the literature and devise a solution. Some advances in medicine happen at the bedside rather than in the lab.
