Chulito

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I won't bore you with the reasons, but it would be beneficial for me to be certified in both Family Practice and Internal Medicine. I'm not willing to complete two full 3-year residencies to make this happen, however. Given that there is a lot of overlap between these two specialities, is it possible to do some sort of combined residency--say, 2 years of FP + 2 years of IM, or 3 years of FP + 1 year intership in IM--and then test for both and be fully certified/licensed in both? If no formalized programs already exist for this, are there schools or community programs that are flexible in allowing residents to create innovative, unorthodox residency careers? Or am I out of luck?
 

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I won't bore you with the reasons, but it would be beneficial for me to be licensed in both Family Practice and Internal Medicine. I'm not willing to complete two full 3-year residencies to make this happen, however. Given that there is a lot of overlap between these two specialities, is it possible to do some sort of combined residency--say, 2 years of FP + 2 years of IM, or 3 years of FP + 1 year intership in IM--and then test for both and be fully certified/licensed in both? If no formalized programs already exist for this, are there schools or community programs that are flexible in allowing residents to create innovative, unorthodox residency careers? Or am I out of luck?

there are a few IM/FM programs. check those out. do AMA freida search for all the Fm/Im programs. other wise it is possible but you will probably have to do 5 years at least.
 

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What is your goal? Is there a purpose for you personally to train in both? For the vast majority of physicians, what you are talking about makes no sense. Both will train you for a career in primary care, and depending on what you want your focus and scope to be, you should pick one or the other. Are you thinking that doing both will somehow make you a more desirable candidate? I think that's wishful thinking.

This is an unorthodox career for a reason. It's like going to the naval academy and then entering the marines. It makes no sense. Pick one.
 
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Chulito

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Kent-

Thanks for the link. That's helpful. Do you (or others) think that at least some other schools/hospitals would be open to the idea of cobbling together a combined program for an interested student if they don't have such a program already established?



Yaah (and anyone else with advice)-

My interest stems from the fact that community clinics in my part of the country hire almost exclusively FPs, not pediatricians or internists. They value the versatility greatly. I would like the additional depth of medicine provided by IM training, and also the flexibility to go on and further specialize in one of the IM subspecialties. In the clinic where I currently work, one of our great struggles is finding cardiologists and orthopaedists who will see pre-urgent patients with no insurance or only medicare/medicaid. I'm exploring options that would allow me to practice as a primary care physician in a clinic with admitting privileges in a hospital as a cardiologist, for example, or as a primary care physician in a clinic who happens to also have the expertise of a cardiologist, or some other variation on the theme. Any thoughts? Any caveats?
 

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While I understand your interest, IMHO its hard to do many things and do them well. FP and IM are often combined because there is enough similarity in their field of scope for the practice of training individuals to make sense. However, once you start specializing, in the case of cardiology, there is such a focus that it makes it hard to give the same focus to another, related but separate field. You can't be everything to everybody...if you want to be a FP who does procedures, there are residency programs that train you to do endoscopy, even appys. You might even be able to get some minor ortho training as well. To maintain your credentials as a cardiologist, you'd have to do a certain number of procedures - which could be hard if you're a full-time FP as well. Just my thoughts on the subject...

As for programs cobbling something together, you want to train in an accredited residency program - if you can convince a program in the area of the country to get their act together, do the paperwork and get approved, it might work. That being said, they might not necessarily be motivated or see the benefit in doing so.

Finally, the problem your community has with attracting orthopods or other specialists, is not unique by any means. These can be high paying specialties and many practitioners do not want to have to deal with the hassles of Medicare (which may reimburse them far lower than they bill) or the non-insured. Common problem. Perhaps would better serve your community by training in such a specialty and committing yourself to the underserved and uninsured population which needs specialist care but can't get it locally.
 

Chulito

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Thanks, Kimberli. I've been considering an arrangement that would have me practicing in the clinic as an FP 4 days per week and as a cardiologist in a hospital with exclusively uninsured or government-insured patients one day per week. I have imagined that the greatest difficulty with this arrangement would be finding a hospital willing to allow me to practice in their facility while not following their general rules regarding the ratio of insured-to-uninsured patients. If I were to manage to surmount that hurdle, however, do you think that the problem of staying current and effective in the field of cardiology would still be relevant?

I would appreciate criticism, thoughts, general observations, advice, etc. from as many people as are willing to give them as I try to refine my perspective and forge a plan here, so keep it coming, folks.
 

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I don't understand - what is stopping you from just being IM and seeing patients at this clinic? If you want to do the procedures that FPs do, can't you learn them in elective time? If the purpose is that you want to see every spectrum of patients (like FP) and then also be subspecialty trained, I guess I can see your point but even though do you really need to do FP training to do this? I would think there would be plenty of work for you if you didn't see kids or something, and even then you could probably do that as IM.
 

Chulito

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I don't understand - what is stopping you from just being IM and seeing patients at this clinic? If you want to do the procedures that FPs do, can't you learn them in elective time? If the purpose is that you want to see every spectrum of patients (like FP) and then also be subspecialty trained, I guess I can see your point but even though do you really need to be able to do anything? I would think there would be plenty of work for you if you didn't see kids or something, and even then you could probably do that as IM.

They only hire FPs, not IMs. That's the usual policy around here. They need (or at least want) all providers to be able to see all patients.
 

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They only hire FPs, not IMs. That's the usual policy around here. They need (or at least want) all providers to be able to see all patients.

So they want someone who does IM and a subspecialty but they won't hire one? OK. Sounds like their problem, not yours, but if that's the only way they will hire you, and you know you want to work there under the circumstances you describe, you could do it. It's just weird.
 

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So they want someone who does IM and a subspecialty but they won't hire one? OK. Sounds like their problem, not yours, but if that's the only way they will hire you, and you know you want to work there under the circumstances you describe, you could do it. It's just weird.

No, no, they aren't looking for someone with these qualifications. Clinics in my area are looking to hire FPs with FP training and FP certification, FP aspirations and FP expectations. But as a board member at one such clinic, I deal regularly with the problem of finding specialty care for our patients, and I'm simply looking for my own private strategy to help alleviate the problem. It's certainly possible that I could convince them to hire me as an IM since there are no laws or even official rules against it. They have reservedly said as much, and I may end up taking this route. The fact is, however, I would prefer to see the full range of patients that an FP sees, and if it only entails one extra year of residency to be an FP/IM cardiologist instead of an IM cardiologist, then that would be worth it to me. I'm still very uncertain about the feasibility of practicing this way, however. I'm just not sure that hospitals would be open to the idea of a clinic generalist practicing cardiology for the underserved in their facility one day per week (for example). I am ignorant and naïve, I realize that, which is why I'm looking for people to poke holes in my speculative plans and inform me of factors and difficulties (as well as other options) that I'm not considering.
 

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Why not do a combined IM/Peds residency (only 4 years) and if you really want, do either a cardiology fellowship, a peds cardiology fellowship, or in some places a combine card/ped cards fellowship.

With Med-Peds, you are board eligible in both Pediatrics and Internal Medicine. You will certainly get more training in inpatient pediatrics than Family Medicine and may be more able to handle the sicker kids in the hospital.

Only difference is you won't get any OB or surgery training during residency.
 

Chulito

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Why not do a combined IM/Peds residency (only 4 years) and if you really want, do either a cardiology fellowship, a peds cardiology fellowship, or in some places a combine card/ped cards fellowship.

With Med-Peds, you are board eligible in both Pediatrics and Internal Medicine. You will certainly get more training in inpatient pediatrics than Family Medicine and may be more able to handle the sicker kids in the hospital.

Only difference is you won't get any OB or surgery training during residency.


I've thought about that option. Tell me, is the IM component of IM/Peds not more closely focused on pediatric issues to the exclusion of certain elements in the full range of regular IM?
 
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I can't answer the question of how best to meet your career goals, but I wish you luck.

One of my friends considered IM/FM for this reason: she wanted to specialize in ID, but can do that only after IM residency. However, she wanted to be able to see everyone with HIV, hep C, etc, thus the FM part.

I don't think your plan is not do-able, but as Kimberli pointed out, it will be challenging to stay proficient at all you do. My friend plans to just do ID, but wants to see all age groups in that setting.
 

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I've thought about that option. Tell me, is the IM component of IM/Peds not more closely focused on pediatric issues to the exclusion of certain elements in the full range of regular IM?


No. If you look at most Med-Peds program, you jump between Internal Medicine and Pediatrics in blocks (ie 3 months of IM then 3 months of Peds then back to 3 months of IM). When you're on IM, you are considered "IM", when you are on Peds, you are considered Peds. Continuity clinic differs amongst programs ... some have a pure med-peds clinic, others have you rotate through both IM and Peds clinics, and others are a combination of the two.

The reason you can do IM-Peds in 4 years is due to loss of electives in both IM and Pediatrics, and less repetition in certain rotations (doing 1 PICU month instead of 2 PICU months).

In order to have a Med-Peds program, the place must offer IM residency and Peds residency, so you're getting trained in both programs.
 

Chulito

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No. If you look at most Med-Peds program, you jump between Internal Medicine and Pediatrics in blocks (ie 3 months of IM then 3 months of Peds then back to 3 months of IM). When you're on IM, you are considered "IM", when you are on Peds, you are considered Peds. Continuity clinic differs amongst programs ... some have a pure med-peds clinic, others have you rotate through both IM and Peds clinics, and others are a combination of the two.

The reason you can do IM-Peds in 4 years is due to loss of electives in both IM and Pediatrics, and less repetition in certain rotations (doing 1 PICU month instead of 2 PICU months).

In order to have a Med-Peds program, the place must offer IM residency and Peds residency, so you're getting trained in both programs.

That sounds a lot like the programs listed on KentW's link below (post #4) for IM-FP. Any reason why you would suggest IM-Peds over IM-FP aside from location of the programs available?
 

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That sounds a lot like the programs listed on KentW's link below (post #4) for IM-FP. Any reason why you would suggest IM-Peds over IM-FP aside from location of the programs available?


Stronger pediatrics training for IM-Peds. More outpatient training for IM/FM.

St Vincent IM/FM program
Peds - 3.5 months total of required pediatrics training in a 4 year period (pediatrics/nursery/NICU)

For EVMS IM/FM program
Peds - 5 months total of required pediatrics training (2 months inpt peds, 1 month nursery, 1 month peds ambulatory setting, 1 month peds ER)


For Med-Peds (using same state as St. Vincent and EVMS)

Indiana University Med-Peds Program
Peds - 24 months of pediatrics training

Medical College of Virginia/VCU Med-Peds Program
Peds - 24 months of pediatrics training
 

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That sounds a lot like the programs listed on KentW's link below (post #4) for IM-FP. Any reason why you would suggest IM-Peds over IM-FP aside from location of the programs available?

OB or not OB? That is the question.
Whether 'tis nobler in the residency to suffer the slings and arrows of outrageous 24/7 pager call on your pregnant patients as a resident,
even while on other non-OB call rotations;
Or to take arms against a sea of adult and pediatric general medical troubles,
And by opposing end them? To die: To sleep;
No more: And by sleep we mean more than 15 minutes without your damn pager going off....

I could go on like this for awhile, that was fun. Here's the thing though. Straight IM gives you 3 years of adult general medicine training with some specialty fun thrown in. Straight Peds gives you the same thing but with kids. FM gives you basically 1 year adult general medicine, 1 year pediatric medicine and 1 year of OB w/ little or no (depending on the program) specialty experience and very little option for add'l specialty training in the future (barring sports med and the occassional urgent care or OB fellowship, but certainly not Cards).

Med/Peds, as described above gives you all the core training you will get in a straight IM or Peds residency in 4 years total and allows you to do fellowships in either adult or peds specialties. What you miss in the Med/Peds programs is the Rheumaholiday and Elective months that you have time for in a 3 year program. You will still get all the wards, unit and clinic months your single-boarded peers will get (because the ABIM and ABP require it for board eligibility).

So I guess, if you want the OB experience, do IM/FM, if you don't, do IM/Peds. In either case, you'll still be able to see all the patients in this clinic (which you seem hot to work for but doesn't seem interested in hiring people who do what you want to do which is wierd but a story for another time) and offer them the specialty services you feel they need.

In any event, good luck.
 

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I'll leave the discussion of FP/IM vs IM/Peds etc to those with more experience and opinions on the subject.

And I don't think your plan is neccessarily "un-doable" (I know that probably isn't a word), but I'm not sure about the 4 days FP/1 day Cards plan. Not only would that be hard to keep current doing something so little (ie, 1 day per week) and getting the hospital to give you privileges but I am wondering about the number of cards patients you can realistically see in 1 day.

Are you planning on doing any procedures? If so, you'll need office time with patients as well as procedure time - if you only do Cards stuff 1 day per week, its going to be a LONG wait for patients to get in to see you. Therefore it sort of defeats the purpose of doing Cards to serve the community - after all, if its 12 weeks to get in to see you but they can drive and see a cardiologist in another city in 4 weeks, they might choose that option (if they have a choice).

I guess I'm still sort of confused because it sounds like your community can get FPs but not the specialists. So if the need is for specialists and you can't get any to come to the community, wouldn't you better serve by being a full time cardiologist?

Anywhoo, I would think that to effectively combine the two would require giving more time to Cards patients/procedures than 1 day per week.

Finally, was thinking if you are so wedded to this community and they you, sometimes financial incentives can be made available to future physicians (ie, tuition payments for medical school) in exchange for future employment guarantee.
 

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I'm not willing to complete two full 3-year residencies to make this happen, however.

If time is such a concern to you, why are you willing to complete a rigorous three year fellowship in cardiology to only do practice in this field fifty days a year?

In line with what Kimberli alluded to, if my family member told me they were going to see a cardiologist (or any specialist, for that matter) that only practiced one day a week, I'd have serious reservations about the care they provided and would suggest they seek care elsewhere. I just don't think you can stay current and at the top of your game only seeing patients one day a week--unlike semi-retired docs, it's not like you have been working for years and have lots of experience to rely upon, you NEED to gain this experience to be a competent cardiologist. Plus, how will you be available to your cardiology patients during emergencies when you are wearing your "FP" hat? Your overextension and broad practice base may significantly limit your availability to your patients, and lead to sub-par care.

I admire your commitment to your community and willingness to help those who truly need your help, but I don't think your plan is logistically feasible, and could potentially be unsafe for your patients. I'd love to see you prove me wrong, and do all that you want to do and DO IT WELL, but I don't think it is feasible. Med-Peds residents seem to have similar goals as you have, and are eligible to complete any fellowship in medicine or peds, and would likely give you the most flexibility. I'd recommend trying to do one thing really well rather than trying to fill in all the holes in your medical community.

Best of luck, whatever you decide!
 

Chulito

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I'll leave the discussion of FP/IM vs IM/Peds etc to those with more experience and opinions on the subject.

And I don't think your plan is neccessarily "un-doable" (I know that probably isn't a word), but I'm not sure about the 4 days FP/1 day Cards plan. Not only would that be hard to keep current doing something so little (ie, 1 day per week) and getting the hospital to give you privileges but I am wondering about the number of cards patients you can realistically see in 1 day.

Are you planning on doing any procedures? If so, you'll need office time with patients as well as procedure time - if you only do Cards stuff 1 day per week, its going to be a LONG wait for patients to get in to see you. Therefore it sort of defeats the purpose of doing Cards to serve the community - after all, if its 12 weeks to get in to see you but they can drive and see a cardiologist in another city in 4 weeks, they might choose that option (if they have a choice).

I guess I'm still sort of confused because it sounds like your community can get FPs but not the specialists. So if the need is for specialists and you can't get any to come to the community, wouldn't you better serve by being a full time cardiologist?

Anywhoo, I would think that to effectively combine the two would require giving more time to Cards patients/procedures than 1 day per week.

Finally, was thinking if you are so wedded to this community and they you, sometimes financial incentives can be made available to future physicians (ie, tuition payments for medical school) in exchange for future employment guarantee.



If time is such a concern to you, why are you willing to complete a rigorous three year fellowship in cardiology to only do practice in this field fifty days a year?

In line with what Kimberli alluded to, if my family member told me they were going to see a cardiologist (or any specialist, for that matter) that only practiced one day a week, I'd have serious reservations about the care they provided and would suggest they seek care elsewhere. I just don't think you can stay current and at the top of your game only seeing patients one day a week--unlike semi-retired docs, it's not like you have been working for years and have lots of experience to rely upon, you NEED to gain this experience to be a competent cardiologist. Plus, how will you be available to your cardiology patients during emergencies when you are wearing your "FP" hat? Your overextension and broad practice base may significantly limit your availability to your patients, and lead to sub-par care.

I admire your commitment to your community and willingness to help those who truly need your help, but I don't think your plan is logistically feasible, and could potentially be unsafe for your patients. I'd love to see you prove me wrong, and do all that you want to do and DO IT WELL, but I don't think it is feasible. Med-Peds residents seem to have similar goals as you have, and are eligible to complete any fellowship in medicine or peds, and would likely give you the most flexibility. I'd recommend trying to do one thing really well rather than trying to fill in all the holes in your medical community.

Best of luck, whatever you decide!


Good words, Kimberli, Bitsy. Thanks for the guidance. There are clearly things that I still haven't thought through very well.
 
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I hate to be the realist here, but it basically sounds like you're torn between FP and Cardiology, and in lieu of making a decision, you're trying to do both. (For some reason, Cardiology, specifically, is very popular with pre-meds and MSIs/MSIIs.) My advice would be to keep an open mind when entering med school, THEN decide what you truly enjoy doing during your MSIII year - by then, you may be surprised.
 

Chulito

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I hate to be the realist here, but it basically sounds like you're torn between FP and Cardiology, and in lieu of making a decision, you're trying to do both. (For some reason, Cardiology, specifically, is very popular with pre-meds and MSIs/MSIIs.) My advice would be to keep an open mind when entering med school, THEN decide what you truly enjoy doing during your MSIII year - by then, you may be surprised.

No worries. Realism is very welcome. Be blunt, and call a spade a spade, especially if you think I'm trying to call it a heart. There's a lot that I may not have considered yet. Besides, what you have said isn't harsh at all.

I agree that part of my desire may stem from uncertainty regarding practice preferences (generalist vs. specialist and calm office visits vs. EM, the latter of which is actually the greatest of all temptations for me away from FP). It's definitely something to keep in mind as I weigh options and try to plot the curriculum of my life. I have solid goals and great clarity regarding the population that I want to serve, but much less clarity regarding the way that I want to serve them. I will say that I find cardiology no more interesting than many other IM subspecialties, and am not drawn to it in any particular way. It's just that cardiologists are the IM subspecialists that community clinics (at least in my area) have the greatest difficulty getting for their patients. Orthopaedists are even more difficult, but that's a totally separate residency rather than an IM subspecialty. It would definitely require too much time to get certified in both, and I think that the problem of remaining current is even greater with orthopaedics.

Anyone who reads this and has any opinion or thought on the matter, please comment. Advice, help, direction, encouragement, criticism, warning, irritation--all are welcome.
 

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Anyone who reads this and has any opinion or thought on the matter, please comment. Advice, help, direction, encouragement, criticism, warning, irritation--all are welcome.

I understand that you have a target patient population that you'd like to serve, but instead of trying to figure out what specialty will help them them the most why don't you see what you actually enjoy when you get to 3rd and 4th year of med school? Even if the population you want to serve desperately needs cardiologists, if you hate IM and Cards, then doing training for those will be foolish for 3 reasons: 1. You'll hate your job. 2. You probably won't be very good at your job if you hate it. 3. You might end up (after a while) wanting to see a different subset of patients.

Find what specialty you really want and then go for that. Worry about educating yourself to be the best [insert specialty here] you can be, and then go see how you can treat the types of patients you want to treat.

That's just my $.02. Good luck!
 
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