FM vs. Med-peds. Need advice.

[eimaise]

Hello everyone,

3rd year student here. I am really enjoying rotations (So far, I've done Peds, Geriatrics, rural family medicine, and about 6 weeks of inpatient internal medicine).

Since July or so, I have been kind of "planning" on applying for med-peds programs in 10 months time. But I've been waffling recently and really keep going back and forth between FM and Med-Peds. I've done a lot of reading around the web and on SDN, including some other threads that compare the two fields.

I guess my main thoughts are as follows

• As a family doc, do you feel comfortable with taking care of kids? As in, sick kids. Not the relatively straight forward clinic stuff, but sick kids in a hospital with DKA, sepsis, osteo, etc, as well as doing pediatric intubations, pediatric codes, etc.
• Do you ever feel inferior to IM docs in terms of your level of comfort in an inpatient setting? I understand you can work as a hospitalist after FP residency, but is there a stigma against FP docs in this setting? Some of the IM residents on my rotation seemed to look down on the FP docs a bit. I was not comfortable with this attitude at all.
• How reasonable is it for a FP doc to have a job in a semi-suburban to suburban area (i.e not a city and not rural) that could also include some inpatient work on the side along with the standard outpatient work?

I guess I felt like I wanted to do Med-Peds due to the depth and breadth of training. I could feel "really comfortable" after that 4-year residency to manage adults and kids in an inpatient or outpatient setting (sans OB and procedural stuff of course) depending on my practice interests down the road.

But how true is this? As Family docs/residents, do you feel not as prepared as a meds-peds doc might be for handling the breadth and depth of inpatient and outpatient care?

What opened my eyes to this was doing a rural family med rotation with a 58-year-old FP doc who did A LOT of different things in the area he was. He was one of 5 docs in the region (two new docs just showed up in the last 2 years) and they did adult and pediatric inpatient and outpatient, office procedures, OB-related problems, EGD's, colonoscopies, etc. It was fun. I began to question whether med-peds was really necessary.

Thoughts?

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[VA Hopeful Dr]

Let me try and answer your main thoughts first, then I'll go rambling off in other directions...

1. Everywhere that I have ever been, kids with DKA/sepsis/osteo all get taken care of by pediatric intensivists. Your regular pediatrician, or even med-peds, isn't go to manage those kids. If you want to do that kind of work, then you're going to need a fellowship after either a peds or med-peds residency.
2. This depends a great deal on your FM training. Outside of the ICU, I feel that my skills in hospital medicine are probably within 90-95% of my internist wife's skills. That said, my program was on the heavier-inpatient side for a family program. My only real deficiency is with hospital procedures - mainly intubations and central lines but that was because I didn't try and seek out those procedures. Others in my program did and are doing inpatient work as we speak.
3. Those jobs do exist, but they are becoming harder and harder to find in cities over about 100k people. If you're OK with living somewhere smaller, then you should be able to find jobs like that.

Now, my own thoughts about med-peds: outside of academia (or rural, but then lack of OB could hurt you), I rarely see med-peds graduates taking full advantage of their training. In the outpatient world, most family offices want family doctors. If you join an internist practice, they aren't going to be thrilled about you bringing in kids (that they have to cover if you're sick/on vacation). The converse is true for a pediatric practice. You could do hospitalist work certainly, but places with a free standing children's hospital are going to be academic and places without are going to have separate adult and peds hospitalist services.

 

[deleted87716]

Some of the IM residents on my rotation seemed to look down on the FP docs a bit. I was not comfortable with this attitude at all.

Then you probably aren't going to like med-peds. That attitude is the reason most folks choose med-peds in the first place.

 

[cabinbuilder]

Sounds like you would be happier doing family medicine. You can gauge your electives in residency to learn the things you mentioned in your post: inpatient peds, scopes, procedures, OB, etc. However, depending on where you plan to practice, you may too busy to do "everything" and many time the really sick children get shipped out because the hospital where you are may not have all the resources available - that's reality of a lot of smaller places. Many times it comes down to the knowledge of the nursing staff. For example, I had to ship a patient in DKA to the next town because I had no nursing staff who had ICU experience and they didn't understand the K+ protocols/draws or insulin titration. The nurse manager actually stepped in and requested the transfer.
So your FP doc you rotated with who does scopes would not likely manage a child in ICU. I guess you will have to decide what is most important to you and determine your residency course from there. I wanted to learn scopes in residency (and I did) but once I got out and into practice, there just wasn't time to keep up the skills, or where I worked didn't have a proctor to sign me off, or since I'm in very rural places there wasn't the equipment. I had to let it go.

 

[eimaise]

Thanks everyone for the awesome replies.

One thing that attracts me to med-peds over family med is the ability to get that training in the ICU's, NICU, PICU, etc. that I wouldn't get as much of during a family practice residency. I guess I feel like if one can manage the most complex and sick patients with confidence, then they can manage less complex patients comfortably too. But from what I see and hear, the reverse is not always true (depending on training, etc.).

I have heard something said by a lot of internal medicine residents that is along the lines of, "family docs don't feel as comfortable in the hospital" or "family docs don't manage patients as well in the hospital."

Of course, I know this is not true across the board, but I have no way to gauge these statements for myself. I have been looking at some places like Via Christi family medicine residency in Wichita or JPS in Dallas that look awesome in terms of the scope of their training during the 3 years of residency. Would you guys recommend I do an away at one of these places during fourth year to try to assess if it would work well for me?

In terms of my career goals, I am not entirely sure in what context I would like to practice. I like inpatient medicine better than outpatient (but I wouldn't mind doing outpatient clinic 2 afternoons a week for example). My wife (a nurse) are considering many options for the future including overseas missions work, rural work, or urban city work. I can see pros and cons for me going into either FM or Med-Peds. I do like the idea of doing a 3-year residency vs. a 4 year residency.

One last question: do you ever see family medicine docs working in the ICU?

 

[DIce3]

Would you guys recommend I do an away at one of these places during fourth year to try to assess if it would work well for me?

I don't think it would really be that helpful in helping to make a decision but would be more of a factor of the individual attending you round with that month.

I like inpatient medicine better than outpatient

Then I think you are planning on IM/Peds unless you plan on working in a rural hospital.

One last question: do you ever see family medicine docs working in the ICU?

Not outside of a rural hospital

 

[VenturaResident]

Thanks everyone for the awesome replies.
I have heard something said by a lot of internal medicine residents that is along the lines of, "family docs don't feel as comfortable in the hospital" or "family docs don't manage patients as well in the hospital."
.....
One last question: do you ever see family medicine docs working in the ICU?

Up until a few months ago, the majority of our ICU attendings were Family Med trained. Now one of them went to work full time in the ER and they brought on a new person who is IM trained who worked here in the past, so the balance is now 50-50 I believe. This includes a FM doc who wrote the particular ICU manual we use when on that rotation. This includes people who teach courses nationwide about ICU procedures. We occasionally have a critical-care fellowship for FM grads from our program as well.

Similar situation with our hospitalists - clear majority are FM trained, including someone who has written multiple Tarascon guidebooks about hospital medicine.

Is it that way everywhere? Definitely not. But our FM docs are stellar in the ICU and on the wards. I can't blame the IM folks you talked to for their ignorance necessarily - no one can know how things happen everywhere - but I can tell you that at least in our corner of the country, their comments are wildly inaccurate and your concerns, though common, are not applicable here.

 

[VenturaResident]

I don't think it would really be that helpful in helping to make a decision but would be more of a factor of the individual attending you round with that month.

One last question: do you ever see family medicine docs working in the ICU?

Not outside of a rural hospital

I beg to differ. Our "town" has over 100,000 and is contiguous with a "town" of 200,000. Not rural here.

 

[smq123]

I guess I feel like if one can manage the most complex and sick patients with confidence, then they can manage less complex patients comfortably too.

Not true at all. A common fallacy, but definitely not true at all.

 

[MadHopsMD]

I think the two big differences:
1. You will never do OB if you choose MED-PEDS
2. You will never do inpatient Peds if you do FM residency *^

* even though some FM have hospital peds privileges, these are few in between. But most FM are not comfortable doing inpatient peds. The EXTRA year of MED-PEds just gives you the confidence that you need to do peds in the inpatient setting.
^ most Med-peds end up doing one adults or kids. At least those I know of.

 

[VA Hopeful Dr]

I think the two big differences:
1. You will never do OB if you choose MED-PEDS
2. You will never do inpatient Peds if you do FM residency *^

* even though some FM have hospital peds privileges, these are few in between. But most FM are not comfortable doing inpatient peds. The EXTRA year of MED-PEds just gives you the confidence that you need to do peds in the inpatient setting.
^ most Med-peds end up doing one adults or kids. At least those I know of.

The only folks I've seen who do both are either in academia or outpatient only. I've never seen a non-academic med-peds person do both adult and peds inpatient.