FP or Med-Peds??

[mochamuffins]

Well I am into my 4th day of family practice and very confused what to set up for rotations for residency.

So my back ground is that originally for three years I really thought I would go into family practice. Then I did my pediatric rotation and realized I loved it but not enough to go into it solely and started looking at med-peds program. I felt family practice residencies did not give enough of pediatric training for the amount of pediatrics I would ideally want in my practice. I have set up some rotations and subI focusing on med-peds residency. I have already got LOR focusing on me applying to med-peds. My personal statement also reflects this. Now having almost finished my first week of FP, I really enjoy it and am confused ( and maybe scared) that I made a mistake on focusing on med-peds. I am not sure if it is the brainwashing of the FPs who know my dilemna and I wont get to work with Med-Peds physicians until it is way into the application process. I have liked most of my rotations so far but have not had that " A-HA!!! This is definitely for me " experience. I am also an older female student( mid 30 s, recently single) and would like to settle and have a family one day...so I am keeping in mind that also. A friend suggested to go for med-peds because it may be harder to get into ( I only have a few programs so far that I like) and if it does not work out, scramble into FP.

Well thanks for reading my distraught ramblings. Hoping to get some advice from residents/ physicians that were in a similar dilemna

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[cdow18]

This has been talked about multiple times on SDN so do a search and you should find some answers. I'll still give my two cents anyway. I'll start by saying that I am about to be a 3rd year family medicine resident and my brother is Med-Peds two years out of residency so I have a decent idea of both sides of the training. I went through the same dilemma you are doing now in terms of deciding between the two and I'll tell you why I chose FM and you can take it for what it's worth.
A couple of things to think about when deciding are what you enjoy doing: inpt vs. outpt, whether you enjoy doing women's health, whether you enjoy doing procedures outpt and inpt, whether you know you want to do just primary care or you might want to do a fellowship or not.

Inpt vs. outpt: For the most part you will get better inpt training at a med-peds program. These programs usually have more ICU experience especially when it comes to peds and exposure to the different specialists services. The problem with family medicine is there is a drastic difference between programs in terms of the amount of inpt training that is received. I am at an unopposed fm program in which the inpt is very strong. We don't compete with the IM residents for cases which occurs at a lot of university programs so we have plenty of volume to learn from. We also take care of our own ICU pts, manage vents, etc. Procedure wise we do our own central lines, intubations, LP's, Thoro/paracentesis and are the code team for the hospital. In terms of oupt, fm's do more clinic work. By the third year most programs have residents in clinic 3-5 half days a week. Most med-peds that I've seen including my brother's program were 1-2 days.

Women's Health: The biggest argument I hear from people for doing med-peds over fm is that you have to do two months of OB for fm. In general not even the fm doctors are planning to do OB so most feel it is a waste of time. There are some fm's that do deliver babies and even do C-sections but this is not the norm. We also get a lot of GYN training which lends itself to a lot of office procedures as well, colposcopy, LEEP, endometrial biopsies. I don't mind women's health and I like doing the procedures.

Procedures: Usually med-peds are more comfortable than fm's at doing inpt procedures, but as mentioned for fm this is very program dependent. As far as outpt procedures it's no contest, fm's usually receive much more training in outpt procedures mostly because that is where most of our training time is spent. At my program we do stress test, minor skin procedures, colonoscopies, joint injections, and the women's health procedures mentioned above. The training in these types of procedures is also very program dependent, some programs stress this part of the training more than others.

Fellowships: If you are not 100% sure that you want to do just primary care I would not do fm. There are fellowships in fm but they don't lead to any board certifications and they don't help you make more money for the most part. So if you think you may want to do cards, gi, nephro, etc., go for med-peds.

Peds: A lot of people feel that fm's are not qualifed to take care of kids and can't imagine that any parent would take their kid to a fm over a pediatrician, but this is really not the case. 50% of all peds visits in the US are seen by fm doctors, so there are plenty of them out there taking care of kids. Once again, this is very program dependent in terms of fm, some programs have better training than others. I would say that for the most part if you want to take care of kids in the hospital I would do med-peds. If you just plan on seeing kids in the outpt setting you could do either, but you have to do your research in terms of the peds experience at the fm program.

The moral of the story is both specialties have their pros and cons. I enjoy the clinic setting and doing procedures. So to me, fm was one less year with more outpt procedure training which is where I plan on spending most of my time. I would advise against choosing med peds just b/c it is more competitive and then scramble into fm if you don't get a spot. This is how a lot of people end up being unhappy at fm. Although, fm is probably the least competitive specialty, the good programs are competitive and if you are going somewhere that isn't matching their spots chances are the training is may not be that great. You really have to do your research when looking at fm programs as mentioned some stress inpt, peds, women's health, procedures more than others. For the most part you can find a program that tailors to your wants and needs.

 

[oldbearprofessor]

50% of all peds visits in the US are seen by fm doctors.

Reference?

The number published last year was 16-26%

http://pediatrics.aappublications.org/cgi/content/abstract/118/3/1200

 

[cdow18]

Sorry 20%. I forgot to mention peds was one of the reasons my brother chose medpeds. He really wanted to take care of kids in the hospital. He also wasn't sure if he wanted to do a fellowship or not and wanted to keep his options open.

 

[Sharn Penndroen]

I'm a 4th year student planning on applying to Med-Peds and I get asked all the time why not FM. My answer is:

1) I don't plan on delivering babies. Even if I really wanted to, I couldn't afford the insurance.

2) More Peds exposure. I talked with several FMP and asked them what percentage of their visits were Peds patients. Most of them told me about 10-15% percent. (This is in my state and in places I want to practice.) I talked to Med-Peds docs in town and the lowest was 30% the highest was 50%. For people in the places I want to work, a lot of parents want to take their children especially the really small ones to board certified pediatricians. I'm not saying they have a good reason to feel that way or trying to bash FMPs ped knowledge, I'm just saying that is the way it is around here. Most of the FM residents I talked to here are fine seeing only about 15% peds so they don't have a problem with the current set up. My wife actually tried to take our son to a FMP when he was 9mo old. He refered her to a Pediatrician saying that he didn't feel comfortable seeing children under 1 year old. He did it in a very nice and professional way of course, that is just the practice set up he had. So yeah, I want to see more peds than most family docs in town.

3) I may specialize. I really enjoy A/I, Endocrine, and Cards. I could see possibly specializing in those, so I want to keep my options open. Actually I should have reversed the order of these for importance. This is the most important reason I'm choosing Med-Peds.

Overall, if you go primary care, you will likely do fine with either specialty, in my opinion. You just need to think about which one is a good fit for you. Good luck!

 

[jimmybee]

I'm currently a second year Med/Peds resident and I have a few thoughts.

To the first post, you should do Med/Peds as it is obvious that you are confused about your future plans. Although most people would deny that this is why they went into Med/Peds, most don't know what they want to do until they have endured a year of residency. Med/Peds will give you the flexibility to 1) change to another residency (IM, Peds, or FP) without losing much/any time; 2) do a fellowship; or 3) stick with M/P. You can't go wrong.

To the other post that said both programs will make you equally qualified for primary care, I couldn't disagree more. I will admit that I thought this initially when I applied to residency but I have found that this is not the case. FP is much more adept to giving you the outpatient experience that you need to hit the ground running after residency and making it in the outpatient world. I interviewed at a lot of places and I didn't find a program that had clinic more than twice a week (almost all were once per week). My program is once per week. I tell people that if they know 100% that they want to do primary care, go FP. You will save a year and be better off atleast initially.

 

[Sharn Penndroen]

To the other post that said both programs will make you equally qualified for primary care, I couldn't disagree more. I will admit that I thought this initially when I applied to residency but I have found that this is not the case. FP is much more adept to giving you the outpatient experience that you need to hit the ground running after residency and making it in the outpatient world. I interviewed at a lot of places and I didn't find a program that had clinic more than twice a week (almost all were once per week). My program is once per week. I tell people that if they know 100% that they want to do primary care, go FP. You will save a year and be better off atleast initially.

If you are referring to my post, I did NOT say "equally qualified for primary care." I said, "you would do fine with either speciality." Plesae don't put words into my mouth. What I meant by my statement is that though FM is more geared toward outpatient care, doing Med-Peds does not prevent you from being a good primary care doctor. I.e. you'll do fine. There is a private practice Med-Peds clinic here in town with two recently graduated Med-Peds physicians. They see 60% adults and 40% children. They are very capable and are having success in their clinic. Just pointing out that if you do Med-Peds and decide you want to do primary care, that is still a very valid option for you.

 

[jimmybee]

my bad

 

[ChildNeuro]

Peds: A lot of people feel that fm's are not qualifed to take care of kids and can't imagine that any parent would take their kid to a fm over a pediatrician, but this is really not the case. 50% of all peds visits in the US are seen by fm doctors, so there are plenty of them out there taking care of kids.

I have seen family practice doctors take care of kids, and their approach is somewhat less intense and hollistic than pediatricians who know more about the development of children and probably more pediatric medicine due to their training. It was actually kind of scary, on FP just gave vaccines, didn't ask about school or ask about milestones, and just plain didn't seem interested in digging at least a little bit deeper with each patient to make sure he had a good feel with them.

One family practice program I googled had 18 weeks of a rotation labeled as Pediatric something. The others were adult medicine, community medicine, ob/gyn, gastroenterology, etc . . . A pediatrician who has been seeing just kids for three years, i.e. maybe 136+ weeks of sole pediatric work would have a huge advantage of picking up on sick kids, and also would be able to help kids who had more subtle problems. If more FPs are not actually doing ob or procedures, then perhaps FP residencies should be phase out and converted into med/peds residencies. . . I would rather my kid see a pediatrician than an FP just due to the training issue.

 

[sophiejane]

It was actually kind of scary, one FP just gave vaccines, didn't ask about school or ask about milestones, and just plain didn't seem interested in digging at least a little bit deeper with each patient to make sure he had a good feel with them.

Basing your opinion of how FPs care for children on Google searches and what you have personally seen (i.e. "one" FP) is probably a mistake. You don't know how well that FP may have known the family. Maybe they were in last week and discussed developmental issues, maybe he's been caring for the whole family for years and knows them really well, including the child. Maybe he was having an off day--we all have them. Also, at our clinic, the nurse does the Denver and all the household lead questions, etc. It's in the chart when we walk in, so yeah, if there are no major issues there, I'm not going to spend a lot of time asking the parents what the nurse already asked. I'll ask if they have concerns, in a general way.

I have seen FPs do a better, more thorough job with kids than some pediatricians, but that doesn't make me think FPs as a whole are better at peds than the specialists.

 

[ChildNeuro]

Basing your opinion of how FPs care for children on Google searches and what you have personally seen (i.e. "one" FP) is probably a mistake. You don't know how well that FP may have known the family. Maybe they were in last week and discussed developmental issues, maybe he's been caring for the whole family for years and knows them really well, including the child. Maybe he was having an off day--we all have them. Also, at our clinic, the nurse does the Denver and all the household lead questions, etc. It's in the chart when we walk in, so yeah, if there are no major issues there, I'm not going to spend a lot of time asking the parents what the nurse already asked. I'll ask if they have concerns, in a general way.

I have seen FPs do a better, more thorough job with kids than some pediatricians, but that doesn't make me think FPs as a whole are better at peds than the specialists.

Ok, not to knock the many FPs who are working deligently to see children in their practice, I just think that overall the pediatric training in FP is very watered down from what pediatricians get. Personally, I have been in FP office's where they have a questionnaire where you check-off what symptoms you have or a nurse asks some questions and then you see the FP. I think that this can lead to a very bad practice of medicine if you used improperly. Number one, as a doctor we receive more training in how to ask open ended questions, and how to ask focused questions with a reason in mind. If you just ask a whole bunch of screening questions and don't really talk to the doctor, then your needs are not met. A large part of going to see a doctor is to get face time with the doctor and to have the doctor ask questions concerning health. Personally, if I was running an FP clinic I would let the nurses do vitals, weight et. . . But I would want to do the comprehensive first visit myself, write down/input the PMHx myself, and then decide to ask questions based on that. What is the whole purpose of medical school where we are taught to interview patients in clinics, on wards, etc . . . if we don't use it? There is a high level of anxiety and concern for your patient's health that seems to be produced during medical school, I have had family members go to NPs who have not dug as deep as I would have.

 

[McDoctor]

Ok, not to knock the many FPs who are working deligently to see children in their practice, I just think that overall the pediatric training in FP is very watered down from what pediatricians get. Personally, I have been in FP office's where they have a questionnaire where you check-off what symptoms you have or a nurse asks some questions and then you see the FP. I think that this can lead to a very bad practice of medicine if you used improperly. Number one, as a doctor we receive more training in how to ask open ended questions, and how to ask focused questions with a reason in mind. If you just ask a whole bunch of screening questions and don't really talk to the doctor, then your needs are not met. A large part of going to see a doctor is to get face time with the doctor and to have the doctor ask questions concerning health. Personally, if I was running an FP clinic I would let the nurses do vitals, weight et. . . But I would want to do the comprehensive first visit myself, write down/input the PMHx myself, and then decide to ask questions based on that. What is the whole purpose of medical school where we are taught to interview patients in clinics, on wards, etc . . . if we don't use it? There is a high level of anxiety and concern for your patient's health that seems to be produced during medical school, I have had family members go to NPs who have not dug as deep as I would have.

Obviously, pediatricians have more exposure to caring for children than family physicians. This is what their whole residency is devoted towards. IMO, the best family docs are the ones who know their scope of practice and aren't afraid to refer to a pediatrician under appropriate circumstances. But alot of straightforward illnesses and routine health maintenance certainly can fall within the scope of practice of a family doctor. You don't need to have done several rotations in pediatric Infectious Disease to treat strep throat or recognize infectious mononucleosis.

As far as the experience at the FP's office you describe, this is typical of many pediatricians as well. Peds faces the same financial pressures as primary care, which tends to demand patients be scheduled every 10 minutes with occasional double-booking for add ons in many offices. This demands delegation of certain duties to ancillary staff, and of course it is frustrating. The main drawback to declining reimbursement in primary care isn't necessarily how it impacts your salary, it's how it impact your ability to practice medicine the way you want. You will find these frustrating circumstances in peds, FP, IM/Peds,...pretty much any non-procedural field of medicine.

 

[iatrosB]

Obviously, pediatricians have more exposure to caring for children than family physicians. This is what their whole residency is devoted towards. IMO, the best family docs are the ones who know their scope of practice and aren't afraid to refer to a pediatrician under appropriate circumstances. But alot of straightforward illnesses and routine health maintenance certainly can fall within the scope of practice of a family doctor. You don't need to have done several rotations in pediatric Infectious Disease to treat strep throat or recognize infectious mononucleosis.

As far as the experience at the FP's office you describe, this is typical of many pediatricians as well. Peds faces the same financial pressures as primary care, which tends to demand patients be scheduled every 10 minutes with occasional double-booking for add ons in many offices. This demands delegation of certain duties to ancillary staff, and of course it is frustrating. The main drawback to declining reimbursement in primary care isn't necessarily how it impacts your salary, it's how it impact your ability to practice medicine the way you want. You will find these frustrating circumstances in peds, FP, IM/Peds,...pretty much any non-procedural field of medicine.

Well said. Sadly, at the end of the day, it's not about training, its about re-imbursements. I have seen many peds practices ran just like the FM practices as well. It's not what is best for the patient, but insurance and the government have dictated this style of practice.

 

[sophiejane]

There is a high level of anxiety and concern for your patient's health that seems to be produced during medical school, I have had family members go to NPs who have not dug as deep as I would have.

Good luck with that. Get back to us in a few years on how that's workin' for ya.

I'm about the most optimistic and pro-patient person there is, but even I have come to understand that you are the most valuable resource the patient has, and you have to distribute your resources carefully. You simply cannot give every patient the depth and face-time they all deserve, and remain financially viable. If you go bankrupt, all that depth of questioning and earnest conversations you have with all of your patients will come to a screeching halt.

 

[sophiejane]

Ok, not to knock the many FPs who are working deligently to see children in their practice, I just think that overall the pediatric training in FP is very watered down from what pediatricians get.

The pediatrics training I will get at my program is pretty extensive (we care for NICU babies, for example) and we have a lot of it, both inpatient and outpatient. We are the peds service at our hospital. There is a great variety in peds training at different programs.

On the other hand, you could say that about everything in FM. It has to be somewhat watered down because of the breadth of scope. We are generalist specialists. We are the ones who filter the background noise and often send the patients who need it off to the appropriate specialist with the diagnosis pretty much wrapped up.

Let's compare apples to apples. Pediatricians are not FPs and FPs are not pediatricians.

 

[deleted87716]

Personally, if I was running an FP clinic I would let the nurses do vitals, weight et. . . But I would want to do the comprehensive first visit myself, write down/input the PMHx myself, and then decide to ask questions based on that.

Personally, I am running a family medicine office (I hate the term "clinic"), and that's exactly how I do it. Remember, there's always more than one way to skin a cat, and you can learn as much from what others are doing wrong as you can from what they're doing right.

Incidentally, all of my well-child checks are scheduled as 30-minute appointments...with me, not the nurse. I wonder how many pediatricians can say that?

 

[Tn Family MD]

Our FP program is also the sole pediatric service in our hospital. We do two months of peds in-pt rotations at a private children's hospital in our city with the pediatric hospitalists group over there during our intern year. We do a month of newborn/NICU during intern year as well. We also do two months of out-pt peds with a local peds group in second year. In addition to that, we admit all the peds cases to our hospital and also take care of every newborn we deliver during our three years of residency. To top it off, we can schedule up to three months of peds sub-specialty electives (I will personally do another month of NICU, a month of Peds ID, and a month of Peds derm). That is, in fact, a fair amount of peds exposure. In my opinion.

As for what to do, man, it's totally up to you. I personally have an interest in women's health and love delivering babies. In fact, I plan on doing a fellowship to get trained in c-sections. I also love doing out-pt procedures. Therefore, FP was the obvious choice for me.

Also, FWIW, a peds doc took car of my first born during his first two years of life. An FP now takes care of him and my three month old little girl. I am overall much more impressed with the care our FP has delivered. He is much more genuine and thorough.

 

[hidradenitis]

Can't comment on what it's like to be an M/P resident, but I just finished an FP residency. A couple of thoughts:

1. FP programs do indeed vary quite a bit. Mine was unopposed, which gave us a lot more 'hands on'. Only way to do it, IMHO. If your plan is to scramble into FP because you know there will be one open, you may be disappointed to find the only ones left will be pretty shabby.

2. FP training experience is more than the sum total of rotations given the amount of clinic. 'Only two' months of OB equated to quite a bit more than that once you factor in the off-rotation OB calls and the continuity patients - I was hatching babies up into my last week of residency, even though my last OB month had finished more than a year and a half previously. Ditto for peds. (Caveat -- see #1 above).

3. Everyone gravitates towards the practice they like/are most comfortable with. At some point, you will limit your practice accordingly. NOBODY does everything. The question is what are you willing to do without.

4. Med students agonize more about these distinctions than do docs in the real world. Most docs care more about a) your competence in your given field and b) whether you're a jerk/arrogant/condescending or not. If you are good at what you do and play nice with the other kids, you will have no problems.

5. If specializing is anywhere in your future, go M/P (or better yet, IM or Peds -- save yourself the hassle). I would also go M/P if you want a generalist view of the world but really dig inpatient medicine or if you really hate anything gyn-related. If you know primary care is your thing for sure or if you like procedures in an office setting, go FP.

Good luck!

 

[McDoctor]

Personally, I am running a family medicine office (I hate the term "clinic"), and that's exactly how I do it. Remember, there's always more than one way to skin a cat, and you can learn as much from what others are doing wrong as you can from what they're doing right.

Incidentally, all of my well-child checks are scheduled as 30-minute appointments...with me, not the nurse. I wonder how many pediatricians can say that?

Do PA's or nurse practitioners do well-child checks in your office?

 

[McDoctor]

The pediatrics training I will get at my program is pretty extensive (we care for NICU babies, for example) and we have a lot of it, both inpatient and outpatient. We are the peds service at our hospital.

I'm not sure theres much value to a NICU rotation. You very likely are not going to have these responsibilities when you finish training. Alot of residents did it any my program because it was a blow-off rotation, mostly involving gathering data and following protocols. Those that did the rotation said that alot of the NICU work was done by mid-levels, and medical decision making was minimal. I could be wrong, I didn't do NICU myself. But I think the time is better spent on ambulatory peds.

 

[sophiejane]

I'm not sure theres much value to a NICU rotation. You very likely are not going to have these responsibilities when you finish training. Alot of residents did it any my program because it was a blow-off rotation, mostly involving gathering data and following protocols. Those that did the rotation said that alot of the NICU work was done by mid-levels, and medical decision making was minimal. I could be wrong, I didn't do NICU myself. But I think the time is better spent on ambulatory peds.

I don't really have much choice. Babies born on our OB service who are admitted to the NICU are followed by our peds service. It's just how we're set up. We have a big high-risk OB population so it's common to have one or two NICU babies, apparently. I will find out in December when I'm on peds!

 

[deleted87716]

Do PA's or nurse practitioners do well-child checks in your office?

No mid-levels. Just three docs.

 

[heartdoc345]

I'm not sure theres much value to a NICU rotation. ... Alot of residents did it any my program because it was a blow-off rotation, mostly involving gathering data and following protocols. Those that did the rotation said that alot of the NICU work was done by mid-levels, and medical decision making was minimal. I could be wrong, I didn't do NICU myself. But I think the time is better spent on ambulatory peds.

It depends on what kind of NICU...

If it's a level I or II, then it's probably a waste of time as a med student, unless there is a large volume of deliveries to go to - in a level I or II the only sick kids would be the ones you have to resuscitate at delivery before you ship them off to a higher level.

In my residency program (I'm med-peds) we have rotations at two level III and one level IV NICU. The level IV NICU has lots of surgical kids, not just feeder-grower preemies, and we have plenty of sick kids on vents who need umbilical lines, etc at the level III nurseries. I don't know how much they would let a med student do in terms of procedures, but if you can rotate at a NICU with kids with congenital heart disease, Hirschsprung's disease, congenital diaphragmatic hernia, or other surgical anomalies, you could learn a ton.

 

[heartdoc345]

3. Everyone gravitates towards the practice they like/are most comfortable with....

4. Med students agonize more about these distinctions than do docs in the real world. ...

5. If specializing is anywhere in your future, go M/P (or better yet, IM or Peds -- save yourself the hassle). I would also go M/P if you want a generalist view of the world but really dig inpatient medicine or if you really hate anything gyn-related. If you know primary care is your thing for sure or if you like procedures in an office setting, go FP.

Excellent points, especially #4

My primary care doctor is a med/peds doc, and he has a practice with another med/peds doc, four FPs, and a PA. They get along just fine, but the med/peds docs tend to take internal referrals from the FPs with sicker kids or frequently hospitalized adults.

I hemmed and hawed the same question four years ago, and ultimately did med/peds because of wanting to possibly specialize. I'm really glad I did med/peds because what I didn't know in med school was that I was going to like the ICU a lot more than clinic (I will have done 8 ICU rotations in residency).

At the time I made my decision, it was a matter of a) hating OB b) loving neonatal resusciation and c) not knowing if I would specialize or not. At the time, I was afraid of ICU care since I never got to do much of it in med school. It turns out I love ICU and don't like outpatient medicine much, so med/peds is a great fit for me.

However, many of my colleagues love outpatient medicine and do electives in all sorts of outpatient fields. You can really taylor a med/peds residency to fit your needs. But, as previous posters have said, you will definitely have a lot more inpatient time in med/peds than FP.

If you do FP, I would definitely recommend an unopposed program. Every academic med center I've been too has been full of people who look down on FP, which I think is unfair, since some of the best doctors I know are FPs.