FP vs. Med/Peds

[Noelle]

I hope not to offend anyone in asking this but I'm asking to get some ideas of why I might choose one field over the other. I am considering primary care and I'd like to know peoples thoughts about what the differences really are - besides the obvious OB training. I don't want to do OB anyway. My biggest concern is the pediatric requirement in FP. At my school the only requirement for residency is 1 month NICU, 2 months PICU, and 1 month outpatient peds clinic. Is that TRULY enough to know how to REALLY take care of a child? Maybe this is different at other schools. Any thoughts would be well appreciated.

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[deleted6669]

most fp residencies have you spend a few days a week in clinic with pts of all ages so you see a lot of routine peds cases there as well as on peds specific rotations.
med/peds prepares you more for inpt care of sick kids and adults while fp covers management of pts across the age spectrum in all settings with an emphasis on outpt medicine. studies have shown no advantage to doing med/peds over fp in most primary care situations. if you want to do mostly inpt medicine go med/peds. if you want full spectrum training do fp. I will try to find and attatch an article I saw a while ago on the subject.
here it is:
What is the difference between a family practice residency and combined residencies in internal medicine and pediatrics, family practice and psychiatry, and family practice and internal medicine?

During the past several years, modest growth has occurred in the development of residency education programs that use other models for generalist training, such as combined residencies in internal medicine and pediatrics or family practice and another specialty.

Combined specialty programs must be approved by each respective board in order for graduates to be eligible for certification. In dual certification, each board makes an independent ruling on the eligibility of every candidate for board certification.

The American Board of Family Practice and the American Board of Internal Medicine each offer certification to graduates of a handful of programs that provide for completion of four years of combined training. Currently, fewer than five such programs are available in the United States. The certifying boards of family practice and psychiatry and neurology each offer certification for the completion of at least five years of training in a combined residency. At present, fewer than 15 of these programs are available in this country. The American Board of Internal Medicine and the American Board of Pediatrics offer certification for the completion of a combined residency that includes two years in each specialty, for a total of at least four years. In 1998, there were approximately 100 such programs.32

Compared with family practice residencies, dual certification programs tend to emphasize inpatient medicine. They also tend to offer broader exposure to the "specialist aspects" of each specialty. They tend to place less emphasis on continuity of care in the outpatient setting.

No evidence shows that the graduates of any of these combined programs are more effective in practice or obtain more privileges than those who graduate from a family practice residency program.33 In fact, evaluations of these programs often use family practice as the benchmark. Only about 68 percent of physicians trained in internal medicine and pediatrics, for example, actually practice primary care medicine, and only about 55 percent practice both internal medicine and pediatrics.34 In contrast, family medicine is practiced by more than 91 percent of the physicians who received training in a family practice residency during the first 25 years that the training was offered, and family medicine is practiced by more than 93 percent of current graduates of family practice residency programs.35,36

Graduates of dual certification programs face some special challenges. Some have complained about difficulties in being listed by managed care organizations under both specialties at the same time. They must maintain certification with two boards and membership in two national organizations. They also must obtain coverage for patients during off hours. Unless another physician with the same dual certification is available, coverage must be obtained from two physicians at the same time. However, family physicians are able to provide coverage for patients of almost all dual-certified physicians who are practicing primary care medicine.

 

[bulldawg]

In my opinion, those who choose med-peds over family practice were probably not given enough hugs as children. Or perhaps their parents have not told them that they are proud of them. From my experience, most of the people at my med school who are the professed "med-peds people" have parents who are physicians or surgeons. It's as if they feel that fam med is just not a sexy enough doctor for them to tell people at cocktail parties.

I'm mostly kidding, but there may be some truth to this. Any thoughts?

 

[seattledoc]

The major drawback to going the FP route is that it doesn't allow for further training outside of primary care. Sure you can do sports med/geriatrics training but if you decide at a later date that seeing primary care stuff is no longer any fun, you're out of luck unless you want to get out of patient care altogether and do administration or something.

In contrast with Med/Peds, you can go back for a fellowship and get out of the primary care situation and into any number of fields.

So if there's a chance you might want to train further than a 3/4 year residency, then Med/Peds is your baby.

By the way, I agree with bulldawg that FP has a stigma and people therefore are more accepting of Med/peds training

 

[Noelle]

Well I can definitely tell you my parents or any close relatives are physicians. I just have a hard time believing that I would be comfortable taking care of someone's child with a 3 month pediatrics requirement. If a family doc is aptly qualified to take care of a child for the span of its life why bother doing pediatrics for 3 years? Whats the need? Maybe I'm blowing this way out of proportion because I'm a mother. But if it is my child I think I'd prefer the doc with 3 years of training.

 

[Noelle]

whoops. My parents are not physicians!!

 

[phd2b]

This is an interesting topic insofar as there are many of contemplating the two routes. I believe that the arguments have been pretty well laid out.

I was surprised the other day to see that UTKnoxville (http://www.utmck.edu/fammed/) has fellowship training for family practice that includes:

-Sports Med
-Advanced obstetrics
-Emergency Med
-Behavioral Med.

So, I suppose that makes 5 fellowship opportunities (including geriatrics) that are readily available, at the minimum.

For those of us who are *still* unsure and are afraid that we might want to do hem/onc, GI, cards, etc, one day, Med-Peds is a safer route. That said, for those of us who are pleased to see patients with all of the variety that comes with it, FP should fit the bill.

I'm going for Neonatal Psychiatric Dermatology, myself.

Your mileage may vary...

 

[deleted6669]

pediatricians have more inpt peds experience than fp docs but the outpt(clinic/er) training is very similar
there are actualy a lot more fp fellowships out there than just sports med and geriatrics. h ere is a partial list from www.aafp.org

Other Types of Fellowships
Maricopa Medical Center Advanced Hospital Training Phoenix AZ
Maricopa Integrated Health Systems Indigent Care Phoenix AZ
UCSF-Fresno Family Practice Fresno CA
Loma Linda University Substance Abuse Loma Linda CA
UCLA Division of Sports Medicine Primary Care Sports Medicine Los Angeles CA
University of CA / Davis Primary Care Outcomes Research Sacramento CA
San Diego Sports Medicine & Primary Care Sports Medicine San Diego CA
Geriatric - Osteopathic Colorado Springs CO
University of Colorado Primary Care Sports Medicine Denver CO
Yale Occupational/Environmental Med Prog Occupational/Environmental Medicine New Haven CT
Georgetown Univ Medical Ctr Medical Editing/Faculty Development Washington DC
Georgetown U. Medicial Center Community Medicine Washington DC
Georgetown University School of Medicine Health Policy Washington DC
Georgetown University Medical Center Primary Care Informatics Washington DC
Family Practice Residency of Idaho, Inc Primary Care Sports Medicine Boise ID
MacNeal FPR Family Systems Medicine Berwyn IL
MacNeal Family Practice Residency Women's Health Berwyn IL
National Headache Foundation Headache Chicago IL
PCC Community Health Center Maternal & Child Health Oak Park IL
University of Illinois - Peoria Women's Health Peoria IL
Indiana University Underserved Medicine Indianapolis IN
Commonwealth Fund Minority Health Policy Boston MA
Commonwealth Fund Leadership & Health Policy Training Boston MA
EMMC Family Practice Residency Program Osteopathic Manipulative Medicine Bangor ME
Wayne State University Occupational/Environmental Medicine Detroit MI
Univ of MN Medical School Clinical Research Minneapolis MN
Univ of MS Medical Center Health Psychology Jackson MS
Duke University Medical Center Preventive Medicine/Occupational Med Specialty Durham NC
E. Carolina University Primary Care Women's Health Greenville NC
New Hampshire Dartmouth FPR Preventive Medicine/Leadership Concord NH
Cooper Health System Medical Acupuncture Camden NJ
UMDNJ-Robert Wood Johnson Health Policy New Brunswick NJ
UMDNJ-RWJ Medical School Women's Health New Brunswick NJ
Epicd Palliative Care Palliative Care Albuquerque NM
SUNY/Health Science Ctr at Brooklyn Women's Health Brooklyn NY
Family Medicine Center Behavior Change Rochester NY
University of Rochester Public Healthcare & Health Services Research Rochester NY
Family Medicine Center Family Planning & Reproductive Health Rochester NY
Family Medicine Center Patient-Centered Care Rochester NY
Family Medicine Center Family Systems Medicine Rochester NY
OHSU School of Medicine Clinical Leadership Portland OR
Oregan Health Sci University Residency Instructor Portland OR
Montgomery FPRP Family Practice Hospitalist Norristown PA
University of Pennsylvania Health System Research/Faculty Development Philadelphia PA
University of Tennessee at Memphis Emergency Medicine Covington TN
University of Tennessee Emergency Medicine Knoxville TN
UT Department of FM - Knoxville Behavioral Medicine Knoxville TN
Palliative Medicine Memphis TN
University of Texas Primary Care Houston TX
Swedish Family Medicine Residency Advanced Training in Geriatrics Seattle WA

 

[Ponyboy]

Pediatricians have a much more intensive view of inpatient pediatrics than their FP counterparts. In fact, some peds residents spend more time in the NICU than some FP residents spend in peds altogether. As you can imagine, pediatricians will be much more comfortable than an FP in a hospital setting. But pediatric residents also spend much more time in both general and subspecialty peds clinics than FP's so they are much more comfortable working up complex, subspecialty problems in the outpatient setting. The same applies for Med/Peds programs, more inpatient and more outpatient subspecialty time, makes them more comfortable with complex patients. As an example, how comfortable would an FP vs. pediatrician feel taking care of an ex-32 week preemie with chronic lung disease from mechanical ventilator, CF and delayed development?

 

[oldandtired]

It doesnt matter. Have you guys actually spent time in a pediatrician's clinic in an affluent area? It is 99%+ well child care, URI and a few other common maladies.

Refer the heavy inpatient stuff to people who do it all the time, i.e hospitalists, intensivists, pulmonologists.


Primary care will slowly wither away as technology and medicine advance. PAs, NPs will be more cost effective future of primary care

 

[Ponyboy]

Eventually, even the heavy inpatient stuff gets discharged home and has to see a doctor for a check-up and other complaints. Who would you want managing your child with multiple medical problems?

While I haven't worked in an affluent peds clinic, I have worked in an inner city peds clinic and I do see the complex, ex-NICU kids, the recently immigrated children with seven years of no healthcare, etc. Granted many of my patients are easy healthy kids, I still have the complex, difficult patients to see. This is where dedicated peds subspecialty training is invaluable.

 

[seattledoc]

any ex-NICU, multiple complication child that comes to my FP office gets transferred to the pediatricians office ASAP and I would imagine that they refer them on to specialists for some of the care.
FP's can handle many peds situations, the trick is knowing your own comfort zone and working within it.
Now some people may say, why not just have all children seen by pediatricians...and if the pediatricians were able to do this, then that would be great, but I doubt there are enough to meet demand.

 

[GeddyLee]

I think my biggest fear of FP doing peds is not that they can't take care of most problems or that they won't refer when outside their comfort level, but that they may not recognize a disorder that needs referral. I've heard plenty of stories of FP's putting off referral to ophthalmology for strabismus, hence the child develops amblyopia because the FP didn't realize that the child had it, or thought it would correct itself. I think children should be seen by pediatricians in order to attain the highest quality of care. Same goes for pregnant women...they should see an OB/Gyn. I guess I just don't understand FP or something. Certainly I think the specialty is great for rural areas where you need a "jack-of-all trades", but FP's practice in urban areas too...maybe it's just more convenient for the patients. Anyway, just my thoughts, I'd only take my children to a pediatrician, therefore that's what I would recommend to my patients or the general public.

 

[deleted6669]

I take my kids to a peds doc too, however I think when they turn 12 or so that we will start taking them to the family fp .

 

[bustbones26]

Why do med/peds over FP? Simple. if you hate gyn/obstetrics! I realize that FP's are not obligated to do obstetrics when they are attendings, but they have to do a great deal of it during their three year residency.

My wife is an FP resident. When she does her obstetric months I watch her come home for 10 minutes, then get paged to go back to the hospital again. It is true hell! She never sleeps during her obstetric months!

A friend of mine once put it this way. An FP is a jack of all trades, master of nothing. So if you want to be a jack of all trades, but don't feel like enduring the hell of obstetrics, then med/peds is for you.

Also, as of late, many people are taking an avid interest in becoming hospitalist. I personally think that a med/peds person has a great background to be a hospitalist.

Here is another thought. What if you want to be an endocrinologist? Instead of doing IM, then doing fellowship in endo and living out a life of seeing adult diabetics, with the extra peds background, you can manage peds endocrine cases as well. In fact, what if you want to do a fellowship in any of the IM specialties? With the extra peds background, you may not have to limit your cases to just adults.

 

[secretwave101]

I just have a hard time believing that I would be comfortable taking care of someone's child with a 3 month pediatrics requirement.

Just refer any you are uncomfortable with - and take care of the rest. Pretty simple.

Also, atomizing medicine isn't the salvation it may appear to be. Docs who can think comprehensively, and who have good knowledge about the entire family unit are always going to be valuable. I don't think they will ever be replaced.

Most people I know would rather have 1 doctor they really know and trust, that lots of docs that know little parts of their lives. Yes, we need people who are autistic about one sliver of medical knowledge, but a really good generalist (a TRUE generalist) who refers out when necessary, is best option for a busy family with lots of kids and obligations.