Med/Peds advice?

[TommyGunn04]

As the end of my clinical year approaches, I've been thinking more and more about residency programs. I'm facing a bit of a dilemma, for I'm leaning towards doing a combined med/peds residency program, but it is highly likely that I will pursue further training and perhaps end up treating only adults or only children. I'm particularly interested in oncology, but unfortunately have not been able to get any experience in the adult oncology world (I have worked previously in pediatric oncology and absolutely love it!).

So my big conflict is that while I thoroughly enjoy the problems of adult medicine and the training, I'm not a big fan of the specialty work, and while I love the peds specialty work (especially peds heme/onc), I pretty much abhor the training and the common problems, which make up a good 50% or more of the residency, especially the boring well-child checks and otitis media busywork stuff. The other thing I'm wrestling with is that peds is much less intellectual and evidence based, at least at my school. At this point I'm basically debating whether or not I should do a combined program to keep my options open for future training, as I'm sure my perspective will change as I go through the process. I just feel like I'm not ready at this point in my career to give up working with both adults and chidren.

I've been doing lots of reading (medpeds.org and old threads here) and asking, but I was hoping to hear from some folks who've been through this sort of decision process, or perhaps those who are current med/peds residents, etc. Most people seem to say that if you're planning on specializing then med/peds is a waste of time, and that you lose out on elective rotations, etc., but truthfully a good 20% or so of med/peds residents pursue further training.

Any words of wisdom for a lost med student? 🙂

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[The Med-Peds Dude]

I'm a Med-Peds PD...you seem to have a reasonable grasp of the situation. I like having bright, intellectually curious people in my program, but in your case would worry you might get a year or 2 down the road and decide that IM or Peds is just not worth the trouble. Four years can be a long time if you don't like 1/2 your residency.

j

 

[TommyGunn04]

Four years can be a long time if you don't like 1/2 your residency.

True, very true. For me though it would be a matter of possibly disliking 25% of the residency (the peds outpatient work, which I gather is generally 50% of the peds half of med/peds), which I've found is pretty standard for most residents in general. For example, medicine residents often have a fixed dislike for the MICU, or the VA, or their clinic, or some specific aspect of the residency (like their internship! ), but that doesn't stop it from being worth enduring in order to get where you want to go. I've also found the same to be true for peds residents; most of the ones here hate the NICU and the acute care clinic. In fact, I know a bunch of students who just matched in peds or med/peds who are somewhat like me in that they really dislike outpatient general pediatrics, yet they know they want to work in a peds specialty and therefore feel it's a worthwhile thing to endure.

Regarding your concerns as a Program Director about residents deciding to leave the combined program for one or the other, how do you fairly assess this through the application/interview process? In my limited experience the med/peds residents I've come across all seem to have somewhat of a preference one way or the other...what makes you worry and what are you comfortable with? Personally I can't see myself ever backing out of a commitment like that, but I understand your concern, for I've seen it happen here with a couple of med/peds residents.

 

[Sheon]

I think that everyone is going to dislike some portion of their specialty. Most of the surgical residents I know hate the floor work. That's more than half of their time. Hey, give some to get some.

 

[The Med-Peds Dude]

Fairly assess? Just about impossible. How interested are they in the residency itself, do they stress one specialty over another in their personal statement or interview, do the reference letter writers seem to know the applicants residency plans? You do get some folks, esp in the scramble, who really seem to be looking for a foot in the door. Sometimes this slips out a bit. A few years ago we scrambled two people, both originally wanting to do peds. One did switch to peds, the other went through the program and ended up doing an adult ID fellowship. So you never know.

 

[RuralMedicine]

I'm currently a Med-Peds 3rd year who did a fair amount of soul searching to get to Med-Peds and now many calls later I still think I made the right decision. 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. In my opinion, 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 theirs 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. 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.

I also really like inpatient and acute care work (and actually plan additional training in critical care after residency). That said I've found that sometimes going to my continuity clinic (especially during the months in the MICU) and being able to see "my patients" (a small group of patients who have been I've seen since my internship--a majority of peds patients (I sometimes think we "grew up together") but some medicine patients)is rewarding and renewing. I don't particularly enjoy seeing the patients who seem to bounce from doctor to doctor in our clinic (either because they can't seem to find a physician they like, they miss so many appointments that someone forgets who their PCP is and just schedules them into next available since, or due to scheduling errors). Also while I do enjoy well child care (because if you have a relationship with the child/family its fun to watch them grow up, additionally I tend to inherit the children with chronic conditions that our FP staff is uncomfortable and I kind of like that niche) I don't enjoy adult "worried well". I suppose my rambling point is that you too may find areas of outpatient care that you didn't think you would like and you will.

You are correct about 20-30% of Med-Peds graduates pursuing fellowship training. There is the option to do combined fellowships(cardiology, endocrinology, and rheumatology are areas where the Med-Peds training is especially beneficial but other areas could work as well). Dual fellowships seems to be an increasing trend in our program, however, nationwide the majority of fellowship trained Med-Peds grads do end up selecting do a stand alone medicine or pediatrics fellowship. Even then I think their original residency training gives them additional knowledge and skills. They end up being the adult cardiologist who is comfortable caring for the now adult CHD patients or the pediatric gastroenterologist who has seen both sides of the remicaid debate. One of the programs I interviewed at had a resident transfer into their Med-Peds program from Peds because he thought that would better prepare him for a PICU fellowship.

As far as EBM I think that nationwide the EBM impact will always be stronger in Medicine Programs. The reality is that children are often excluded from our randomized controlled trials and much anecdotal practice is espoused (the familiar "We do it the (insert name of training program) way!"). I know our program director really challenges us to not leave our evidenced based approach at the door when we enter our children's hospital. There are exceptions but many attendings actually welcome our approach (although you might never guess they would from outward appearances).

Good luck in your decision and enjoy your 4th year!

 

[AMPAD]

Are there combined Med\Peds cardiology fellowship programs available? I don't see them on FREIDA. Thanks.

 

[The Med-Peds Dude]

Are there combined Med\Peds cardiology fellowship programs available? I don't see them on FREIDA. Thanks.

There are no formal combined fellowships, at least not in the way combined residencies are organized. Some institutions have done it, and thus may be more open to the idea, but you won't find them in FREIDA.

Look at http://medpeds.org/fellowship_guide.htm

 

[RuralMedicine]

Combined fellowships usually take a little navigating and negotiating but are definitely feasible and possible. Baylor and Ohio State University are both very amenable to their fellows pursuing a combined route in cardiology (I'm sure there are other options this is just off the top of my head).

 

[magnolia014]

What and interesting forum! Thank you RuralMedicine for your words of advice. I love the idea that residents can take a comparative approach to adults and children as they treat them medically. Thank you for moving me a little closer to my med-peds decision....here is my story.

I am also going to be a MSIV. Since this winter I have been 98% sure that Ob/Gyn was my calling. Before that, all through 2nd year I was sure about FP. Anyway...Women's Health has always been my passion and I just needed an avenue for its practice....ob/gyn seemed to be the most logical choice, although I know that there are a handful of IM programs that have Women's Health tracks. I loved the combined surgery/medicine aspect of ob/gyn and still do...however, I am now doing IM and love the intellectual challenge....

I know it's weird, but now I'm 50% ob/gyn and 50% med/peds....and I don't know if I would consider medicine separate from pediatrics...and I definitely didn't consider pediatrics on it's own. Maybe because the rotation at my hospital wasn't that great coupled with the fact that it was my first rotation and I didn't do too hot on the shelf exam.

Anyway, It's the diversity of med/peds that appeals to me...along with it's depth, like the ICU care which is lacking in FP. Also, I never really enjoyed the OB part of Ob/gyn and was envisioning about specializing in gyn onc or REI...love the gyn surgeries, onc medicine and endocrinology. But it takes 7-8 years and lots of research to reach such a specialization and general med/peds practice seems to appeal to me more.

I'm mostly babbling here...but I would like to know how hard a med/peds residency really is. I know of people dropping out because it's too hard and time intensive... but as someone who was seriously considering ob/gyn, i'm not intimidated by the difficulty level or time intensivenss during residency. I am worried though that by doing a "dual residency", I wouldn't feel like I really fit in with either the int. med group or peds group of residents. Do med-peds programs to a good job to ensure you don't feel this way?

Also, how do internist and pediatricians feel about med/peds physicians? Do they look down on them? Do they appreciate them? or do they think their just obnoxious by trying to do both?

I would love any response, advice and comments.

ps. is it necessary to do a med/peds elective in the 4th year?
which med/peds programs are the best all around?
how competitive is this field to get into?

 

[The Med-Peds Dude]

I'm mostly babbling here...but I would like to know how hard a med/peds residency really is. I know of people dropping out because it's too hard and time intensive... but as someone who was seriously considering ob/gyn, i'm not intimidated by the difficulty level or time intensivenss during residency. I am worried though that by doing a "dual residency", I wouldn't feel like I really fit in with either the int. med group or peds group of residents. Do med-peds programs to a good job to ensure you don't feel this way?

Also, how do internist and pediatricians feel about med/peds physicians? Do they look down on them? Do they appreciate them? or do they think their just obnoxious by trying to do both?

I would love any response, advice and comments.

ps. is it necessary to do a med/peds elective in the 4th year?
which med/peds programs are the best all around?
how competitive is this field to get into?

1. You can expect to work a little harder than your fellow categorical program residents. This is a bit of a juggling act and requires more mental overhead.
2. How well you fit with the other residents just depends on where you go and what the other interns are like - the latter is suprisingly variable from year to year. Hopefully the med-peds residents are a supportive group of people. A good question to ask during interviews.
3. My personal, nonscientific observation is that pediatricians may be a little more circumspect about your qualifications. This may be an unfair characterization/generalization, but possibly true. Not at all the case in my organization. Most people are impressed you can really do both.
4. Med-Peds electives only important if you want to see/work with someone who's been through this. You need to do well on your IM and Peds experiences. Med schools tend to skimp on peds training, so a little more experience helps.
5. All our programs are the best 🙂 Seriously, some have a long track record, though not sure that automatically makes them better. I was in the 1st year of our program, which by default took it out of the "best" category, but feel I received very good training.
6. A little more competetive than IM; I was dissapointed in the number of unequivocally qualified applicants this year. We ranked 5 for every slot last year. Nationally, the avg applicant ranked 6.5 programs. 352/400 positions filled in the match, with 22 programs unfilled.

Hope this helps.

 

[Masreya]

Forncroj,
I am also interested in Medpeds. I wanted to know how it's looked upon if a student applies to med/peds and also to IM residencies. I was told that med/peds, even though programs are losing funding, is still competitive and to apply for IM as backup in case I don't match into med/peds. I am also limited geographyically so that limits the number of progams I can apply to. So, what do you think???

thanks 🙂

 

[magnolia014]

thank you for the great advice!

BTW, you talk about this great program, but you don't mention what or where it is 😕

Also, one more question...how do you envision the future outlook for med-peds physicians??

 

[The Med-Peds Dude]

Forncroj,
I am also interested in Medpeds. I wanted to know how it's looked upon if a student applies to med/peds and also to IM residencies. I was told that med/peds, even though programs are losing funding, is still competitive and to apply for IM as backup in case I don't match into med/peds. I am also limited geographyically so that limits the number of progams I can apply to. So, what do you think???

thanks 🙂

Well, I suppose it looks a little better if you aren't, but I don't always ask. In the end I rank based on how badly I want them to come and try not to guess whether or not the applicant's still interested. IM is the more common back-up plan.

Med-Peds programs were spared funding losses several years ago, so please stop that rumor at the source.

Hopefully you are limited to a region with a lot of programs to choose from. Not sure how you are limited - distance? Like HI?

 

[The Med-Peds Dude]

thank you for the great advice!

BTW, you talk about this great program, but you don't mention what or where it is 😕

Also, one more question...how do you envision the future outlook for med-peds physicians??

I'd love to blow my own horn, but also want to avoid the flames of wrath from getting to personal. A private message might work.

The opportunities for primary care physicians are expanding along with the aging of the population. Peds may be a little flushed with Dr's in a few years, but predictions like this are often wildly inaccurate.

 

[Thewonderer]

I have a feeling that many students consider med-peds because in their medical schools, the medicine department overpowers the pediatric department. At the same time, it is very hard to overcome the preconceived notion that if I want to be a traditional doctor that every lay man thinks of, I have to be involved with internal medicine somehow. But then, if you look at that view strictly, how about all the psychiatrists, orthopedic surgeons, dermatologists, radiologists, ec. out there? Are they really not "true doctors?"

In the end, you just gotta look inside of you to find what you truly love and not let other people's opinions and perceptions sway you. I have a feeling, a lot of times, people will find pediatrics (and not internal medicine) to be their true callings.

 

[magnolia014]

I have a feeling that many students consider med-peds because in their medical schools, the medicine department overpowers the pediatric department.

In the end, you just gotta look inside of you to find what you truly love and not let other people's opinions and perceptions sway you. I have a feeling, a lot of times, people will find pediatrics (and not internal medicine) to be their true callings.

I never really considered pediatrics or medicine separate from med-peds. What I like about the combination is a concept of Gestaltism...the whole is greater than the sum of it's parts. If not med-peds, I think I'd rather do adult and pediatric gynecology. I know that not everyone going into med-peds feels the same way I do and maybe some of them are just afraid to do pediatrics by itself...but from what I know most pediatricians and future pediatricians are pretty clear and sure that they do not want to treat adults. But I must say that it is very hard as a medical student to really know what life is going to be like in a certain specialty and by the time 4th year electives roll around...it's kind of too late ... 😳

 

[Chimera]

Not to hijack the thread, but I am pretty sure I want to end up being a Pediatric Intensivist (PICU) and was planning on doing a straight pediatric residency, but I've had many people approach me and tell me to do Med/Peds because of the more applicable training. Any thoughts on this?