Required training to see children in California (for Internist)

[glorybrian]

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My wife is finishing her internal medicine residency by June 30.
She will start to practice in the existing outpatient clinic July 1.
The owner planned to retire end of the December.
Current setting is Family Practice.
Children population is about 40%.
My wife cannot keep the children due to her training limitation and insurance.

The owner's specialty is Family Practice.
He suggests finding a way to see/keep the children.
He would like to help my wife in two ways.
1. He can supervise and/or train her for treating children for 1 year.
2. My wife can train at training hospital part-time basis.

If it is reasonable to get a training for pediatrics ( more like to see children and immunization), she would like to consider to do it.

I have two concerns.

- takes too long
She finished two residency trainings, one in abroad and another one here.
Also she is wife of a middle age man. (I learned not to mention about woman's age in this country).

- Insurance premium might be too high for non-board certified physician

If you have any suggestion of comment, I would appreciate it.

 

[antihero94]

My biggest concern would be the kids. There is a reason why pediatrics training in this country is 3 years, and not just an additional year after an Internal Medicine residency. Treating kids is not just memorizing the immunization schedule and handing out stickers. Some pediatricians even have concerns about the amount of training some family practitioners get in general pediatrics. Whatever your wife decides make sure she does what is best for the patients, not for her insurance premiums or business model.

 

[Stitch]

She's going to miss something. While I'm sure she's plenty smart and good at what she does, internal medicine is very different from peds. The differential diagnoses are often totally different and kids give many fewer cues that they are sick. It's easy to think a kid is going to be fine because most of them do well, however part of peds is being a little paranoid. Moreover, getting informal training from a partner is not the same as doing a residency or even a fellowship. It's not academic and it won't teach her what she needs to know in order to provide the best care to her patients and in order to keep up to date.

Med/Peds residencies do an excellent job of training people in both specialities, and if she wanted to see kids, that route would have been the best way to do so.

 

[chartero]

She could hire or affiliate with an FP or pediatrician who could see pediatric patients part-time, maybe a semi-retiree or parent, maybe another new physician in town or one of the next towns over who could use the patient census.

She could refer to one or more outside pediatricians or FPs. She could not make this conditional, but eventually pediatricians need an FP or internist to refer their patients to, and if hey, they know this new internist in town taking new patients... Really, generally, word-of-mouth would get around as all the children's parents explain their kids need a new doctor. Why? Because Dr. Mrs. Glorybrian specializes in adult medicine. She creates word of mouth, brands herself as a specialist in adult medicine, and brands herself as responsible.

She should wear what she trained as proudly and refer to one or more pediatricians or FPs.

 

[DarthNeurology]

The owner's specialty is Family Practice.
He suggests finding a way to see/keep the children.
He would like to help my wife in two ways.
1. He can supervise and/or train her for treating children for 1 year.
2. My wife can train at training hospital part-time basis.

There are state laws concerning practicing outside of your scope, i.e. a radiologist who treats family members for common medical problems in the capacity of an internist or something like that . . . She could get in legal trouble. I think that the owner of the practice is greedy and not concerned about practicing good medicine.

There are *plenty* of hospitalist and ambulatory jobs for internists, your wife should quit and find one of them. Don't be in business with someone willing to "supervise" an internist for a year to see kids.

 

[bks524]

Much of the above is not necessarily true. You can see patients outside of your field, but you must practice at the same standard of care. As a pediatrician, I have seen adults as old as 50 both in a service for fee and for free. The liability comes in when I don't recognize the confounders many older adults may have. Hospitals can even give you privelidges to see these patients, but again you must perform to the standard of care.

A reasonable alternative may be for her to limit her practice to children older than a certain age ie 4-6. I would bet that she would still lose many of her kids, but she could still see a lot of them. Especially if this older physician is willing to help her-there may be a compromise.

For instance, I would screen the adults I would see so that they were fairly healthy and had simple complaints-this doesn't always work. That is where it is nice to have an "expert" in that particular field. Just advise her to do her best to learn as much as she can if they decide this is a reasonable route

 

[chartero]

I would be more enthusiastic about how this just might work if the original question had seemed to emphasize achieving such a change in scope of practice well, rather than quickly. It was posted the day before she might start treating children!

The general question will come up again, though; physicians trained outside of pediatrics, FM and EM will find themselves providing episodic or continuing general medical care care to children. This is probably seen most often in urgent care, rural EDs, and rural and underserved primary care practices; the physician with the nontraditional scope is probably usually an internist, but sometimes another specialist, or the poor soul who didn't complete their residency and is trying to do the best they can with their general practice license, and we might meet them elsewhere on SDN.

This might offer a model for others: Physician scope of practice has become a high-profile issue in Ontario, especially in the wake of the troubling 2007 death of a young woman after liposuction at an independent clinic in Toronto. The medical board, the College of Physicians and Surgeons of Ontario, has strengthened their supervision of Changing Scope of Practice. There's extensive information at the link including a guide, forms, FAQs and examples.

I mentioned urgent care. There's one independent board of certification for urgent care medicine, and another in the works. The American Board of Urgent Care Medicine is associated with the American Academy of Urgent Care Medicine. It is not affiliated with the ABMS or AOBMS, and state regulations on identifying physicians as board certified that do not whitelist the ABUCM may limit use of the credential. That said, it's a non-profit organization devoted to the improvement of urgent care medicine, and it offers an exam that includes a content area in pediatrics. New candidates must have completed an accredited residency in EM, FM, GS, IM, ob/gyn, or pediatrics - hey! anyone here in pediatrics want to work adult urgent care? what? no one!? - have a minimum of five years and 7000 hours of urgent care experience, meet CME requirements, etc. It specifies that residencies must be ACGME-accredited; interested AOA or Canadian residency graduates could humbly inquire.

Meanwhile, the American Board of Physician Specialties, the essentially independent board controversial for its Board of Certification in Emergency Medicine that continues to offer a practice pathway, have said that they are developing a certification in Urgent Care Medicine. Ditto the disclaimers above.

 

[Stitch]

The general question will come up again, though; physicians trained outside of pediatrics, FM and EM will find themselves providing episodic or continuing general medical care care to children. This is probably seen most often in urgent care, rural EDs, and rural and underserved primary care practices; the physician with the nontraditional scope is probably usually an internist, but sometimes another specialist, or the poor soul who didn't complete their residency and is trying to do the best they can with their general practice license, and we might meet them elsewhere on SDN.
[/url]. Ditto the disclaimers above.

I'm not sure whether you're saying this is a good thing or not, but I can tell you that I get several phone calls, transfers and follow ups a day from an urgent care center that has screwed up because they were adult people trying to provide care for kids. Peds is a specialty. The differential diagnoses are very different. Handing out Z packs isn't treating the patient. If you're an adult doc trying to treat a kid, you're in over your head, and you WILL miss something, and you WILL have a huge liability risk. And to be fair, if you're a pediatrician trying to treat adults, you're making the same mistake and opening yourself to a probably deserved lawsuit.

Stay within the scope of where you were trained, even if the complaint seems 'simple.' It's safer for you and it's safer for patients. The best thing you can do for a patient is get them to someone who can provide them with safe, experienced and knowledgible care, even if that's not you.

 

[bks524]

Stay within the scope of where you were trained, even if the complaint seems 'simple.' It's safer for you and it's safer for patients. The best thing you can do for a patient is get them to someone who can provide them with safe, experienced and knowledgible care, even if that's not you.[/QUOTE]

This is unfortunately not always possible. The ratio of patients to specialist is not always uniform. I know a pediatrician in a decent size town who has to split call with adult physicians. They each cover each others patients on call. This is the only way for them to function. In the "big city" it is entirely possible to only see specialists, but in the more rural areas this is not always possible.

Also, I have seen kids in the ER from Pediatricians that have missed stuff or did the wrong thing. We are all prone to mistakes and incur the exact same liability. Read, practice good logical medicine, and have good follow up-these things will get all of us through.

 

[BigNavyPedsGuy]

Where is this practice? I live in California and want to tell my patients to NEVER go there.