Med-Peds: Versatile Training for 21st Century Physicians

Combined Internal Medicine & Pediatrics Med-Peds Versatile training for the 21st century physician Created by Allen Friedland, MD, FACP, FAAP ' Association

Lets Get Basic Internship The first year out of medical school = The first year of residency = Post Graduate Year 1 (PGY-1) Residency Depending on the specialty can be from 1 7 years in duration = Post Graduate Years 1 7 Combined specialties Two or more residency specialties offered together: med- peds, internal medicine-emergency medicine, pediatrics- psychiatry-child & adolescent psychiatry Fellowship A physician may also choose to continue their training for a sub-specialty such as cardiology, critical care, pediatric emergency medicine, geriatrics, bariatric surgery, adolescent gynecology

Residency Programs Program Type Number Programs Number Residents Duration Pediatrics 201 8,529 3 years Internal Medicine 390 22,971 3 years Med-Peds Combined specialty 80 1,441 4 years not 6 years Family Medicine 469 10,777 3 years Obstetrics-Gynecology 242 4,942 4 years General Surgery 252 7,890 5 years

Who We Are As Med-Peds Pediatricians are specialists for children Internists are specialists for adults As Med-Peds physicians we provide care in two specialties, complete two type residency programs, take two separate Board Certifications (Internal Medicine & Pediatrics), care for two groups of people As Med-Peds physicians we are specialists for a population

The Versatile Med-Peds Physician Go to fullsize image Treat/prevent common diseases Survivors of chronic health conditions We draw from the skills and abilities of internists & pediatricians to care for individuals and generations of families Flexibility and versatility are synonymous with Med-Peds Graduates follow many careers paths that can change over time Global Health

The Versatile Med-Peds Physician Preventative care for families Rural settings Can you imagine anyone better prepared than a med-peds physician for these patients? You can choose from primary care, hospital care and subspecialty care or some combination We are able to tailor our practices to what the community, individual and your needs ICU settings Adolescents have unique needs

Unique Characteristics of Internal Medicine-Pediatrics 4 year integrated residency program of 2 primary care specialties It is the first combined specialty approved by any Board (1967) & the only accredited combined specialty by the Accreditation Council of Graduate Medical Education (2007) & also has the most combined residents (~1400) and graduates (~8000) http://www.acgme.org/acgmeweb/Portals/0/PFAssets/2013-PR-FAQ- PIF/700_med_peds_07012013.pdf All 4 years of training are fully funded by CMS under President Clinton Balanced Budget Act (BBA of 1997) http://www.gpo.gov/fdsys/pkg/PLAW-105publ33/html/PLAW-105publ33.htm

Unique Characteristics of Internal Medicine-Pediatrics The perfect double major to serve age continuum, in/outpatient settings, cross fertilization, versatility and special niches (e.gs. transition and global health) Two years of pediatrics training included Most graduates are in outpatient practices but many also care for hospitalized patients or become a hospitalist or specialize in any pediatric and medicine fellowship

Med-Peds Requirements Transitions Rotate every 3-6 months between specialties in year 1-2 General Medicine and General Pediatrics Plenty of general medicine and pediatrics inpatient and outpatient rotations in different settings depending on the residency program ICU Time Limited to 8 months in NICU, PICU, CCU and MICU Subspecialty Rotations Rotations like adolescent medicine, development-behavioral, geriatrics and others like cardiology, infectious diseases, women s health Med-Peds Time Journal clubs, business meetings, conferences and other times just for med-peds residents. Can include research, transition care, global health Resident Practice Have a panel of continuity patients for each med-peds resident

Internal Medicine Number of months Pediatrics Number of months General Inpatient Medicine 8 General Inpatient Pediatrics 5 Medical Intensive Care Unit 1-2 Pediatric Intensive Care Unit 1-2 Cardiac Intensive Care Unit 1-2 Neonatal Intensive Care Unit 2 Geriatrics 1 Newborn Nursery 1 Emergency Medicine 1 Emergency Pediatrics and Acute Illness Pediatrics 3 Outpatient Med-Peds continuity 36 clinics per year Behavioral-Developmental Adolescent Medicine 2 Subspecialty experience (e.g. Infectious Diseases, Nephrology, etc.) 4 Subspecialty experience (e.g. Infectious Diseases, Nephrology, etc.) 5 Overall Ambulatory Experience (minimum) 33% Overall Ambulatory Experience (minimum) 40% 8 months 10 months

The Changing Landscape People with the broadest perspective and the most comprehensive knowledge will lead the transformation in health care Dr. Dale Vidal- Dartmouth Health Care Delivery Masters Program 2014 Pediatric survivors now adults Adult disorders in children 1. Diabetes 2. Obesity 1. Congenital heart disease 2. Cystic fibrosis 3. Hypertension 3. Sickle cell disease 4. Sleep apnea 4. Cancer 5. Hyperlipidemia 5. Spina Bifida People are surviving conditions that were once fatal in childhood. As well, illnesses that used to be seen only in adults are becoming epidemic in children

Fellowships After Med-Peds Can do an adult fellowship, pediatric fellowship or combined (adult-pediatric) fellowship Check out how and see the fellowship guide http://www.medpeds.org/residents/fellowship-guide/ Adolescent Medicine Allergy-Immunology Cardiology (general, interventional congenital heart, electrophysiology) Child Abuse Critical Care (MICU, PICU) Developmental-Behavioral Endocrinology Gastroenterology Genetics Geriatrics Hematology-Oncology Hospice and Palliative Care Infectious Diseases Medical Informatics Nephrology Neurodevelopmental Pediatrics Pediatric Emergency Medicine Perinatology Pulmonary Rheumatology Sleep Medicine Sports Medicine Toxicology Transplant Hepatology Weight Management

Med-Peds Programs Med-Peds are 5-8 % of all IM residents and 13% of all pediatric residents 15% of all IM programs and 40% of all Pediatric programs have an affiliated Med-Peds program National Intern Class Size Frequency 38% 40% 30% 20% 16% 14% 12% 11% 9% 10% 0% 2 3 4 5 6 7 + National Residency Matching Program data 2012, 2013, 2014

Med-Peds Match 2016 (79 programs with 386 positions) NE: 4 spots IN: 14 spots MI(6): 28 spots OH(4): 27 spots MN: 10 spots WI (2): 8 spots KY(2): 11 spots IL(5): 24 spots ME: 3 spots NY(4): 20 spots MA(4): 20 spots CT: 4 spots RI: 4 spots PA(4): 17 spots NJ(2): 6 spots DE: 4 spots DC: 4 spots MD: 8 spots WA ND MT ME MN VT WI NH NY OR ID SD WY MI MA PA RI CT IA NE NJ IL OH IN UT NV DE CO WV KS KY VA MD DC MO CA TN NC AR OK NM SC AZ MS GA AL TX CA (4): 18 spots CO: 4 spots UT: 3 spots AZ: 6 spots LA HI FL PR OK(2): 6 spots AR: 5 spots TX(3): 22 spots LA(3):16 spots MO (2): 10 spots KS: 3 spots VA:6 spots WV(3): 8 spots TN(2):18 spots NC(3):18 spots MS: 4 spots SC(2): 7 spots AL: 6 spots FL(2): 10 spots P. Rico: 2 spots

Med-Peds Resident Distribution On Duty December 31, 2014 90% 1189 residents 80% 70% 60% 83% 50% 40% 30% 20% 1 residents 137 residents 112 residents 10% 10% 8% 0% Allopathic Medical Graduates Brotherton S and Etzel S. Graduate Medical Education, 2014-2015. JAMA 312 (22); December 8, 2015; pages 2436-2454. Osteopathic Medical Graduates International Medical Graduates Canadaian Medical Graduates

Med-Peds Gender Distribution On Duty December 31, 2014 Males in Other Specialties Females in Other Specialties Pediatrics 27.0% Pediatrics 73.0% Females 58.9% Males 41.1% Internal Medicine 56.8% Internal Medicine 43.2% Family Medicine 44.3% Family Medicine 55.7% Brotherton S and Etzel S. Graduate Medical Education, 2014-2015. JAMA 312 (22); December 8, 2015; pages 2436-2454.

How it All Fits Together Learn both Complete both Practice both Pass both

It is Possible to Complete Both Approximate Completion Rate Nationally (%) 98 97 95 95 100 91 90 90 88 86 90 80 70 60 50 40 30 20 10 0 Class of 2007 Class of 2008 Class of 2009 Class of 2010 Class of 2011 Class of 2012 Class of 2013 Class of 2014 Class of 2015 Estimates calculated from American Board of Pediatrics Annual Reports

It is Possible to Learn Both HOW IS IT POSSIBLE TO LEARN TWO DISCIPLINES? Fundamental clinical skills in common: (history and physical, communication, organization) Advanced clinical skills in common: (information processing, reasoning, hypothesis testing, deduction, epidemiology) Some differences: manifestations/incidence of same conditions at different ages, nuances of treatment, neonatology and first two years of life John Chamberlain, MD 2002

Why Learn Both? Comprehensive view of health and illness The most complicated patients will still need to be managed/led by physicians in outpatient and inpatient settings Know and see as much of health system(s) to bring the proper perspective through the depth and breadth of clinical training across different departments, service lines and systems Critical and sophistication of thinking so to not consult everyone Adaptable the ability to change (or be changed) to fit changing circumstances Flexible the ability to cope with variable circumstances Versatile having a wide variety of skills Cross fertilization of ideas for system wide improvement Clinical Relevance Niches

It is Possible to Practice Both About 50-60% of graduates go into primary care practice. The majority (between 77-93%) provide care for both adults and children. 40% also have an academic appointment with a medical school About 18-25% of graduates pursue fellowship and 50% provide care for both adults and children. 60% also have an academic appointment with a medical school Freed GL, Fant KE, Nahra TA, Wheeler JR. Internal medicine-pediatrics physicians: their care of children versus care of adults. Academic Medicine 2005;80:858-64. Frohna J, Melgar T, Mueller C and Borden S. Internal medicine-pediatrics Residency Training: Current Trends and Outcomes. Academic Medicine. 2004

It is Possible to Practice Both Age Distribution (percentages) of Patient Visits to Primary Care Providers Recorded in the National Ambulatory Medical Care Survey from 2000-2006 60 2 years/old 3-18 years/old 19-40 years/old 41-64 years/old 15% children 43% children 50 40 % visits 30 20 10 0 Med-Peds Family Medicine Pediatrics Internal Medicine Fortuna, Ting, Kaelber and Simon. Characteristics of Medicine-Pediatrics Practices. Academic Medicine (84) 3; March 2009: 396-401

Well Trained to Practice Inpatient Care 18-25% of recent Med-Peds graduates are hospitalists Many provide care to adults who survived congenital & child onset conditions 40% of hospitalist internists do not feel comfortable caring for adults with child onset conditions but had to care for this group of patients anyway .but a med-peds hospitalist would feel comfortable O Toole JK, Friedland A, Gonzaga A. Hartig J. Holliday S, Lukela M, Moutsios S. Kolarik R, The Practice Patterns and Professional Activities of Recently Graduated Internal Medicine-Pediatric Hospitalists. Accepted for Publication Journal of Pediatric Hospitalist Medicine Hunt, S. and Sharma, N. Pediatric to adult-care transitions in childhood-onset chronic disease: Hospitalist perspectives. J. Hosp. Med. 2013, 8: 627 630

It is Possible to Pass Both Board Pass Rate (2010-2015) American Board of Internal Medicine & American Board of Pediatrics The pass rate for med-peds graduates is statistically equivalent to categorical residents MPPDA Annual Meeting with American Board of Internal Medicine and American Board of Pediatrics. 2015

Impact of Med-Peds on Pediatrics 60% of graduating pediatrics residents said that combined programs enhanced their education, 39% no effect, only 1% negative impact Friedland A, Melgar T, Kaelber D, Cull W, Chamberlain J, Kan B. Impact of combined pediatric residency training programs on the educational experience of the categorical pediatric residents. Association Pediatric Program Directors Annual Meeting, Poster Presentation 2009 Pediatric residency programs with combined Med-Peds programs did better on pediatrics boards Falcone JL. Residencies with Dual Internal Medicine and Pediatrics Programs Outperforms Others on the American Board of Pediatrics Certifying Exam. Clinical Pediatrics. 2014 May 6;53(9):854-857

It not possible to determine the future shape of health care delivery and to project the workforce needed; therefore, the maximization of provider career flexibility will be crucial Nasca and Thomas. Medicine in 2035: Selected Insight from ACGME Scenario Planning. Journal of Graduate Medical Education. March 2015 Med-Peds graduates are well positioned to adapt to a changing medical landscape Frohna J. The Role of the Med-Peds Physician in a Changing Medical World. J of Pediatrics. 2007;151:338-339.

The Future of Med-Peds is Bright Med-Peds graduates will be important in the care of children an indirect impact will be to help maintain interdisciplinary integration within medical centers create new collaborative bridges with other fields.. .created a legacy that pediatric departments can use to increase familiarity with access to other areas of excellence within own institutions improve the morbidities pediatricians strive to prevent will not be underemphasized as children transition to adult care. ..The operative factors will be expanded skill set, an evidence based approach to generalist care across the age spectrum, a unique perspective, and the prevailing emphasis on primary care. Final Report of the Future of Pediatric Education II Pediatric Generalists for the Future. Working Group 2000. Pediatrics. 106. Supplement. 1199-1223.

Why Do Medical Students Chose Med-Peds? 1. Age spectrum 2. Variety & depth of training 3. Liked both 4. Flexible career 5. Primary care focus 6. Ability to specialize 7. Role models 8. Did not want OB/Surg 9. Transition & adolescent 10. More Pediatrics Robbins BW, Ostrovsky, D, and Melgar, T. Factors in Medical Students Selection and Ranking of Combined Medicine-Pediatrics Programs. Academic Medicine. 80 (2), February 2005;199

Fourth Year Electives Many Types of Electives Med-Peds specific electives Settings: Inpatient, outpatient, both Types: Primary care, specialty, hospitalist, combination Can help a student decide if med-peds is for them, role modeling, career paths Categorical Electives in Pediatrics or Internal Medicine Get on a team with a med-peds resident or attending Try to arrange to participate in med-peds activities anyway during the elective Get to know the hospital system , career paths

Summary of Med-Peds Depth and breadth of two disciplines that allows flexible career goals without Surgery and OB training. The perfect double major Four years of training that is rigorous but humane; gives added maturity to your career Wide variety of practice styles and settings; effective with variety of patient problems Dual board certification in Internal Medicine and Pediatrics that is unique Niches of special populations; cross fertilization of knowledge Almost 50 years of rich history in Med-Peds Visit www.med-peds.org & http://www2.aap.org/sections/med-peds/