Combined
Internal Medicine & Pediatrics
Med-Peds
Versatile training for the 21st
century physician
Created by Allen Friedland, MD, FACP, FAAP '
Association
Let’s 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: medpeds, internal medicine-emergency medicine, pediatricspsychiatry-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
201
Number
Residents
8,529
Duration
Internal Medicine
390
22,971
3 years
Med-Peds
Combined specialty
80
1,441
4 years
Family Medicine
469
10,777
3 years
Obstetrics-Gynecology
242
4,942
4 years
General Surgery
252
7,890
5 years
Pediatrics
3 years
not 6 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
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
Adolescents have
your needs
unique needs
ICU settings
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-FAQPIF/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.)
5
Subspecialty experience (e.g.
Infectious Diseases,
Nephrology, etc.)
Overall Ambulatory
Experience (minimum)
4
33%
8 months
Overall Ambulatory Experience
(minimum)
40%
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
1. Congenital heart disease
2. Cystic fibrosis
3. Sickle cell disease
4. Cancer
5. Spina Bifida
Adult disorders in children
1. Diabetes
2. Obesity
3. Hypertension
4. Sleep apnea
5. Hyperlipidemia
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
 5-8% of internal medicine residents
 15% of internal medicine programs
&
&
13% of pediatric residents
40% of pediatric programs
National Intern Class Size Frequency
38%
40%
30%
20%
16%
12%
10%
11%
14%
9%
0%
2
3
4
5
6
7+
National Residency Matching Program data 2012, 2013,
2014
Med-Peds Match 2015 (78 programs with 380 positions)
NE:
2 spots
MI(6): 26 spots
MN: 10 spots
KY(2): 11 spots
WA
IN:
OH(4):
WI (2):
IL(5):
14 spots
27 spots
8 spots
24 spots
ME:
3 spots
NY(4): 19 spots
MA(4): 20 spots
CT:
4 spots
RI:
4 spots
PA(4): 17 spots
NJ(2): 7 spots
DE:
4 spots
DC:
4 spots
MD:
8 spots
ND
MT
ME
MN
VT
WI
OR
ID
SD
WY
NH
NY
MI
MA
RI
CT
PA
IA
NE
NV
NJ
IL
UT
OH
IN
CO
DE
WV
KS
KY
MO
VA
MD
DC
CA
TN
AR
OK
NM
AZ
SC
MS
AL
CA (4): 18 spots
CO:
4 spots
UT:
3 spots
AZ:
6 spots
NC
TX
GA
LA
HI
FL
OK(2): 6 spots
TX(2): 14 spots
MO (2): 9 spots
AR: 6 spots
LA(3):16 spots
KS: 3 spots
VA:6 spots
WV(3): 8 spots
NC(3):18 spots MS:
4 spots
AL: 6 spots
FL(2): 11 spots
PR
TN(2):18 spots
SC(2): 7 spots
P. Rico: 2 spots
Med-Peds Resident Distribution
On Duty December 31, 2013
90%
1208 residents
80%
70%
60%
50%
40%
30%
20%
10%
98 residents
133 residents
2 residents
Osteopathic
Medical
Graduates
International
Medical
Graduates
Canadaian
Medical
Graduates
0%
Allopathic
Medical
Graduates
Brotherton S and Etzel S. Graduate Medical Education, 2013-2014.
JAMA 312 (22); December 14, 2014; pages 2427-2445.
Med-Peds Gender Distribution
On Duty December 31, 2013
Males in Other
Specialties
Females in Other
Specialties
Pediatrics
73.1%
Females
59.4%
Males
40.6%
Pediatrics
27.9%
Internal Medicine
43.5%
Internal Medicine
56.5%
Family Medicine
55.2%
Family Medicine
44.8%
Brotherton S and Etzel S. Graduate Medical Education, 2013-2014.
JAMA 312 (22); December 14, 2014; pages 2427-2445.
How it All Fits Together
Complete both
Practice
both
Learn
both
Pass both
It is Possible to Complete Both
Approximate Completion Rate Nationally (%)
100
90
80
70
60
50
40
30
20
10
0
86
90
88
90
91
95
95
98
97
Class of Class of Class of Class of Class of Class of Class of Class of Class of
2007
2008
2009
2010
2011
2012
2013
2014
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
50
43%
children
≤ 2 years/old
3-18 years/old
19-40 years/old
41-64 years/old
15%
children
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
 45 years of rich history in Med-Peds
 Visit www.med-peds.org &
http://www2.aap.org/sections/med-peds/