The medicine-pediatrics physician: Past, present, and future

The medicine-pediatrics physician: Past, present, and future

Gary M. Onady, MD, PhD

Medicine-pediatrics, the child of pediatrics and internalmedicine, has become a young adult, and its parents can be proud of itsachievements to date. This expert's crystal ball shows a rosy future aswell.

In the 30 years that medicine-pediatrics (med-peds) has been a part ofthe medical practice environment, the number of residents choosing thiscombined specialty has increased tremendously. During the first decade oftraining, there were under ten PGY-1 positions; today, over 1,500 med-pedsresidents are in training and over 2,000 med-peds physicians are in practice.What has their experience been, what contributions are they making to thefield of pediatrics, and what can be expected of this new specialty in theyears to come?

Historical perspective

The American Board of Internal Medicine (ABIM) and the American Boardof Pediatrics (ABP) first recognized combined internal medicine­pediatricsresidency programs as an option for postgraduate education in 1967.¹During the next decade, this ABIM/ABP collaborative response to the primarycare movement of the late 1960s was offset by the recognition of familymedicine as a legitimate specialty, and few elected the combined residency.

The changing medical environment of the 1980s accelerated developmentof med-peds programs. High-cost medical liability insurance, stringent credentialingtrends, and competitive markets influenced increasing numbers of familyphysicians to limit the range of services they provided.² Ambulatorytraining became more important to general internal medicine and pediatricsresidency programs, though tertiary-care standards for physician credentialingwere maintained. Med-peds programs grew rapidly, expanding from nine internpositions in four programs before 1980 to 456 positions in 106 programsin 1998 (Figure 1).

Medical students perceive internists, pediatricians, and med-peds physiciansas having a different practice style from family practice physicians.³In line with these findings, medical students choosing med-peds report thatthey considered internal medicine and pediatrics as their second and thirdoptions, not family practice.⁴

In percentage of positions filled, med-peds has followed an upward trendsimilar to that of pediatrics over the past decade, with increasing representationby US medical graduates filling 89% of positions, the highest percentageamong all primary care specialties. Within the past year, the percentageof positions filled has reached the same level as internal medicine (Figure2). Data compiled for 1998 through the National Residency Matching Programindicate that med-peds residents filled 21% of the current PGY-1 positionsin pediatrics and 9.5% in internal medicine, with a total of 1,529 med-pedsresidents in training.^5,6

There were 120 med-peds graduates in 1986. A decade later, a survey bythe ABIM and ABP identified over 1,500 graduate med-peds physicians.

As the number of med-peds graduates increased, med-peds specialty societieswere organized to coordinate the efforts of this relatively unknown groupof physicians. The first organized meeting of med-peds physicians was in1987. By 1991 the Medicine-Pediatrics Program Directors Association hadorganized formally, with the purpose of fostering collaborative interactionsand maintaining high training standards. Within this organization, a secondorganization was launched as a graduate network. That network has evolvedinto the Med-Peds Section of the American Academy of Pediatrics, with additionalrepresentation within the American College of Physicians/American Societyof Internal Medicine.

Through the efforts of these organizations, the contributions of med-pedsphysicians to their parent specialties have been formally recognized. Medicine-pediatricsphysicians have recently gained national specialty representation separatefrom internal medicine, pediatrics, and family medicine as members on thePrimary Care Organizations Consortium, which coordinates the professionalefforts of primary care physicians in national health care and educationalinitiatives.

Where are they now?

Med-peds residents receive training similar to that received in the parentspecialties, and there is evidence to show that it is equally thorough.After residency, most med-peds physicians choose to practice primary care.

Residency training. The ABIM and ABP, in collaboration with leaders fromthe combined physician specialty, have created formal residency trainingguidelines emphasizing a primary care curriculum.^7,8 This curriculumcontinues to represent a balance between the two parent specialties overfour years of training. A 42% minimum ambulatory training requirement, whichoccupies 20 months of the four-year training period, reinforces a primarycare experience. It compares with 12-, 18-, and 21-month minimum ambulatorytraining requirements over three years in internal medicine, pediatricsand family practice, respectively.⁹

The increased ambulatory care training for med-peds and family practicephysicians would predict increased experience in ambulatory- based proceduralskills. The med-peds training guidelines formally address suturing and orthopedicsfor the three months required in acute care training.⁸ Suturingskills were reported to be maintained by 87% of med-peds physicians in arecent survey of 670 graduates.¹⁰ Over three quarters of thesephysicians performed joint aspiration, compared with 87% of family physiciansin this same survey. Over 90% of med-peds and family physicians from thiscomparison indicated they perform gynecological care for their patients.An outcome study following utilization trends found med-peds physiciansprovided 1.8% of services coded as procedural compared with 1.7% of theirfamily practice colleagues. These services included wound repair, tendoninjection, joint aspiration, sigmoidoscopy, burns, cerumen removal, andwomen's health procedures.¹¹

The med-peds program maintains pediatric requirements for emergency medicine,behavioral/developmental, neonatal, and adolescent training and IM requirementsfor training in cardiology, consultative medicine, emergency medicine, andgeriatrics. Condensing six years of categorical curricula into four yearsof combined training has not sacrificed knowledge, it appears, as overallpass rates compiled on ABIM and ABP certification examinations are essentiallythe same for med-peds as for pediatricians and internists (see table).¹²

Between two thirds and three fourths of graduates enter primary carepractice, while from 17% to 21% choose subspecialty training, accordingto recent studies.^4,13,14 Some 87% of med-peds physicians incommunity-based general practice care for both adults and children.¹⁴

Career choices. The ABIM and ABP recently reported a survey of 908 board-certifiedmed-peds physicians. Practice trends demonstrate that 70% devote at least70% of their time to direct patient care; most (90%) are in group practice.¹⁵Consistent with graduate surveys, the majority of med-peds practices reflecta strong preference for primary care partnerships; as Figure 3shows, ofmed-peds physicians in multispecialty group practice, only 21% and 29% practicewith pediatric and internal medicine subspecialists, respectively.

Acceptance of med-peds physicians in the medicine workforce is supportedby trends reported in the most recent American Medical Association databaseof 1995 graduates. Med-peds physicians have the lowest unemployment rateamong primary care specialties at 0.7%, with only 2.5% reporting significantdifficulty in finding jobs, which is less than the parent specialties ofinternal medicine, 6.6%, and pediatrics, 4.9%.¹⁶

Eighty-five percent of med-peds physicians care for hospitalized patients,divided roughly equally between pediatric and adult inpatients (Figure 4).¹²About half work in adult intensive care, and 40% continue to provide levelI-II nursery coverage. These practice trends reflect the curriculum contentrecommended in the combined medicine-pediatrics training guidelines, whichprepares the med-peds physician for a wide spectrum of primary care practiceenvironments.

Two outcome measures have reported on the practice environments of med-pedsphysicians. One study evaluated a specialty group made up entirely of med-pedsphysicians in an upper-middle-class suburb of an Eastern city through afour-year transition.¹⁷ Practice demographics indicated an attractionto young and growing families. The proportion of pediatric to adult carewas 61% to 39% in the first year of practice; four years later, it was 45%pediatric to 55% adult. Two age groups dominated the practice: 24% of patientswere less than 2 years old, and 34% were between 18 and 39 years of age.Adolescents and the elderly were underrepresented.

Although 71% of patients indicated that they realized these physicianscared for both adults and children, only 12% originally enrolled into thepractice with the intent of finding a family physician. Slightly over halfenrolled for pediatric care, and a third enrolled in order to be seen byan internist. It seems that patients were initially attracted into the practicein search of a specialist. Over the four years of the study, however, patientattitudes changed. Of the 53% entering the practice for pediatric care,41% enrolled adult household members into the practice, and of the 33% insearch of an internist, 16% enrolled their children. At the end of fouryears, 40% of patient care was provided to families.

The second study evaluated a multispecialty partnership between med-pedphysicians and family practice physicians in a large Midwestern city, comparingpatient demographic and utilization trends in this partnership with othercommunity-based primary care physicians.¹¹ Med-peds physicianscared for about three times as many toddlers and infants as family practicephysicians did; otherwise, the demographic distribution of patients wasvery similar, with bimodal peaks for ages 6 to 17 at 18% and ages 35 to44 at 21% of patient visits. Med-peds physicians provided for a higher levelof illness, in part due to a 40% increase in internal referrals from familypractice colleagues, and for a much greater volume of health maintenancevisits across all ages (Figure 5). This collaborative practice setting alsoshowed more cost-effective use of the office by med-peds physicians thanby family practice colleagues despite the greater complexity of care provided.

Whether med-peds physicians will maintain their combined specialty expertisecan only be speculated at this time, since dual recertification data arenot yet available. The 87% of med-peds physicians who care for childrenand adults suggests that the vast majority of med-peds physicians will chooseto recertify in both specialties.

Future directions for the specialty

Medicine-pediatrics has evolved through effective collaboration betweenthe two longest-established primary care specialties. Collaboration, timing,and adaptability to the changing medical environment have been the keysto the new specialty's success. For over a decade it has been argued thatcollaboration and not competition among primary care physicians is the idealas we advance toward the next century.^18,19

This brings us to the concept of the generic primary care physician.Until recently, discussions of med-peds fulfilling this role have been overlooked.But outcome studies show that the med-peds specialist delivers both comprehensiveoutpatient primary care and inpatient tertiary care for children and adultsina collaborative environment. Such physicians should thrive in a managedcare environment.¹⁸

Asa generic primary care physician, the practice style med-peds bringsto contemporary medicine is multifaceted:

Med-peds as a pediatrician. As pediatricians, med-peds physicians aretrained to manage a wide spectrum of acute and chronic illnesses of childhood,in ambulatory or hospital settings.²⁰ Pediatricians are trainedto provide a medical "home" for children²¹ by givingroutine preventive services and anticipatory guidance on a continuing basis.Pediatricians are children's advocates and have the ability to implementcommunity intervention.

Med-peds physicians, through their knowledge of health maintenance anddisease management for adults, have developed a keen sense of what liesahead for their pediatric patients and can guide them effectively into adulthood.They are well prepared to provide comprehensive health care for adolescentsin a setting where their pediatrician is also their internist.

Med-peds as an internist. Internists' training philosophy is similarto pediatricians', centering on health promotion, disease prevention, andacute and chronic illness.²² Disease prevention applies clinicalskills to the antecedents of prevalent diseases associated with aging.

The med-peds physician has a unique perspective that incorporates anticipatoryguidance into disease prevention. This emphasis on patient education shouldhelp patients stay healthy throughout their adult lives.

Internal medicine reinforces a training philosophy centered on a rigorousprocess of deductive reasoning.²³ This philosophy is integratedinto the med-peds approach to problem solving on a case-by- case basis.The internist's deductive approach to patient care represents a unique qualitythe med-peds physician contributes as a family care provider.²⁴

Med-peds as a family provider. Med-peds and family medicine both providehealth care to families. The med-peds physician additionally contributesa collaborative approach to family care,^12,15 in that 90% ofmed-peds providers practice in multispecialty groups. Only 18% of familyphysicians practice in multispecialty groups.²⁵ Family physiciansrefer a greater percentage of patients to subspecialists, which risks continuityof care, supports the existing subspecialist-generalist imbalance, and hasbeen demonstrated to be less efficient than a collaborative practice environment.¹¹

Practice outcomes reported to date have demonstrated that med-peds physiciansprovidea significant proportion of health care to children within familycare environments. Med-peds physicians would be predicted to provide a greaterproportion of care to young families than family physicians. Outcome measuresdemonstrate that family physicians provide between 15%¹⁹ and27%²⁶ of care to families with children, while med-peds provide33%¹¹ to 40%.¹⁷

Family physicians can integrate psychosocial aspects of health care intofamily care,²⁷ and med-peds have a similar opportunity. The twogroups of physicians overlap considerably on social-behavioral trainingduring residency.⁹ Both family practice and internal medicinetraining provide exposure to clinical bioethics, substance abuse, principlesin recognition and management of domestic violence, and end-of-life care.Pediatrics behavioral training includes behavioral/developmental, adolescentpsychology, peer and family relations/structure, counseling, and referral.Patient preferences demonstrate the acceptance of med-peds physicians asfamily health-care providers.¹⁷

Med-peds as a med-peds physician. The pediatric roots of the med-pedsphysician provide a developmental perspective on physical, personal, andbehavioral growth. Internal medicine roots impart a problem-solving approachto the case-by-case management of individual patients and promote a generalistrole when the physician serves as a consultant.

Internal medicine training guidelines require formal consultative experience,which prepares the med-peds physician to collaborate with pediatric subspecialistsin the management of chronic pediatric diseases. Patients with cystic fibrosis,congenital heart disease, and neurologic and genetic syndromes, as wellas those who have survived childhood cancer, have specific health-care needsthat are well known to the med-peds physician, who can also manage theirprimary and secondary prevention health-care needs effectively from childhoodthrough adulthood.

The practice style chosen by med-peds physicians is shaped not only byresidency training but by personal preferences, community setting, and thepractice environment.²¹ In a rural community or small town, themed-ped physician may play an important role as consultant in the care ofhigh-risk newborns and children with chronic illness, or as a hospitalistfor children and adults. In a more competitive environment, internal medicineand pediatric practices can use the med-peds physician to attract new patients,especially adolescents and families desiring health care for everyone inthe same practice setting.

Med-peds as a teacher. Data from many sources have demonstrated the roleof the med-peds physician in medical education. Between 15% and 18% of recentmed-peds graduates choose academic careers.^14,16 An ABIM/ABPsurvey of med-peds physicians who completed training between 1985 and 1995showed that one third spend more than 10% of their time in teaching activities,and 7.1% spend more than 30% of their time teaching.²⁸ The surveynotes that 50% of all med-peds physicians have medical school or facultyappointments in internal medicine, pediatrics, family practice, and emergencymedicine departments. While direct comparisons cannot be made, the AmericanMedical Association Database reports that 9.3% of family physicians, 15.3%of pediatricians, and 18.8% of general internists practice in academic medicalenvironments.¹⁶ The interest of med-peds physicians in medicaleducation is probably one reason US medical school graduates are fillingan expanding number of med-peds training positions.

A lesson in collaboration

Although debate over the virtues of collaboration in primary care continues,medicine-pediatricshas demonstrated what collaboration can accomplish. Partnerships betweenother medical groups, such as internal medicine and family medicine, arealso being considered but may fail unless ill feelings from the past canbe put aside and the true spirit of collaboration embraced.^29,30

Managed care companies have little patience with the competition andrhetoric of the academic environment. Increased collaboration among primarycare faculty would set a good example for medical students and residentsabout to enter practice. In addition, the experience of medicine-pediatricsphysicians can provide a focus for national discussions on academic andmanaged care issues related to collaboration. It is therefore importantto continue to include med-peds practitioners and faculty in national discussionson primary care.

As we proceed into the next century, the specialty of medicine-pediatricsis poised to play a central role in medical practice. Medicine-pediatricsis uniquely situated among primary care specialties to integrate the componentsof comprehensive health care efficiently. Collaboration and flexibilitytogether will allow medicine-pediatrics to grow to meet future needs inprimary care.

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DR. ONADY is Associate Professor of Internal Medicine and AssociateProfessor of Pediatrics in the Medicine-Pediatrics Program at Wright StateUniversity School of Medicine, Dayton, OH.