Med-Peds Program Directors Association & National Med-Peds Residents’ Association
Medical Student Guide to Combined Internal Medicine and Pediatrics Residency Training Versatile Training for the 21st Century Physician
What is residency?
After medical school and obtaining your medical degree, most physicians generally enter a “residency” program for additional training in a specific field. The types of residency programs are divided into two general groups: surgical and non surgical. Below are examples of different types of residency programs and the length of training required in order to take board exam(s) at the conclusion of residency. The process of getting into a residency program is called the “match”. This occurs during the last year of medical school. Senior medical students apply electronically (Electronic Residency Application Service), interview and then rank individual residency program(s) in one or more fields generally through the National Resident Matching Program (NRMP) or the American Osteopathic Association (AOA) match. Program directors also rank individual medical students through the NRMP or AOA and a “match” is made. An “intern” is the name given to a first year resident. After completion of a residency program and fulfilling other requirements you then take board exam(s) in that field in order to receive certification. The majority of Med-Peds trained physicians take a total of 2 board examinations: internal medicine and pediatrics. There is no combined board examination. This is not the same as a license to practice. “The medical license is the documentation of a medical practitioner’s authority to practice medicine within a certain locality”. A license to practice is determined specifically by each state.
In the beginning
If you ask most people outside of Med-Peds, most would say that Med-Peds is a new field. Actually, the initial version of combined Med-Peds training occurred in 1949 in a two year rotating internship. This was replaced by a one year post graduate program. Med-Peds transformed and started to blossom after the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) recognized a four-year Combined Internal Medicine-Pediatrics (Med-Peds) training program as an avenue for postgraduate education in 1967. That same year, a three-year curriculum in general practice was organized that ultimately developed into the Family Medicine specialty. These programs represented the first formalized comprehensive primary care curricula to include the spectrum of health care for families and spanned all ages. As you will learn, Med-Peds has so much more to offer than in the past, stay tuned. Congress and Med-Peds From the standpoint of health care policy, both Houses of Congress have recognized the potential of the Med-Peds physician by protecting funding for training of Med-Peds residents through the Primary Care Promotion Act, incorporated into the Balanced Budget Act of 1997 (Section. 4627. Medicare Special Reimbursement rule for primary care combined residency programs).1 The specialty of Med-Peds has a secure established role in providing health care in this nation.
A Changing World
The medical managed care environment which rapidly evolved through the 1980’s and 1990’s led to many changes, ultimately resulting in the decline in services offered by traditional generalist physicians. The spectrum of care provided by primary care specialists was becoming more similar. Ambulatory training became increasingly important in general internal medicine. Medicine and Pediatric Departments increasingly received funding for the combined generalist curriculum of Medicine-Pediatrics. Lifestyle issues and perceptions regarding the medical practice environment had increasingly impacted students’ choices regarding resident training. All of these factors fed the rapid growth of Med-Peds programs which expanded from 9 intern positions in 4 programs in 1980 to approximately 362 positions in 79 programs in 2008, while consistently attracting the greatest proportion of US Medical School Graduates among the primary care specialties.2 Med-Peds has changed over the years, not just offering ambulatory primary care but as you will learn the ability to sub-specialize, participate in global and international health or become a hospitalist. We can also take care of people with child onset illnesses that survive into adulthood (e.g. cystic fibrosis, cancer, sickle cell anemia) or take care of people with adult conditions that now present in childhood (e.g. obesity, Type 2 diabetes) or transitional diseases.
The Med-Peds basic operation
Med-Peds programs include 4 years (48 months) of training in two specialties, pediatrics (study of children and adolescents) and internal medicine (adult medicine). The training is integrative and rotations in general are 1 month in duration while alternating between internal medicine rotations and pediatrics rotations approximately every 3 to 6 months. In addition, residents constantly transition between children and adults in resident ambulatory practices and conferences to reflect Med-Peds in “real life”. Residents have mandatory rotations and elective rotations during the 4 years. There are no programs that have a curriculum of 2 years of one specialty followed by 2 years of the specialty. Rotations include but are not limited to3:
|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||2-3|
|Emergency Medicine||1||Adolescent Medicine||1|
|Subspecialty experience (e.g. Infectious Diseases, Nephrology, etc.)||4||Emergency Pediatrics and Acute Illness Pediatrics||3|
|Subspecialty experience (e.g. Infectious Diseases, Nephrology, etc.)||4|
|Overall Ambulatory Experience (minimum)||33%||Overall Ambulatory Experience (minimum)||40%|
Med-Peds programs provide experiences and guidance in topics such as child advocacy, risk management, cost effective care, quality improvement, evidence based practice, substance use disorders, informatics, medical genetics, health care financing, ethics, end of life care, organization and structure of practices. As well, subspecialty work in psychiatry, dermatology, ophthalmology and gynecology are included in our programs.3 The Accreditation Council of Graduate Medical Education (ACGME) is responsible to oversee residency and fellowship training programs for the public. “The Accreditation Council for Graduate Medical Education is a private, non-profit council that evaluates and accredits medical residency programs in the United States. The mission of the ACGME is to “improve health care by assessing and advancing the quality of resident physicians’ education through accreditation”.4 Before 2007, the American Board of Pediatrics and the American Board of Internal Medicine was responsible to oversee Med-Peds programs. In 2007, Med-Peds programs underwent accreditation in a similar fashion to our categorical medicine and categorical pediatrics programs. Med-Peds programs are the only combined residency programs to undergo accreditation. As the largest group of combined residents, accreditation allows for minimum standards across all programs, facilitates licensure in all 50 states and provides a voice for Med-Peds residents about their training. The requirements for Med-Peds programs are available for review at: http://www.acgme.org/acWebsite/downloads/RRC_progReq/700prAddendum06272006.pdf”
Low Attrition Rates
Aren’t Med-Peds Programs difficult? Can I complete both?
Med-Peds residencies are somewhat rigorous because Med-Peds training incorporates all of the important elements of two, three-year training programs into Fellowships one four-year integrated program. However, the attrition rate for Med-Peds residents is at a level amongst the lowest of all residents at around 9%.5 Though Med-Peds residents have reduced redundancy in their schedules, exposure to both these specialties allows you to appreciate the tremendous similarities and common fundamental skills necessary to be an excellent internist and pediatrician.
Why do Med-Peds physicians take two board examinations and not one? Can I pass both?
Most Med-Peds physicians take and pass the same board examinations in internal medicine and pediatrics given to our categorical counterparts.5 There is no combined board examination. It allows us to say to our colleagues and patients with conviction that we are full fledged pediatricians and internists using the same benchmarks. These board examinations may be taken in the same year or different years after the conclusion of four years of Med-Peds residency training.
Can Med-Peds trained physicians pursue sub-specialty training (fellowship)?
After completion of a residency program, additional training may be obtained. Many fellowships lead to additional board examination(s) but not all do. Currently approximately 18-25% of our graduates pursue subspecialty training in either pediatrics, internal medicine or both.5,6 We will display in the following table the fellowships you can pursue from a Med-Peds, internal medicine, pediatrics and family medicine residency and the number of years it will take to complete fellowship. Med-Peds graduates have the largest number of possible fellowships available to them.7,8,9,10
|Fellowship Type||Training length (adult)||Training length (peds)||Training length (FM)||Med-Peds||Peds||Internal Medicine||Family Medicine|
|Clinical Cardiac Electrophysiology||1||x||x|
|Emergency Medicine (peds only)||3||x||x|
|Hematology-Oncology (may be separated)||2||3||x||x||x|
|Hospice and Palliative Care||1||1||1||x||x||x||x|
What is a Combined Med-Peds fellowship?
In addition to the enjoyment of being able to continue to care for adults and children, graduates of Combined Med-Peds fellowships can fill unique niches. A Med-Peds sub-specialist can serve in specialized centers caring for adults and children with congenital heart disease, cystic fibrosis, sickle cell disease, international health, outcomes research, etc. Many of our graduates combine a pediatric and internal medicine fellowship (combined fellowship and can become quadruple boarded), complete either a pediatric or internal medicine fellowship (can become triple boarded) The amount of time needed to complete a combined fellowship generally is: adult fellowship (in years) + pediatric fellowship (in years) – 1 year. An entire guide on the NMPRA web-site will discuss in more detail about fellowships.
What do most people consider if they do not go into Med-Peds?
As you can see most Med-Peds interns generally considered internal medicine or pediatrics if they did not go into Med-Peds. 11 Peds 32% Family Med 18% Medicine 41% Other 9%
What can I do when I finish my training in a Med-Peds residency? Can I do both after I finish?
Recent published articles looked at what senior residents thought of their specialty and what type of careers they wanted.6
|Med-Peds Senior Residents||Medicine||Pediatrics|
|Equally prepared for primary care in both specialties||80%||77%|
|Equally prepared for fellowships in both specialties||90%||87%|
|Would choose same specialty again||90%||93%|
|Primary care career||55%||50%|
|Other types of practice||10%||11%|
Med-Peds graduates are well positioned to adapt to a changing medical landscape.”12 Currently there are about 6000 Med-Peds practitioners. Med-Peds residencies are amongst the most versatile residencies available. As singing sensation Hannah Montana said about her life; “it is the best of both worlds”. Med-Peds physicians have a wide range of opportunities available to them following graduation including private practice, fellowship and subspecialty care, teaching, academics, hospital medicine, research, public health, rural practice, international medicine, transitional care and other variations and combinations of clinical and research activities. Upon graduation about half of graduates go into primary care practice. The majority (between 77-93%) in primary care provide care for both adults and children. Forty percent also hold some type of academic appointment with a medical school.13 About 18-25% of graduates pursue fellowship training. At least 50% of those completing fellowship provide care for both adults and children. Sixty percent also hold some type of academic appointment with a medical school.13
What kind of practices do Med-Peds physicians enter?
Med-Peds physicians practice in a variety of environments. In most areas of the country, Med-Peds physicians are considered extremely valuable and they have many job opportunities. One-third of Med-Peds physicians work with other dual-trained physicians either exclusively or in multi-specialty practices. Most Med-Peds physicians work in practices that combine pediatricians, internists, and/or family physicians in multi-specialty Med-Peds physicians practice in a variety of environments. In most areas of the country, Med-Peds physicians are considered extremely valuable and they have many job opportunities. One-third of Med-Peds physicians work with other dual-trained physicians either exclusively or in multi-specialty practices. Most Med-Peds physicians work in practices that combine pediatricians, internists, and/or family physicians in multi-specialty group settings.5 Med-Peds physicians specializing in the care of hospitalized patients, “hospitalists,” have become increasingly popular in the last decade. Approximately 15% of our graduates enter this type of practice.6
How does Med-Peds training differ from Family Medicine training?
This question is asked of us very often. Much of the difference between Med-Peds training and Family Medicine training depends on your perspective and your personal career goals. Med-Peds is a four-year curriculum that focuses on two specialty areas, internal medicine and pediatrics. Family medicine includes other specialties such as obstetrics and surgery in a three-year curriculum. Both programs provide excellent physicians and in fact many Med-Peds graduates work side by side with family medicine colleagues. This table below illustrates some of the requirement differences between the two training programs.3,14
|Years of training||4||3|
|Number of individual fellowships available after graduation||See previous table||See previous table|
|Percent ambulatory (minimum)||36%||50%|
|Number of required pediatrics rotations||24 months||4 months|
|Number of required adult rotations||24 months||8 months|
|Maternity Care||0||2 months|
|General Surgery||0||2 months|
|Sports medicine, orthopedics, rehabilitation medicine||Required||2 months|
|Emergency Care||1 month||1 month|
|Intensive Care||8 months||Required|
The amount of outpatient time and ambulatory rotations in both Med-Peds and family medicine are comparable by virtue that Med-Peds training is 12 months longer. Family medicine does require more ambulatory time in their continuity practice and more instruction in psychiatry.
Why do medical students choose Med-Peds?
The top 10 reasons medical students like you chose Med-Peds as a career (in order chosen): 15
- Age spectrum
- Variety/depth of training
- Liked both medicine and pediatrics
- Flexible career options
- Primary care focus
- Ability to sub-specialize
- Role models
- Did not want Obstetrics or Surgery
- Transition and adolescent medicine
- More pediatrics training
Is it possible to keep up with both fields of internal medicine and pediatrics when I train and after I graduate? Can I learn both?
Although it may be more challenging, it can be done well. In fact, being familiar with the advances of one area enhances your practice of the other area. We feel that the extra effort to keep up with two fields is well worth the ability to care for patients of all ages, including families and patients with complex medical problems. There are many commercially available programs that summarize adult and pediatric literature from the common medical journals. There are Med-Peds conferences in many areas of the country that help you keep up with both fields. Remember, medical knowledge is only one core competency of an excellent physician. The other competencies are just as important and overlap even more among our fields.
Where are the Med-Peds programs? Are there geographic differences in Med-Peds? How many Med-Peds programs are there?
Currently, there are approximately 79 Med-Peds programs offering approximately 362 first-year resident positions. This makes up almost 7 percent of the internal medicine and around 13 percent of all pediatric residency positions. 2 Med-Peds residency programs and positions are not evenly distributed throughout the country. Most positions are east of the Mississippi where there are more medical schools and more experience with Med-Peds physicians. However, Med-Peds practitioners do practice in every part of the country including the west coast. A list of active Med-Peds programs (map)2 can be found on several websites: 1. www.Med-Peds.org 2. www.acgme.org/adspublic/ 3. www.nrmp.org
Aren’t Med-Peds programs extremely competitive? Should I rank “back-up” categorical programs?
Ranking a back-up categorical program is usually not necessary. The competitive nature will vary, however, from one program to the next. Almost any motivated student should be able to match in a Med-Peds program if you do not place too many restrictions on your “rank” list and realistically evaluate how competitive your application is with the individual programs. 92% of U.S. seniors matched to their preferred specialty in Med-Peds. There are currently more positions for Med-Peds than there are all U.S. seniors.2 The median consecutive Med-Peds programs ranked by U.S. seniors that matched into Med-Peds were 7 programs versus 3 programs for those that did not match into Med-Peds.16
How do I judge the relative strengths of Med-Peds programs?
This can be done in many ways. Remember that a Med-Peds program cannot stand alone, but relies upon both the departments of Internal Medicine and Pediatrics to provide the resources for training. Therefore, in evaluating the quality of a Med-Peds program, one should carefully also evaluate the two categorical programs. Applicants should look specifically at the Med-Peds portion of the program and evaluate the Med-Peds curriculum, meetings, ambulatory practice and sequence of rotations. This will identify if coordination, communication and cooperation between the departments occurs. The relative ease at which things get done for its Med-Peds residents will speak volumes about the institutional support that is critical for a combined residents’ success. Students in a recent survey revealed the top five factors for their Med-Peds rank list was: intuitive feel (55%), resident satisfaction (48%), location/family (36%), Med-Peds clinic (32%), and coordination/cooperation (30%).15
Can I find a student elective in Med-Peds?
Many (29 programs) offer fourth year medical students and several offer third year medical students the opportunity to work with Med-Peds residents and faculty in outpatient and/or inpatient rotations. If these are not offered or are not available to you then call the Med-Peds program director to help you find a rotation in either internal medicine or pediatrics but still allow you to get to know the hospital, Med-Peds faculty and Med-Peds residents.
Is it important for a Med-Peds program to have a Med-Peds-trained director?
A dual-trained director may be better equipped to coordinate a Med-Peds program as well as act as a mentor or role model. However, there are many excellent programs without a dual-trained director and many superb program directors that are trained in one field or the other. Give each program director a chance to explain how their program is unique and how they are equipped to help you become the best Med-Peds physician.
Should the program I choose have many Med-Peds-trained faculty?
Regardless of how many Med-Peds faculty a program has, faculty in the categorical programs will do the majority of the teaching. Be sure to evaluate the categorical faculty in both departments. Med-Peds trained physicians on faculty or in the community can serve as role models and mentors, but the number is not as critical as their level of involvement with you.
Is it important for a Med-Peds program to have a combined outpatient Med-Peds continuity clinic?
There are several models for outpatient Med-Peds clinics. Clinics are usually held once or twice per week over the entire four years.
- Combined Med-Peds practice: each week schedules have adult and pediatric patients either split into two halves (adults first half and pediatrics second half or vice versa) or integrated throughout.
- Alternating medicine, alternating pediatrics: Every other week you see medicine patients while on the in-between weeks you see pediatric patients. In cases where there are two clinics per week, there will be a separate medicine and a separate pediatrics session each week.
There are advantages to a combined clinic and advantages to attending separate internal medicine and pediatrics clinics. A combined clinic offers residents the opportunity to treat whole families, to see children and adults in the same setting on the same day and to follow-up patients at the resident’s next clinic day if needed. These practices are generally led by Med-Peds faculty. On the other hand, concentrating on one area or the other with a categorical preceptor or Med-Peds faculty may also offer advantages. Panel sizes and ratios of pediatrics to medicine patients may be best managed in this system. This may prevent having a panel of patients that is not balance between adults and children. Several programs offer the option of either or both models during the course of the residency program.
What are the Med-Peds organizations that will support me?
Med-Peds Program Directors Association
The first organized meeting of Med-Peds physicians occurred in 1987 through the residency program directors association. By 1991, the Medicine-Pediatrics Program Directors Association (MPPDA) was formally organized with the mission to foster collaborative interactions and maintain high training standards that addressed the spectrum of comprehensive health and illness care for all ages. Now with over 250 members that include directors, associate directors, faculty and others important people to Med-Peds, MPPDA works closely with each other to provide the tools necessary to have a thriving Med-Peds program in your part of the country. We work with other organizations that are vital to Med-Peds like the Association of Program Directors in Internal Medicine (APDIM), Association of Pediatric Program Directors (APPD), Primary Care Organizations Consortium (PCOC) and the American Academy of Pediatrics Committee of Pediatric Education (COPE).
National Med-Peds Residents’ Association
The National Med-Peds Residents’ Association (NMPRA) was formed in 1997 as a resident driven organization dedicated to providing information, opportunities and programs to Med-Peds residents and students. NMPRA has over 1000 resident members. NMPRA is the site that has the best information to learn the basics about Med-Peds. They have newsletters, forums to send questions to program directors and list med student electives in Med-Peds. They hold an annual meeting and let you know where and when national and regional Med-Peds events are held like the annual NMPRA annual meeting, the annual northeast Med-Peds meeting and the annual Midwest Med-Peds meeting. Visit our site and ask for a Med-Peds speaker to come to your medical school!!!
American Academy of Pediatrics – Med-Peds section in conjunction with the American College of Physicians
Within MPPDA, a second organization was launched to advocate and provide a graduate network. This evolved under separate leadership into the Med-Peds Section within the American Academy of Pediatrics (AAP) and American College of Physicians (ACP). Now with over 1000 members, this organization provides tools to people in practice, residents and medical students to better understand Med-Peds physicians and their practices. This section provides twice yearly workshops and lectures for you to attend that provide important Med-Peds content at a national level. The Med-Peds section is also pivotal in publishing Med-Peds research each year. We are looking for medical students that are interested to be a member of this section!!!
Conclusions: Why is Med-Peds a viable option?
- The depth and breadth of two disciplines that allows flexible career goals without Surgery and OB training. The perfect “double major”.
- There is four years of training that is rigorous but humane; gives added maturity to your career (think of it as 6 years minus 2).
- A wide variety of practice styles and settings for an effective and satisfying career.
- Obtaining dual board certification in Internal Medicine and Pediatrics that is still quite unique.
- There are niches of special populations and cross fertilization of knowledge.
- A great 40 years of rich history in Med-Peds.
- Section 4627 of Balanced Budget Act of 1997. Medicare Special Reimbursement rule for primary care combined residency programs. Accessed January 28, 2008 at http://www.ows.doleta.gov/dmstree/pl/pl_105-33.pdf
- National Residency Match Program (NRMP) 2008 at www.nrmp.org
- Accreditation Council for Graduate Medical Education. Med-Peds Program Requirements. Accessed January 28, 2008 at http://www.acgme.org/acWebsite/downloads/RRC_progReq/700prAddendum06272006.pdf
- Accreditation Council for Graduate Medical Education at http://www.acgme.org/acWebsite/about/ab_mission.asp
- Frohna, J, Melgar T, Mueller C, and Borden S. Internal Medicine-Pediatrics Residency Training: Current Trends and Outcomes. Academic Medicine. 2004; 79:591–596.
- Chamberlain, J; Cull W; Melgar T; Kaelber D; Kan B. The effect of dual training in internal medicine and pediatrics on the career path and job search experience of pediatric graduates. J Pediatrics. 2007, 151:419-24.
- American Board of Internal Medicine at www.abim.org accessed February 15, 2008
- American Board of pediatrics at www.abp.org/ABPwebsite/certinfo/subspec/subintro.htm accessed February 15, 2008
- American Board of Family Practice at www.abfp.org accessed February 15, 2008
- Accreditation Council of Graduate Medical Education www.acgme.org accessed February 15, 2008
- Melgar, T; Frohna , JG. Choosing a Career in Combined Internal Medicine and Pediatrics: Insights from Interns. Family Medicine. 2007;39: 326-330.
- Frohna J. The Role of the Med-Peds Physician in a Changing Medical World. J of Pediatrics. 2007;151:338-339.
- 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.
- Accreditation Council for Graduate Medical Education. Family medicine program requirements. Accessed January 28, 2008 at http://www.acgme.org/acWebsite/downloads/RRC_progReq/120pr07012007.pdf
- Robbins BW, Ostrovsky, D, and Melgar, T. Factors in Medical Students’ Selection and Ranking of Combined Medicine-Pediatrics Programs.Academic Medicine. Vol 80, No. 2, February 2005, p. 199.
- National Resident Matching Program and Association of American Medical Colleges. “Charting Outcomes in the Match” 2007. Accessed January 28, 2008 at http://www.nrmp.org/data/chartingoutcomes2007.pdf
- AAP Section on Med-Peds
- American Board of Internal Medicine
- American Board of Pediatrics
- American College of Graduate Medical Education-ACGME
- American College of Physicians
- AMA FRIEDA Online
- Electronic Residency Application Service
- Medicine-Pediatrics Program Directors Association
- National Med-Peds Residents Association
- National Residency Matching Program
Board Editor in Chief Allen Friedland, MD Christiana Care Health System, Med-Peds Program Director Chair, MPPDA Recruiting Committee Assistant Editor John Frohna, MD, MPH Vice Chair for Education University of Wisconsin School of Medicine and Public Health A collaboration between the Med-Peds Program Directors Association (MPPDA) and the National Med-Peds Residents’ Association (NMPRA)