Where do med-peds fit?

April 8, 2005

Who are these double-boarded physicians and do they pose a threat to other primary care doctors?

Are med-peds gluttons for punishment or are they just unsure of what they want to be when they grow up? Neither, actually. Med-peds say the reason they go through four years of residency, sit for two board exams (in internal medicine and pediatrics) and soldier on for periodic recertification in two specialties is that they actually want to know all that stuff. But many of them also want to keep open the possibility of subspecializing.

"Med-peds was the best way to be Marcus Welby and also have an option to do something else if I changed my mind," says Salvatore S. Volpe, a med-peds physician in Staten Island, NY.

Before we go any further, let's make one thing perfectly clear: Med-peds (medicine-pediatrics) is not recognized as a separate specialty. Even though doctors started being trained as med-peds in 1967-two years before family medicine was officially recognized as a specialty-and there are med-peds residency programs, med-peds is a combination of two specialties. So a physician who says he's a med-peds is both a general internist and a pediatrician.

Coexistence with family medicine How do med-peds differ from family physicians? More than you might think, because of some major differences in their training. While family physicians are taught a broader range of skills-how to deliver babies, set bones, and perform minor surgery-med-peds receive more in-depth training in pediatrics and the diseases of internal organs.

Allen R. Friedland, president of the Medicine-Pediatrics Program Directors Association and a med-peds physician, notes that while it's true that med-peds can't do obstetrics or surgery, they do handle gynecological problems, minor procedures, and musculoskeletal complaints. "Our training provides us with the tools to give longitudinal and comprehensive care to individuals and families in both the hospital and in the office," he says. "Our skill sets allow for great collaboration with our family medicine colleagues."

In any case, med-peds hardly pose a threat to family physicians, with whom they frequently practice in groups. There are only a little more than 3,500 practicing med-peds and 1,600 med-peds residents. While these residency programs have had no trouble attracting young doctors, the number of med-peds positions has leveled off in recent years, Friedland says. And only a small percentage of doctors going into med-peds choose it in preference to family medicine. So the specialty isn't draining away residents who would otherwise become family doctors.

Nevertheless, there's evidence that what FP Norman B. Kahn Jr., vice president of science and education at the American Academy of Family Physicians, calls the "denigration" of family practice in academic medical centers influences some medical students to pursue a residency in med-peds. Scott M. Bolhack, a med-peds who trained in New York City and later moved to Tucson, recalls being told that med-peds provided more opportunities than family medicine did. Why? Because a med-peds was more likely to get admitting privileges and would have more prestige than an FP. "That probably had to do with the prejudices of East Coast medical schools and how they feel about family practitioners," he says. "West of the Mississippi, FPs get a lot more respect."

What med-peds do varies widely While about two-thirds of med-peds go into primary care, their practices vary widely. Some become hospitalists, and others practice mostly pediatrics or mostly internal medicine. Volpe estimates that the average med-peds physician spends about 75 percent of his time practicing internal medicine and 25 percent doing pediatrics. Friedland says that today's med-peds tend to split their practice right down the middle after residency.