Internal medicine-pediatrics combined residency graduates: what are they doing now? Results of a survey

Zebras in the Forest: the experiences of Dual-Trained Child Psychiatrists and Paediatricians in Australia and New Zealand

OBJECTIVES

The objectives of this study were to examine the experiences of dual-trained child psychiatrists and paediatricians in Australia and New Zealand and inform the review of the Dual Fellowship Training Programme by the Royal Australian and New Zealand College of Psychiatrists and Royal Australasian College of Physicians.

METHODS

All dual-trained child psychiatrists and paediatricians and current trainees were electronically surveyed in 2015.

RESULTS

Seven out of eight specialists (88%) and four out of six trainees (67%) responded. Six (55%) completed or were undertaking training as part of the Dual Fellowship Training Programme. Most respondents entered dual training without difficulty, found the transition from paediatrics to adult psychiatry challenging, and were reassured by their decision to undertake dual training on reaching advanced training in child psychiatry. Benefits and downsides of dual training were noted during and following training. A significant proportion of specialists (55%) were working in hospital-based environments, especially consult liaison services, suggesting that they added long-term value to both the fields of child psychiatry and paediatrics.

CONCLUSIONS

The Dual Fellowship Training Programme remains a valuable vehicle for gaining skills in paediatrics and child psychiatry. There is support for its continuation by previous and current participants.

A Survey of Graduates of Combined Emergency Medicine-Pediatrics Residency Programs: An Update

BACKGROUND

In 1998, emergency medicine-pediatrics (EM-PEDS) graduates were no longer eligible for the pediatric emergency medicine (PEM) sub-board certification examination. There is a paucity of guidance regarding the various training options for medical students who are interested in PEM.

OBJECTIVES

We sought to to determine attitudes and personal satisfaction of graduates from EM-PEDS combined training programs.

METHODS

We surveyed 71 graduates from three EM-PEDS residences in the United States.

RESULTS

All respondents consider their combined training to be an asset when seeking a job, 92% find it to be an asset to their career, and 88% think it provided added flexibility to job searches. The most commonly reported shortcoming was their ineligibility for the PEM sub-board certification. The lack of this designation was perceived to be a detriment to securing academic positions in dedicated children's hospitals. When surveyed regarding which training offers the better skill set for the practice of PEM, 90% (44/49) stated combined EM-PEDS training. When asked which training track gives them the better professional advancement in PEM, 52% (23/44) chose combined EM-PEDS residency, 27% (12/44) chose a pediatrics residency followed by a PEM fellowship, and 25% (11/44) chose an EM residency then a PEM fellowship. No EM-PEDS respondents considered PEM fellowship training after the completion of the dual training program.

CONCLUSION

EM-PEDS graduates found combined training to be an asset in their career. They felt that it provided flexibility in job searches, and that it was ideal training for the skill set required for the practice of PEM. EM-PEDS graduates' practices varied, including mixed settings, free-standing children's hospitals, and community emergency departments.

The Med-Peds Hospitalist Workforce: Results From the American Academy of Pediatrics Workforce Survey

OBJECTIVE

There is no published literature about the med-peds hospitalist workforce, physicians dually trained in internal medicine and pediatrics. Our objective was to analyze this subset of physicians by using data from the American Academy of Pediatrics (AAP) workforce survey to assess practice patterns and workforce demographics. We hypothesized that demographic differences exist between hospitalists and nonhospitalists.

METHODS

The AAP surveyed med-peds physicians from the Society of Hospital Medicine and the AAP to define workforce demographics and patterns of practice. We compared self-identified hospitalists with nonhospitalist physicians on multiple characteristics. Almost one-half of the hospitalists self-identified as being both primary care physicians and hospitalists; we therefore also compared the physicians self-identifying as being both primary care physicians and hospitalists with those who identified themselves solely as hospitalists.

RESULTS

Of 1321 respondents, 297 physicians (22.4%) self-reported practicing as hospitalists. Hospitalists were more likely than nonhospitalists to have been practicing<10 years (P<.001), be employed by a health care organization (P<.001), work>50 hours per week (P<.001), and see only adults (P<.001) or children (P=.03) in their practice rather than a mix of both groups. Most, 191/229 (83.4%), see both adults and children in practice, and 250/277 (90.3%) stated that their training left them well prepared to practice both adult and pediatric medicine.

CONCLUSIONS

Med-peds hospitalists are more likely to be newer to practice and be employed by a health care organization than nonhospitalists and to report satisfaction that their training sufficiently prepared them to see adults and children in practice.

Residencies with dual internal medicine and pediatrics programs outperform others on the American Board of Pediatrics Certifying Examination

OBJECTIVE

The purpose was to evaluate American Board of Pediatrics Certifying Examination performance based on if a residency offers a dual internal medicine-pediatrics program, hypothesizing that having a dual-accreditation program is associated with higher exam performance.

METHODS

Pediatric residency programs in the United States were retrospectively evaluated from 2010 to 2012. The accreditation status was determined. Mann-Whitney U tests were performed for continuous variables, and χ(2) tests were performed for categorical variables, using an α = .05.

RESULTS

For 190 residencies, 75 (39%) had dual Med-Peds accreditation whereas 115 (61%) did not. The median overall residency pass rate for Med-Peds accredited programs (83%; interquartile range = 74% to 91%) was higher than other programs (78%; interquartile range = 65% to 89%; P = .02). The pass rate for examinees from Med-Peds accredited programs (n = 4,108; 84.2%) was higher than examinees from other programs (n = 4,310; 79.6%; P < .001).

CONCLUSIONS

The presence of a dual-accreditation residency program should be a consideration of future applicants.

Shortage of pediatricians in Japan: a longitudinal analysis using physicians' survey data

BACKGROUND

Currently, there is a shortage of hospital pediatricians in Japan. In the present study, using data from the Survey of Physicians, Dentists, and Pharmacists in Japan, we analyzed the dynamics and distribution of pediatricians, using a time series approach.

METHODS

The total number of pediatricians, the ratios of hospital-working and female pediatricians, their mean age and geographic distribution in 1974, 1984, 1994, and 2004 were determined. The dynamics of pediatricians were analyzed by identifying the annual number of physicians participating in and withdrawing from pediatrics, and by following up withdrawal rates from pediatrics and movement rates from hospitals. The withdrawal rates of male and female pediatricians registered in 1992, 1994, and 1996 were also analyzed.

RESULTS

The number of pediatricians per 10,000 children increased from 1.9 to 7.4 between 1974 and 2004. The percentage of women among pediatricians was significantly higher than that of women among all physicians in 2004 (P < 0.01). The numbers of physicians who withdrew from pediatrics increased from the periods 1985-1994 to 1995-2004. Younger pediatricians tended to leave pediatrics earlier than elder pediatricians. There were no differences in the withdrawal rates of pediatricians between men and women registered in 1992, 1994, and 1996.

CONCLUSIONS

It is anticipated that the number of pediatricians in Japan will decrease in the near future unless practical strategies are implemented to improve the early withdrawal of younger pediatricians and the current working conditions of female pediatricians.

Combined residency training in emergency medicine and internal medicine: an update on career outcomes and job satisfaction

OBJECTIVES

This study was designed to provide an update on the career outcomes and experiences of graduates of combined emergency medicine-internal medicine (EM-IM) residency programs.

METHODS

The graduates of the American Board of Emergency Medicine (ABEM) and American Board of Internal Medicine (ABIM)-accredited EM-IM residencies from 1998 to 2008 were contacted and asked to complete a survey concerning demographics, board certification, fellowships completed, practice setting, academic affiliation, and perceptions about EM-IM training and careers.

RESULTS

There were 127 respondents of a possible 163 total graduates for a response rate of 78%. Seventy graduates (55%) practice EM only, 47 graduates (37%) practice both EM and IM, and nine graduates (7%) practice IM or an IM subspecialty only. Thirty-one graduates (24%) pursued formal fellowship training in either EM or IM. Graduates spend the majority of their time practicing clinical EM in an urban (72%) and academic (60%) environment. Eighty-seven graduates (69%) spend at least 10% of their time in an academic setting. Most graduates (64%) believe it practical to practice both EM and IM. A total of 112 graduates (88%) would complete EM-IM training again.

CONCLUSIONS

Dual training in EM-IM affords a great deal of career opportunities, particularly in academics and clinical practice, in a number of environments. Graduates hold their training in high esteem and would do it again if given the opportunity.

Characteristics of medicine-pediatrics practices: results from the national ambulatory medical care survey

BACKGROUND

Combined medicine-pediatrics (med-peds) training has existed for 40 years, yet little is known about national med-peds practices. A more comprehensive understanding of med-peds practices is important to inform medical students and guide evolving curricula and accreditation standards.

METHOD

The authors used data from the National Ambulatory Medical Care Survey from 2000 to 2006 to characterize the age distribution and types of visits seen by med-peds, internal medicine, pediatric, and family physicians.

RESULTS

Forty-three percent of visits to med-peds physicians were from children < or = 18 years of age. Compared with family physicians, med-peds physicians saw a higher proportion of infants and toddlers < or = 2 years of age (21.0% versus 3.7%; P = .002) and children < or = 18 years of age (42.9% versus 15.5%; P = .002), but they treated fewer adults age 65 or older (13.8% versus 21.3%; P = .013). Compared with internists, med-peds physicians saw a greater percentage of visits from adults 19 to 64 years of age (75.8% versus 61.2%) and fewer visits from patients age 65 or older (24.2% versus 38.8%; P = .006). Med-peds physicians, like family physicians and pediatricians, most commonly treated patients for acute problems and reported high levels of continuity of care for patients-pediatric (93.6%) and adult (94.6%).

CONCLUSIONS

Med-peds physicians care for a considerable proportion of pediatric patients while maintaining high levels of continuity of care for adult and pediatric patients. Within their practices, med-peds physicians treat a larger percentage of pediatric patients than do family physicians, but they see a smaller percentage of elderly patients.

Will generalist physician supply meet demands of an increasing and aging population?

We predict that population growth and aging will increase family physicians' and general internists' workloads by 29 percent between 2005 and 2025. We expect a 13 percent increased workload for care of children by pediatricians and family physicians. However, the supply of generalists for adult care, adjusted for age and sex, will increase 7 percent, or only 2 percent if the number of graduates continues to decline through 2008. We expect deficits of 35,000-44,000 adult care generalists, although the supply for care of children should be adequate. These forces threaten the nation's foundation of primary care for adults.

Comparing perceptions of training for medicine-pediatrics and categorically trained physicians

OBJECTIVE

The objective of this study was to compare the perceptions of clinical preparedness among graduates of categorical pediatric and internal medicine residency programs versus medicine-pediatric training programs and whether these varied for recent or older graduates.

METHODS

A mail survey study was conducted in the fall of 2004 of a random sample of 245 and 246 internal medicine physicians who applied for or took a general certifying examination between 1980 and 1997 (older graduates) and between 1998 and 2003 (recent graduates), respectively, and a random sample of 248 and 247 pediatricians who applied for or took a general certifying examination between 1980 and 1997 (older graduates) and between 1998 and 2003 (recent graduates). Analyses compared results from a recent, similar survey of medicine-pediatric physicians.

RESULTS

Response rate for pediatricians was 78% and for internal medicine physicians was 64%. Categorically trained pediatricians were more likely than medicine-pediatrics-trained physicians to report that they were very well prepared to care for infants (65% vs 50%) but less likely well trained to care for adolescents (17% vs 45%). Categorically trained internal medicine residents were less likely to feel very well prepared to care for both adults and elders than their medicine-pediatrics-trained counterparts.

CONCLUSIONS

Categorically trained pediatricians and internal medicine physicians believed that they were no better prepared to care for their patients than medicine-pediatrics-trained physicians. Regardless of their beliefs of their preparedness, medicine-pediatrics physicians in practice spend a significant majority of their time in the care of adults rather than children. Our findings indicate that this is not because of their perception of a lack of training or preparation in the care of children relative to categorically trained pediatricians. Other factors, including but not limited to patient demographic changes, reimbursement for care, and the job market, potentially play a significant role.

Training experiences of U.S. combined internal medicine and pediatrics residents

PURPOSE

To investigate the demographics and training experiences of internal medicine and pediatrics (med-peds) physicians.

METHOD

A cross-sectional survey addressing demographics, training experiences, and career plans of fourth-year residents graduating from combined internal medicine and pediatrics programs that were identified in the American Academy of Pediatrics database was initiated in May 2003. Questionnaires were mailed up to four times to nonresponders through August 2003.

RESULTS

Valid responses were received from 212 of the 340 graduating residents (62% response rate). The majority (186/208 [89%]) reported that they would choose med-peds training again. Career planning (135/210 [64%]), office management (173/212 [82%]), and outpatient procedures (155/211 [73%]) were the only areas where the majority desired more training. Neonatal intensive care training was the only topic area that the majority of residents (142/212 [67%]) reported could have been carried out in less time. Nearly all residents (183/196 [93%]) planned to care for children and adults. Residents' self-assessment of their preparation was good to excellent for evidence-based medicine (192/210 [91%]), caring for patients with special health care needs (179/209 [86%]), and use of information technology (169/208 [81%]). Residents felt equally well prepared for postgraduate activities in internal medicine and pediatrics primary care (170/212 [80%] versus 163/211 [77%], p = .305, NS) and internal medicine and pediatric fellowships (186/207 [90%] versus 181/208 [87%], p = .058, NS). Only 112 of 209 residents (54%) felt their preparation for research was good to excellent.

CONCLUSIONS

The study findings suggest that med-peds residents are satisfied with their decision to train in med-peds and with their level of preparation. They feel equally well prepared to care for adults and children, and well prepared to care for patients that may transition to adulthood with complex needs, to assess evidence, and to use information technology.

Internal medicine-pediatrics physicians: their care of children versus care of adults

Purpose To determine how practicing physicians who graduated from internal medicine-pediatrics residency programs allocate their practice time and professional activities between adult and child patients, and to investigate whether there are predictors of the extent to which a particular physician's practice is more or less focused on one or the other of these patient groups. Method In 2003, the authors mailed a questionnaire to the 1,300 generalists and 472 subspecialists who, as of 2003, had completed internal medicine-pediatrics training since the inception of the program in 1980. Results The response rate was 73% for the generalists and 65% for the subspecialists. The vast majority of the generalist physicians stated that they provide care to all ages of patients. However, the proportion of care they provided to different age groups was not uniformly distributed, with more care provided to adults than children. Both generalist and subspecialist respondents were more likely to feel better prepared by their residency training to care for adults than for children. Those who felt less well-prepared to care for children were less likely to do so in their practices (odds ratio, 0.68; 95% confidence interval, 0.48-0.96). Fifty-four percent of the subspecialists pursued subspecialty training in internal medicine only, while 38% completed a combined internal medicine-pediatrics subspecialty program. These respondents, like the generalist respondents, also were more likely to focus clinical efforts on adults than children. Fewer than half (43%) provided any care to children zero to one year of age, while 54% provided at least some care to children aged two to 11 years. Conclusions Internal medicine-pediatrics physicians are more likely to spend a majority of their clinical care focused on adults and to perceive that they stay more current in the care of adults than of children. Potential reasons for this disparity may include training issues, greater reimbursement for the care of adults, perceptions of the impact on the medical market of the demographic shifts to older adults, and employment opportunities following training. These results also demonstrate the need for a more detailed and comprehensive assessment of the adequacy of pediatrics training in these programs.

Pediatrician workforce statement

This statement discusses the importance of pediatrician-workforce issues and their relevance to the provision of pediatric health care. It reviews previous work in the health policy arena on physician and pediatrician workforce. Key pediatrician-workforce trends are described, including the growth in the number of pediatricians in relation to the child population, the increase in the number of female pediatricians, the role of international medical graduates, the diversity of the pediatrician workforce, the contributions of internal medicine-pediatrics physicians, the increasing number of nonpediatrician providers of pediatric care, geographic distribution of physicians, and the future of pediatric subspecialists. Methods of influencing the pediatrician workforce are also considered. In the concluding series of recommendations, the statement identifies both overarching policy goals for the pediatrician workforce and implementation strategies designed to ensure that all of America's infants, children, adolescents, and young adults have access to appropriate pediatric health care.

The pediatrician workforce: current status and future prospects

The effective and efficient delivery of children's health care depends on the pediatrician workforce. The number, composition, and distribution of pediatricians necessary to deliver this care have been the subject of long-standing policy and professional debate. This technical report reviews current characteristics and recent trends in the pediatric workforce and couples the workforce to a conceptual model of improvement in children's health and well-being. Important recent changes in the workforce include (1) the growth in the number of pediatricians in relation to the child population, (2) increased numbers of female pediatricians and their attainment of majority gender status in the specialty, (3) the persistence of a large number of international medical graduates entering training programs, (4) a lack of ethnic and racial diversity in pediatricians compared with children, and (5) the persistence of marked regional variation in pediatrician supply. Supply models projecting the pediatric workforce are reviewed and generally indicate that the number of pediatricians per child will increase by 50% over the next 20 years. The differing methods of assessing workforce requirements are presented and critiqued. The report finds that the pediatric workforce is undergoing fundamental changes that will have important effects on the professional lives of pediatricians and children's health care delivery.

Internal medicine-pediatrics residency training: current program trends and outcomes

PURPOSE

Combined internal medicine-pediatrics (med-peds) residency programs have existed since 1967. Due to the rapid growth in the number and size of programs during the 1990s, most current med-peds physicians completed their residency in the last ten years, making older studies of med-peds programs obsolete. The authors sought to determine completion rates of med-peds residency programs and describe the initial career plans for five cohorts of graduating residents from combined med-peds training programs.

METHOD

Program directors of all U.S. med-peds residency programs were asked to complete a Web-based survey and base their responses on the records of cohorts of residents completing their programs from 1998 through 2002. To allow sufficient time to complete both the American Board of Pediatrics (ABP) and American Board of Internal Medicine (ABIM) certification examinations, certification status was requested only for the cohort completing training in 1998.

RESULTS

Responses were obtained from 92% (83/90) of the programs, reflecting 1,595 residents entering med-peds programs. Of these residents, 91% graduated from a med-peds program. Among the graduates, 82% were seeing both adults and children, 22% went on to subspecialty residencies, 21% began practice in rural or underserved areas, and 25% entered an academic position. ABIM and ABP pass rates for the 1998 cohort were 97% and 96%, respectively. Overall, 79% of the 1998 graduates are board certified in both specialties.

CONCLUSIONS

Compared with previous studies, a greater proportion of residents who recently entered med-peds programs completed their dual training, and a larger percentage of graduates are seeing both adults and children. The proportion of residents entering subspecialty residencies has increased significantly, but the proportion of graduates in academic careers has remained stable.

Outcomes of combined internal medicine-pediatrics residency programs: a review of the literature

PURPOSE

To evaluate the outcomes of combined internal medicine and pediatrics (IMP) residency programs using the published literature.

METHOD

A literature search was conducted using Medline. Published articles were categorized as research or non-research (commentary, program requirements, program descriptions). Research articles were summarized and the results grouped under ten outcome variables.

RESULTS

Of the 32 articles located, 18 were research articles, of which only four had been published since 1993. All the research conducted was cross-sectional and most involved surveys of program directors (seven studies) or graduates (four studies). At the time the studies were conducted, 20-33% of IMP residents did not complete their combined training; attrition rates have not been documented recently. Approximately 80% of IMP graduates achieved certification in both specialties, one third subspecialized to some degree, and 80% provided care to both adults and children. One fourth of the graduates felt that more training was needed in ambulatory settings and less was needed in intensive care. Very few studies of the outcomes of IMP physicians were found.

CONCLUSION

The outcomes of IMP residency programs are important for health workforce policy, and this study documents a need for more extensive research on the outcomes of training programs for primary care physicians.