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Article |

Internal Medicine–Pediatrics Combined Residency Graduates:  What Are They Doing Now? Results of a Survey FREE

Carole M. Lannon, MD, MPH; Thomas K. Oliver Jr, MD; Robert O. Guerin, PhD; Susan C. Day, MD; Walter W. Tunnessen Jr, MD
[+] Author Affiliations

From the Department of Pediatrics, University of North Carolina, School of Medicine, Chapel Hill (Dr Lannon); The American Board of Pediatrics, Chapel Hill (Drs Oliver, Guerin, and Tunnessen); and the American Board of Internal Medicine, Philadelphia, Pa (Dr Day). Dr Day is now with Chestnut Hill Healthcare, Philadelphia.


Arch Pediatr Adolesc Med. 1999;153(8):823-828. doi:10.1001/archpedi.153.8.823.
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Background  While the number of internal medicine–pediatrics (med/peds) residency training programs has increased considerably in the past decade, questions continue to be raised about career paths of the graduates of these programs. It is uncertain whether med/peds graduates follow a generalist career path and whether they continue to practice both specialties.

Objective  To determine the career outcomes of graduates of med/peds residency programs.

Design  A survey questionnaire of graduates of med/peds residency programs.

Methods  The computer databases of the American Board of Pediatrics and the American Board of Internal Medicine were used to identify 1482 individuals who had completed training in combined med/peds residency programs between 1986 and 1995 and who had applied to either board for certification. The survey questionnaire was mailed to all graduates identified.

Main Outcome Measures  Time spent in professional activity (patient care, teaching, administration, and research), site of principal clinical activity, ages of the patient population, types of hospital privileges, practice organization, subspecialty activity, night and weekend coverage arrangements, community size of practice, involvement in teaching, and membership in professional organizations.

Results  Of the total group of 1482 graduates, 87.3% are certified by the American Board of Internal Medicine, 91.3% by the American Board of Pediatrics, and 81.6% by both boards. The survey was completed by 1005 graduates (67.8%). The principal activity of almost 70% of the graduates was direct patient care. Most graduates cared for patients of all ages. More than half of all respondents noted that their principal clinical site is a community office practice. Eighty-five percent managed patients who require hospitalization. Approximately 50% of respondents had a medical school appointment.

Conclusions  This study, the largest survey to date of med/peds graduates, provides strong evidence that most med/peds graduates are practicing generalists who care for adults and children. In addition, the fact that 80% of graduates achieve dual board certification suggests that these physicians are well qualified to care for the spectrum of health care needs of children and adults. Because the changing US health care system mandates a strong primary care base, these physicians will play a small but important role in providing high-quality generalist care.

Figures in this Article

I am of old and young, of the foolish as much as the wise Regardless of other, ever regardful of others Maternal as well as paternal, a child as well as a man . . . And these tend inward to me, and I tend outward to them And such as it is to be of these more or less I am And of these one and all I weave the song of myself.—Walt Whitman, Leaves of Grass

THE COMBINED internal medicine–pediatrics (med/peds) residency celebrated its 30th birthday in 1997. This hybrid developed from flexible internships in the 1960s, in which physicians in training completed 6 months of internal medicine and 6 months of pediatric training. In June 1967, the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) agreed that a 4-year program combining training in internal medicine and pediatrics could meet the training requirements for certification by both boards. An institution can petition both boards to develop a combined training program as long as its categorical internal medicine and pediatrics programs are accredited by the appropriate residency review committees.

During the past 30 years, the number of med/peds programs has increased substantially, as has the number of med/peds positions offered by the National Residency Matching Program. In 1980, there were only 4 programs and 9 positions offered by the National Residency Matching Program, whereas 106 programs offered 456 postgraduate year 1 positions in med/peds in 1998. Of the postgraduate year 1 positions offered, 420 (92.1%) were filled, 82% by US medical school graduates. The increasing popularity of combined residency training in med/peds is reflected by the change in the number of residents in training during the past 5 years. In 1991, based on data collected by the ABP, there were 724 residents enrolled in combined med/peds training, whereas in 1998 the number was 1622, an increase of 124%.

As the number of residents training in med/peds has increased, there has been considerable interest in the career outcomes of graduates. The question of whether med/peds graduates are representative of generalist physicians is an important one because academic training programs face increasing political pressure to reallocate residency positions to favor primary care specialties, and Medicare policies related to graduate medical education funding for teaching hospitals create additional financial incentives. In addition, there has been considerable debate about whether med/peds graduates continue to practice both specialties.

Data collected on med/peds program graduates in the mid-1980s showed that 75% were practicing primary care, 17% were in subspecialty practice, and 8% were working in emergency departments.1 Of those practicing primary care, 83% were practicing both internal medicine and pediatrics. A survey of program directors of med/peds training programs about the career outcomes of graduates from 1987 to 1993 also found that most med/peds graduates had chosen generalist careers.2 Of the 708 graduates described, 68% were practicing as generalists and 21% had entered subspecialty training. Of the cohort in primary care, 81% were in practice (rather than academics) and 85% were practicing both internal medicine and pediatrics.

These previous studies about career outcome have surveyed program directors rather than graduates themselves. To develop an accurate database about the career outcomes of med/peds graduates, a survey of med/peds graduates was performed.

The computer databases of the ABP and ABIM were searched in 1995 to identify individuals with combined training who had applied for certification by either board since 1986 and whose credentials were approved. The ABP and ABIM began the process of codifying combined med/peds trainees as a separate category in 1986. An estimated 110 individuals who had satisfactorily completed combined training or who had become certified in either or both specialties before 1986 were not included in the survey. A total of 1482 individuals with combined training who had been approved to take the certifying examinations were identified.

A questionnaire was developed by 3 of us (C.M.L., T.K.O., and S.C.D.). The first mailing was in October 1995, with a second mailing to nonresponders in December 1995. Demographic data available on each candidate from board files included sex, medical school (graduates of accredited medical schools in the United States and Canada were designated American medical graduates, whereas graduates of nonaccredited medical schools, most of which are located abroad, were designated as international medical graduates), date of completion of training, certification status, and geographic location of practice setting.

The survey instrument consisted of 12 questions that asked about percentage of time spent in professional activity (patient care, teaching, research, and administration), principal site of clinical activity, ages of the patient population, types of hospital privileges, practice organization, subspecialty activity, night and weekend coverage arrangements, community size of practice, involvement in teaching, and membership in professional organizations.

Sixty-six percent of the total med/peds graduates known to the boards are men, and 34% are women; 88% are American medical graduates, and 12% are international medical graduates. Of the total group of 1482 graduates, 87.3% are certified by the ABIM, 91.3% by the ABP, and 81.6% by both boards; 151 graduates had not yet attempted certification by the ABP.

Of the 1331 individuals with combined training identified by the ABP, 908 responded. Of the 151 individuals identified only by the ABIM, 97 responded. The overall response rate was 67.8%. The data reported in this survey are based on 1005 responders. Ninety-nine percent of the survey respondents had completed training in the 10-year period (1986-1995), and 68% had completed training between 1990 and 1995.

CLINICAL ACTIVITY

The principal activity of the med/peds graduates was direct patient care. As shown in Table 1, 56.8% of med/peds graduates spent more than 80% of their time in patient care and almost 70% spent more than 70% of their time in direct patient care. In contrast, 67% spent less than 10% of their time in teaching and only 7.1% spent more than 30% of their time in teaching activities. Furthermore, 80% spent less than 10% of their time in research; most (59%) spent no time in this activity. Almost 80% spent 10% or less of their time in administration. Nearly 96% of the respondents worked full-time in professional activities (defined as >26 wk/y or >30 h/wk). The remaining 4% of respondents cited child rearing (66%), lifestyle (20%), or retirement and/or disability (5%) as reasons for devoting less time to professional activities.

Table Graphic Jump LocationTime Spent in Professional Activity by Internal Medicine–Pediatrics Graduates

Respondents who were active clinically care for adults and children. Only 4% of the respondents reported that they saw no children younger than 10 years, whereas 6% reported that they saw no adults older than 60 years. Only 1% of physicians reported that 91% to 100% of their practice consisted of children younger than 10 years, and only 1% reported that 71% to 80% of their patients were adults older than 60 years. The site of principal clinical activity reported by respondents is shown in Figure 1. More than half of the physicians noted that the site of their principal clinical activity was a community office practice.

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Figure 1.

Site of principal clinical activity of internal medicine–pediatrics graduates.

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Eighty-five percent of respondents managed patients who required hospitalization. Figure 2 shows the hospital settings in which patients were managed. Seventy-three percent of respondents spent less than 20% of their clinical activity in the management of hospitalized patients.

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Figure 2.

Management of hospitalized patients by internal medicine–pediatrics graduates. ICU indicates intensive care unit.

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In response to a question on subspecialty activity, 33% of respondents indicated that they had clinical activity or formal training in a subspecialty, and 31% reported that they spend 20% or more of their practice time in a subspecialty. Only 4% had other training, such as The Robert Wood Johnson Clinical Scholars Program or a primary care fellowship.

PRACTICE ORGANIZATION

For practice organization, 90% indicated that they were in group practice, whereas 10% of respondents were in solo practice. Respondents were asked to list all of the specialties represented in their group practices. The composition of these group practices is shown in Figure 3. It is apparent that these practices were composed of generalist physicians. The respondents' night and weekend coverage for adults and children was remarkably similar, as shown in Figure 4.

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Figure 3.

Composition of group practices of internal medicine–pediatrics graduates. Med indicates internal medicine; peds, pediatrics; and ob-gyn, obstetrician-gynecologist.

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Figure 4.

Night and weekend coverage arrangements by internal medicine–pediatrics graduates. Med indicates internal medicine; peds, pediatrics; and ob-gyn, obstetrician-gynecologist.

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The size of the community in which respondents practiced is shown in Figure 5. Most combined med/peds residency programs (80%) are located east of the Mississippi River. Fifty-eight percent of respondents to the ABP questionnaire practiced in states east of the Mississippi River, whereas only 13.6% of respondents practiced in all of the western contiguous states from Montana to New Mexico, Alaska, and Hawaii. This is quite similar to the distribution of certified pediatricians practicing in these areas: 44.9% and 15.9%, respectively (Sarah Brotherton, PhD, personal communication, May 1, 1997).

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Figure 5.

Size of a community in which internal medicine–pediatrics graduates practice.

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MEDICAL SCHOOL AFFILIATION

Approximately 50% of respondents had a medical school faculty appointment, principally in internal medicine or pediatrics, but family practice, emergency medicine, and other specialties were also represented. Thirty-one percent of those with a faculty appointment had a full-time salaried position, whereas 51% were voluntary faculty. The respondents' membership in various pediatric and internal medicine professional organizations was as follows: American Academy of Pediatrics, 74%; American College of Physicians, 62%; American Medical Association, 34%; American Society of Internal Medicine, 7%; Society for General Internal Medicine, 3%; and Ambulatory Pediatric Association, 2%.

To our knowledge, this study is the first to survey med/peds graduates themselves about their career outcomes.1,2 Previous reports have obtained indirect information from program directors. In addition, this study reports on the largest sample of med/peds graduates (n=1005) identified and surveyed to date.

The results of this survey demonstrate that most graduates of med/peds residency programs were generalists who provided care for patients of all ages. More than half of these clinicians practiced with a mixture of generalist physicians in a community practice group setting. More than 80% of med/peds residency graduates achieved dual board certification.

The survey data regarding practice characteristics were similar to the data obtained in 2 other published surveys1,2 regarding career outcomes of med/peds graduates. Internal medicine–pediatrics graduates spent the majority of their time in direct patient care, and most of that time was spent in primary care. Patient care was the primary focus of survey responders, with almost 70% indicating that they spent at least 71% of their professional activity in this endeavor. Thirty-one percent of respondents spent more than 20% of their time in subspecialty practice, but only 26% spent more than 50% in subspecialty practice. This survey was not able to accurately assess the proportion of graduates who had gone on to subspecialty training in pediatrics or internal medicine, combined subspecialty training, or training in another specialty. It seems reasonable to expect that certified subspecialists would spend more than 50% of their time in subspecialty practice. While previous surveys of program directors have found that 17%1 and 21%2 of graduates entered subspecialty fellowships, the eventual subspecialty practice patterns of these graduates are not known.

Although the percentage of med/peds graduates practicing more than 50% of the time in a subspecialty was about the same as the percentage of pediatric categorical graduates certified in a subspecialty (27.1%), it was lower than the percentage of internal medicine graduates certified in a subspecialty from 1986 to 1996 (47%). In future surveys, it will be of interest to see whether and what proportion of med/peds graduates seek dual subspecialty training and certification by both boards. Future research should also assess whether the decreasing interest in subspecialty training among categorical trainees in both specialties will be observed among med/peds graduates.

More than half of med/peds graduates saw patients in community-based office practice, whereas 20% conducted their practice in hospital settings. The percentage practicing in hospital settings is not surprising given the fact that almost half of survey respondents indicated that they had an academic appointment and 31% of those had a full-time salaried appointment. With the marked increase in the development of med/peds programs, one would expect that a significant number of graduates accepted faculty positions at new combined residency training sites. The involvement in medical education reported by almost half of the graduates suggests a commitment to the training of future generalists.

Despite the relatively small number of med/peds graduates, the organization of their practices reflects an interest in seeking physicians with similar training background. Almost 30% of med/peds graduates who practiced in a group were in practice with another med/peds graduate (Figure 3). Only 10% were in solo practice, reflecting a trend toward group practice among primary care providers. Similar percentages of responding physicians practiced in groups with family physicians, general internists, and general pediatricians. In multispecialty groups, the med/peds graduates, like family physicians, take night call for patients of all ages.

The survey question regarding practice community size sought to determine if med/peds graduates are more likely than categorical pediatrics or internal medicine graduates to practice in small communities. Unfortunately, data that allow a similar classification of the practices of categorical graduates are not readily available. One would suspect that med/peds graduates are more likely to sustain successful practices in smaller communities because they care for adults and children.

The sex composition of graduates of med/peds combined training is different from the sex composition of categorical residency programs. In categorical pediatrics, the percentage of female graduates increased to more than 60% between 1985 and 1995, a much higher representation than the 34% of female med/peds graduates. The percentage of female graduates of med/peds residencies is much closer to that of categorical internal medicine training. For the period 1986-1996, women composed 28% of the categorical internal medicine graduates.

The group of individuals to whom survey questionnaires were sent represents the most accurate sample of med/peds graduates that can be identified from any data source. Several limitations of the sampling strategy need to be addressed. We sampled graduates who applied to either board for certification from 1986 to 1995 because 1986 was the first year that either board identified applicants as med/peds trainees. This strategy neglects applicants who applied for certification before 1986; we believe this number to be small. It is estimated that only a few graduates completed training during the 1970s, and there were only 29 med/peds training positions listed and filled in the 1980 and 1981 National Residency Matching Program, the first years that med/peds training programs were listed in the Graduate Medical Education Directory. Since attrition rates in med/peds residencies during the 1980s were often as high as 25%, and since med/peds graduates often stagger the years in which they take specialty certification examinations (eg, taking internal medicine one year and pediatrics the next), it is unlikely that many graduates from 1980 and 1981 were missed by our sampling method.

Our survey "oversampled" more recent graduates because most med/peds residents have finished training since the late 1980s as a result of the considerable increase in the number of med/peds training programs since the mid-1980s. In addition, we surveyed only graduates who had applied for certification. Those who have not applied for certification were not included in the study and are unknown to the boards. This number is thought to be quite small based on the perceived importance of certification to graduates.

Perhaps because there has been little data on the career outcomes of med/peds residency graduates, several questions have developed within the medical student, resident, and physician communities regarding this hybrid discipline3; for example, "do med/peds graduates pursue careers in primary care?" and "do med-peds graduates continue to practice both specialties?" This study, to our knowledge the largest survey to date of med/peds graduates themselves, provides strong evidence that most med/peds graduates are primary care providers who care for both adults and children. In addition, the fact that 80% of graduates achieve dual board certification suggests that these physicians are well qualified to care for the spectrum of health care needs of both children and adults.

The interest in med/peds combined residency training and career opportunities has increased dramatically during the past decade. One can only speculate on the reasons for this change, some of which may be attributed, at least more recently, to the perceived need for individuals trained in primary care. The changing US health care system mandates a strong primary care base. This survey documents that most med/peds physicians are practicing generalists and provides important information regarding the practice patterns of med/peds graduates. Graduates of med/peds residency programs will play a small but important role in providing high-quality generalist medical care. Future research must follow the career outcomes and practice patterns of these well-qualified generalist physicians.

Since the interest in med/peds training has escalated during the past decade, it will be important to follow the career outcomes and practice patterns of graduates with similar surveys. By 2000, the number of individuals who completed combined training will have more than doubled. Survey questions will be developed to gather information about subspecialty training and careers, including interest in dual subspecialty training.

Accepted for publication January 12, 1999.

We thank Lynn M. Manfred, MD, Howard H. Schubiner, MD, and Barbara L. Schuster, MD, for their help with the conceptualization of the survey variables; John J. Norcini, PhD, for providing data from the American Board of Internal Medicine files; and James A. Stockman, MD, for his thoughtful critique.

Reprints: Walter W. Tunnessen, Jr, MD, The American Board of Pediatrics, 111 Silver Cedar Ct, Chapel Hill, NC 27514 (e-mail: wtunnessen@abpeds.org).

Editor's Note: Thanks to the American Board of Pediatrics' staff, we now have important information about internal medicine–pediatrics graduates. At some point, it would be interesting to compare their practices with a comparable group of family medicine graduates. Any bets?—Catherine D. DeAngelis, MD

Ferrari  ND  IIIShumway  JM Combined internal medicine/pediatric residency training programs. Pediatrics. 1989;8494- 97
Schubiner  HLannon  CManfred  L Current positions of graduates of internal medicine–pediatrics training programs. Arch Pediatr Adolesc Med. 1997;151576- 579
Link to Article
Ciccarelli  M The clinical philosophy of medicine-pediatrics. Am J Med. 1998;104330- 331

Figures

Place holder to copy figure label and caption
Figure 1.

Site of principal clinical activity of internal medicine–pediatrics graduates.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Management of hospitalized patients by internal medicine–pediatrics graduates. ICU indicates intensive care unit.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Composition of group practices of internal medicine–pediatrics graduates. Med indicates internal medicine; peds, pediatrics; and ob-gyn, obstetrician-gynecologist.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Night and weekend coverage arrangements by internal medicine–pediatrics graduates. Med indicates internal medicine; peds, pediatrics; and ob-gyn, obstetrician-gynecologist.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Size of a community in which internal medicine–pediatrics graduates practice.

Graphic Jump Location

Tables

Table Graphic Jump LocationTime Spent in Professional Activity by Internal Medicine–Pediatrics Graduates

References

Ferrari  ND  IIIShumway  JM Combined internal medicine/pediatric residency training programs. Pediatrics. 1989;8494- 97
Schubiner  HLannon  CManfred  L Current positions of graduates of internal medicine–pediatrics training programs. Arch Pediatr Adolesc Med. 1997;151576- 579
Link to Article
Ciccarelli  M The clinical philosophy of medicine-pediatrics. Am J Med. 1998;104330- 331

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