What’s the difference between family practice and med-peds?

I like Dr. Rob, the one with the distractible mind. And although I thoroughly agree with the stance he takes in his recent post against cholesterol screening in kids, I must take issue with his opening statement:

I have a unique vantage point when it comes to the issue universal cholesterol screening in children, when compared to most pediatricians.  My unique view stems from the fact that I am also an internist who deals with those children after they grow up on KFC Double Downs.

From Dictionary.com:

“Unique”: existing as the only one or as the sole example; single; solitary in type or characteristics

Your med-peds training allows you to follow patients from birth to death (but no obstetrics or gynecology). You can care for all organ systems and all stages of disease (but without as much training in psychiatry). Congratulations! You’ve just (re)invented family practice (except for the above shortcomings). Oh, wait: that’s already a recognized specialty with its own residency programs, boards and everything for, like, forty years now.

This misuse of the word “unique” is one of my pet peeves.

“Unique?” I do not think that word means what you think it means.

After twenty years in practice, I agree that there probably isn’t much difference between what Dr. Rob does and what I do. After twenty years, I’m not even sure how much relevance remains from our “training”. Still, there remains a great deal of confusion about the very real differences between FP and med-peds residencies.

For starters, med-peds doesn’t provide much in the way of psychiatry or gynecology. I suppose Dr. Rob is either comfortable referring out half his patients for the bulk of their primary care needs, or he has gleaned sufficient on-the-job training to provide office gynecology care. (I’m sure he’s perfectly competent at it by now, though I wouldn’t have wanted to be one of his early patients as he figured out how to use the speculum on his own.) As for psychiatry, I’m sure he will agree that it makes up a hefty chunk of primary care medicine. Hopefully he’s picked up enough of it over the years so that he is comfortable dealing with his patients’ psychiatric issues. So I think we can agree that the farther you get from training, the more our skill sets converge.

The main difference in the training programs is this: med-peds residents mainly see hospital patients. Their outpatient experience is limited to one “continuity clinic” a week throughout their four years of training. First year family practice residents are also in the office (we offer continuous care by definition, so we don’t need the “continuity” modifier) one half-day per week, but this increases over the next two years so that by the third year, we spend 3-4 half-days a week in the office. Family practice provides specific training in outpatient medicine: how to work up problems without a hospital admission; prescribing with an eye towards compliance (and cost); basic office management; the works. My program even required that we do house calls, which I continue to do in my own practice today.

If you’re looking for a doctor to care for your entire family and you come across someone who’s been practicing a decade or two, it probably doesn’t matter whether you find someone who calls herself a family doctor or an “internist and pediatrician,” as you’re likely to get very similar care. But if you’re looking to hire someone fresh out of training, bear in mind that the FP-trained doc is more likely to be able to hit the ground running in an office setting. That’s the real difference between med-peds and family practice.

Lucy Hornstein is a family physician who blogs at Musings of a Dinosaur, and is the author of Declarations of a Dinosaur: 10 Laws I’ve Learned as a Family Doctor.

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  • http://distractible.org Rob

    I have great respect for FP’s. We have a practice with 3 FP’s and 2 Med-Peds. Most of what we do is the same, but there are some differences: we see a ton more pediatrics, and the FP trained physicians stay away from the frail kids. We spent two years of our training focused on peds alone; the FP’s do a ton more procedures than we do, as they spent a lot of time learning outpatient procedures; finally, the FP’s do more GYN than us, which is fine by me.

    I think Med-Peds is a different route to a similar end – primary care medicine. I didn’t think the training for FP was rigorous enough and didn’t want to do surgery and OB/GYN rotations when I had no intent on doing either. Yet I don’t think of FP as inferior, it’s just different. I don’t think it’s wise to divide primary care into parts. We are all pulling toward the same end, each with our own perspective. FP wasn’t for me, but I am smart enough to see the advantages, and so hired tree of them (since I am the senior partner).

    BTW, I don’t refer out psych any more than the FPs (in fact, I do a ton more ADHD than the FP’s do, as we spent a good amount of time in that training arena). For GYN, I just let my partners handle it (for which I am eternally grateful). Your last paragraph is right. FP’s are better trained to do outpatient medicine from the start, but in the bigger picture there are big advantages to both and we should be working together, not fighting.

  • http://thehappyhospitalist.blogspot.com The Happy Hospitalist

    If I’m over 18 and have chronic medical disease, I would choose an internist, hands down

  • MedPeds Doc

    While I really do not want to waste the time of the readers or get into a battle between FP and Med/Peds doctors, I feel obligated to respond to this apparently bitter and angry author. For disclosure, I am a Med/Peds graduate 8 years in practice. Maybe my training experience differs from the authors’ experience in training of over 20 years ago, but we Med/Peds docs get much more outpatient experience than “one continuity clinic per week.” And I assure you, I was just as competent as you from day one to do a GYN exam or treat someone’s depression. Probably a little less competent from the start to do skin biopsies and excisions, but maybe not. I did electives with a focus on procedures commonly done in the outpatient setting. I did not train to do and thus do not do LEEPs or other complicated GYN procedures in my office as FPs in my community do…and I also do not have to frantically call my wife (a Gynecologist and Obstetrician) when there is a complication or uncontrolled bleeding I cannot deal with (like FPs in my community have done in the past).
    And you know what? When my patients get sick, I actually go to the hospital and follow them. That is continuity of care that 0% of FPs do in my community of 400,000 people. There is unmistakenable value in this habit and my patients clearly appreciate it. THIS is continuity of care…for Peds and Adult patients. I am sure I save a fair amount of money for my patients and “the system” as I do not order unnneccessary tests or duplicate tests when I admit my patients to the hospital (as hospitalists inevitably do in caring for FPs or other specialties patients).
    I seriously considered a FP residency but chose Med/Peds because I got an extra year of training, got more Pediatrics exposure, and did not “waste” my time doing OB or general surgery rotations b/c I knew I would not need these skills as part of my future practice. How comfortable, Dr. Hornstein, did you feel doing Peds care right out of residency when you had gotten 3-4 months of Peds rotations as part of your residency. I got 24 months and promise you there is a difference there (more so than care of GYN or psychiatric patients).
    Obsviously, this post hit a nerve with me. I work side by side with my FP colleagues and have great respect for them. Just don’t post a entry like this with a bunch of nonsense and googlygook.

  • Michael F. Mirochna, MD

    I think we are on the same side of the rope.

    Good point about the gen surg rotations. Garbage for true experience. We don’t get to be first assists anymore as those positions have been farmed about to Scrub techs, PA’s and OR RN’s (there are probably more to this list). Would be better to do 2 months of outpatient procedures only, but they were fun months for me to do and I loved working with the surgeons I was able to work with.

  • Viking

    Happy:

    You have got to be kidding me. I think either would do just fine. Management of chronic disease is not that challenging. The problem is recognizing the chronic disease from the more complicated disease. Both specialities should do just fine.

    Happy can tell you all, because of his E/M experience that 5 office visits pays more than one in-patient visit, which takes the same amount of time for straight forward cases. So, it makes sense that FPs and internists use hospitalists.

    Finally, I agree that FP gets enough peds to get through straight forward cases only. Is that a problem, though? There is a shortage of doctors.

    • MedPeds Doc

      I disagree with you that “mamagement of chronic diseases is not that challenging.” I have about 50 diabetics who are very nice and educated but noncomplaint and not motivated to manage their diabetes. They all have HgA1cs >>7%. They are unbelievable challenging and cause me great consternation. Chronic CHF patients are quite often challenging to manage as are afib patients…their issues tend to progress and require titration of meds. I do think FP practices tend to attract more young and healthy patients while IM practices get more of the elderly population…at least in my community.

  • Viking

    Med Peds Doc:

    We see those patients day in day out. I don’t find that challenging. We know what their problem is and have theories on how to control it.

    Diagnosis is the hard part in medicine. Everything else is cookbook or trial and error.

    By the way, my patient population is not young and healthy.

    • MedPeds Doc

      I guess we’ll have to agree to disagree. Those patients are challenging…very challenging. Maybe I internalize more my failure to treat them to goal (the noncompliant/indifferent diabetics) or my need to put the 80 y.o. with CHF on 5 different meds when I know there are interactions and likely noncompliance as the list of meds grow. Many of my partners, like you, don’t fret over that or consider it a particular challenge…and likely you will all live longer than me and practice medicine longer than me.

      90% of diagnoses in medicine are not that hard…they are made during the history or are suspected during the history and physical and confirmed on lab analysis. 10% of the diagnoses we make are challenging and fun to track down. I could certainly be wrong, but I would guess most PCPs would say the challenges in their day to day practices are the management issues and not the diagnostic issues.

  • artiemd

    I must also take issue with this post. I am a pediatrician who is involved in residency training of Pediatricians, Med/Peds, and Fam med residents.

    First off anyone who gets any pediatric training these days will be able to manage a speculum and manage the routine GYN problems of children and adolescents if they choose to. I know many don’t, but the training is there.

    I do agree that the emphasis is on hospital, specialty, and urgent care in training but I feel that that experience definitely increased my competence in primary care. Every day I am grateful for that experience.

    Finally, although the FM residents that I help train are generally very competent, their experience with pediatrics is definitely inadequate for them to provide anything more than very routine primary care for children. Which, of course a nurse can do. The experience with sick children is definitely lacking. I see this daily in my interactions with FM attendings as well as residents, who are easily overwhelmed by tachypneic or cyanotic newborns in the nursery, dehydrated children, or issues of adolescent or child development, or many of the other pediatric issues I see.

    I have not seen any particular difference in the management of children or adolescents with psychiatric problems, so the author’s assertion of increased competence here is a true suprise to me.

    The FM residents I see, although competent, cannot claim to have enough training to provide anything more than immunizations and routine care for kids. Even their management of routine problems like URI’s and bronchiolitis or AGE are lackinig.

    2-4 months of pediatric training just doesn’t make anyone capable of managing medical care of newborns, infants, children and adolescents.