Survey of Medicine/Pediatrics Residency Training Programs JAMES M. SHUMWAY, PhD, NORMAN D. FERRARI, MD The American B o a r d of Internal Medicine a n d the American B o a r d of Pediatrics a g r e e d in 1967 to c r e a t e c o m b / n e d m e d icine/pediatrics residency training programs. These prog r a m s s p a n four y e a r s a n d provide 24 months of training in

each discipline, leading to Board eligibility in both. Little is k n o w n a b o u t their curricula b e c a u s e there is no separate residency r e v i e w committee to critique the current prog r a m s . The directors of the 65 current p r o g r a m s were sur-

v e y e d b y mail. Fifty-seven (88%) responded to questions about: lengths of time p r o g r a m s h a d been in operation, attitudes toward quality of residents, program structures a n d curricula, a n d performances of graduates taking the Boards. More than half of the programs w e r e established a/ter 1980. Forty of the p r o g r a m s ' graduates have p a s s e d the Medicine Boards, a n d 48 have p a s s e d the Pediatrics written Boards. Most programs were structured to have residents switch specialties e v e r y six months. Program Directors, both in Medicine a n d in Pediatrics, rated the quality of combined p r o g r a m residents the same as or slightly better than that of residents in n o n - c o m b i n e d programs. Medicine/pediatrics residencies h a v e b e c o m e a s u c c e s s f u l a n d important s o u r c e of training/or generalists" c a r e e r s in a n d outside of academe, a n d in both p r i m a r y and specialty care. Key words: internal medicine: pediatrics: residency training: survey: curriculum. J GEN INTERN MED 1987;2:377-380.

THE GRADUATE MEDICAL EDUCATION National Advisory C o m m i t t e e c o n c l u d e d t h a t t h e r e w o u l d b e too few p r i m a r y c a r e physicians trained in g e n e r a l internal medicine, g e n e r a l pediatrics, a n d family medicine b y the y e a r 1990.1 The l o n g - p e r c e i v e d n e e d to i n c r e a s e the availability of p r i m a r y c a r e physicians g a v e birth to the specialty of family medicine in 1969. Positions in Family Medicine i n c r e a s e d from a p p r o x i m a t e l y 117 in 1970 to m o r e t h a n 2,000 in 1980. 2 T h e r e h a s b e e n a c o r r e s p o n d i n g i n c r e a s e in the n u m b e r of g e n e r a l internal medicine a n d g e n e r a l pediatrics programs. In 1976 C o n g r e s s p a s s e d Public Law 94-484 to provide f e d e r a l g r a n t support for the d e v e l o p m e n t of p r i m a r y c a r e training programs. G e n e r a l internal medicine, g e n e r a l pediatrics, a n d family medicine h a v e clearly b e c o m e strong forces in training p r i m a r y c a r e physicians. Critics of p r i m a r y c a r e training c a n b e found in e a c h of these specialties. G e n e r a l internal medicine p r o g r a m s h a v e b e e n criticized for too much a c u t e Receivedfrom the Department of Medicineand the Department of Pediatrics, West Virginia University, Morgantown, West Virginia. Presented in part at the session for Medicine/Pediatrics program directors at the Association of Program Directors in Internal Medicine in New Orleans, October 26, 1986. Address correspondenceand reprint requeststo Dr. Shumway: Department of Medicine, MedicalCenter, West Virginia University, Morgantown, WV 26506.

care, too little a m b u l a t o r y training, a n d b a s i n g most of the training in the hospital setting. Their training is often limited to adults a n d adolescents, ignoring a l a r g e s e g m e n t of the population, children. Pediatrics h a s b e e n similarly criticized for its lack of e x p o s u r e to adult care. Family medicine h a s b e e n cited for e n c o m p a s s i n g too b r o a d a r a n g e of patient problems, with too m u c h e m p h a s i s on a m b u l a t o r y care, l e a v i n g too little time for training in the c a r e of acutely ill, hospitalized patients, s In 1967, stemming from a n a g r e e m e n t b e t w e e n the A m e r i c a n Board of Internal Medicine a n d the A m e r i c a n Board of Pediatrics, a n e w a p p r o a c h e m e r g e d for training physicians who treat patients of all ages, from n e o n a t a l to geriatric. T h e s e prog r a m s a r e c o m b i n e d internal m e d i c i n e [ p e d i a t r i c s r e s i d e n c y training programs. T h e y s p a n four y e a r s a n d provide 24 months of training in e a c h discipline, l e a d i n g to b o a r d eligibility in both. There is no s e p a r a t e r e s i d e n c y r e v i e w committee to provide guidelines for c o m b i n e d p r o g r a m curricula. Not much is k n o w n a b o u t their curricula or structure, a n d t h e r e h a s b e e n little e x c h a n g e of information a n d i d e a s a m o n g programs.

METHODS We s u r v e y e d b y marl the 65 p r o g r a m s listed in the 1985 - 86 D i r e c t o r y o f R e s i d e n c y T r a i n i n g Prog r a m s . 4 W h e r e both a n internist a n d a pediatrician w e r e listed as p r o g r a m directors, e a c h of them w a s sent a questionnaire. Thirty-eight questions w e r e included to g a t h e r information on the following topics: h o w long the p r o g r a m s h a d b e e n in operation; w h e t h e r the p r o g r a m s r e c e i v e d f e d e r a l funding for c o m b i n e d p r i m a r y c a r e training; g r a d u a t e s ' b o a r d p a s s a g e rates; h o w the p r o g r a m w a s structured (i.e., the n u m b e r of months spent as a n intern a n d supervisor, the n u m b e r s of inpatient a n d outpatient months, the n u m b e r of months of critical c a r e training, the n u m b e r of continuity clinics); a n d follow-up surveys of c o m b i n e d p r o g r a m g r a d u a t e s . In addition to r e s i d e n c y training data, p r o g r a m directors w e r e a s k e d to c o m p a r e the p e r f o r m a n c e of c o m b i n e d m e d i c i n e [ p e d i a t r i c s residents with those of traditional residents in medicine a n d pediatrics on a five-point scale (1 = w o r s e than, 2 = slightly worse than, 3 ----s a m e as, 4 ----slightly better than, a n d 5 = better than). A follow-up questionnaire w a s mailed to those w h o did not r e s p o n d initially. F r e q u e n c y distribu-

377

Shumway, Ferrari, MEDICINE/PEDIATRICSRESIDENCYTRAINING

378 TABLE 1

Performances on Medicine and Pediatrics Boards American Board of Internal Medicine Number of programs whose graduates: Took boards Did not take boards Did not respond TOTAL Number of graduates who: Took boards Passed boards Failed first time

American Board of Pediatrics Written Oral

10 34 5 49

9 33 7 49

4 35 10 49

45 40 5

49 48 1

22 22 0

tions w e r e constructed to d e s c r i b e the data. Comments written on s u r v e y s w e r e c o d e d s e p a r a t e l y a n d i n t e g r a t e d into the analysis to d e s c r i b e p r o g r a m c o m p o n e n t s accurately. RESULTS

R e s p o n s e s w e r e r e c e i v e d from 57 of the 65 prog r a m s s u r v e y e d (88%). Eight r e s p o n d e n t s indicated that t h e y no l o n g e r h a d c o m b i n e d p r o g r a m s at their institutions. Therefore, the analysis w a s b a s e d on 49 programs. Five c o m b i n e d m e d i c i n e / p e d i a t r i c s r e s i d e n c y training p r o g r a m s h a d existed b e f o r e 1980. T h r e e p r o g r a m s r e c e i v e d f e d e r a l funding to support prim a r y c a r e m e d i c i n e / p e d i a t r i c s curriculum d e v e l o p ment a n d resident positions. Two p r o g r a m s w e r e l o c a t e d in cities with populations of less t h a n 50,000; 71% of the p r o g r a m s w e r e l o c a t e d in cities of 200,000 or more. Eighty-four p e r cent of the p r o g r a m s w e r e e a s t of the Mississippi River. Male residents outnumb e r e d f e m a l e residents almost two to one. The med i a n a g e of residents w a s 29 y e a r s . Residents in 83% of the p r o g r a m s r e c e i v e d the m a j o r part of their clinical training in university t e a c h i n g hospitals a n d / o r in private or public hospitals with university affiliations. As of June 1986, 120 residents h a d c o m p l e t e d c o m b i n e d training p r o g r a m s . T w e n t y - o n e p r o g r a m s h a d no g r a d u a t e s a n d 16 p r o g r a m s h a d two or fewer g r a d u a t e s . Examination p a s s a g e rates a r e b a s e d on d a t a a v a i l a b l e through S e p t e m b e r 1984 (at the time of the survey, results of the 1985 written examinations w e r e not yet available). The d i s c r e p a n c y b e t w e e n the n u m b e r of c a n d i d a t e s w h o h a d completed the p r o g r a m a n d the n u m b e r of those w h o h a d t a k e n the Boards m a y b e e x p l a i n e d b y the fact that p r o g r a m g r a d u a t e s do not n e c e s s a r i l y take both Boards simultaneously; m a n y wait a y e a r bet w e e n taking either o n e or the other. This results in a

d e l a y until t h e y b e c o m e Board-certified in both specialities. Of the 45 g r a d u a t e s w h o took Medicine Boards, 40 p a s s e d (Table 1), a p a s s a g e r a t e of 89%. The A m e r i c a n Board of Internal Medicine h a s r e p o r t e d the p a s s r a t e to b e a r o u n d 60% for all takers a n d a b o u t 84% for first-time A m e r i c a n m e d i c a l school graduates, s T h e r e a r e two s t a g e s to certification b y the A m e r i c a n Board of Pediatrics, a written e x a m i n a tion a n d a n oral examination. Forty-nineM e d i c i n e / Pediatric g r a d u a t e s sat for the Pediatrics written examination, a n d 48 p a s s e d . Of those, 22 h a v e t a k e n a n d p a s s e d the Pediatrics oral e x a m i n a t i o n (Table 1). D a t a r e g a r d i n g the A m e r i c a n Board of Pediatrics' overall p a s s a g e rates a r e not available. Twenty-three p r o g r a m s a l t e r n a t e residents bet w e e n medicine a n d pediatrics e v e r y six months. Five p r o g r a m s h a d residents switch b e t w e e n medicine a n d pediatrics e v e r y three months, a n d three p r o g r a m s h a d them switch e v e r y eight months. The structures of c o m b i n e d m e d i c i n e / p e d i a t r i c s training p r o g r a m s a r e d e s c r i b e d in Table 2. D a t a on the n u m b e r s of months spent a s interns a n d supervising, in inpatient a n d a m b u l a t o r y care, a n d in critical c a r e services a r e s h o w n in Table 3. Residents s p e n t a m e d i a n n u m b e r of six to eight months e a c h in medicine a n d pediatrics as interns, a n d four times as m a n y months in inpatient medicine a s in a m b u l a t o r y medicine. In pediatrics a b o u t twice as m u c h time w a s spent in inpatient pediatrics a s in a m b u l a t o r y pediatrics. Intensive c a r e experie n c e s a c c o u n t e d for a b o u t 20% of the total time spent in the program. TABLE 2 Structures of Medicine/Pediatrics Programs Number of Programs Rotations changed every 6 months 3 months 8 months 24 months 6 months (first 2 years), then every other year 3 months (first year), then mixed 12 months (first 2 years), then every 6 months 8 months/4 months (first year), then every 6 months 9 months (first year and a half), then every 4 months 6 months (first year), then mixed 6 months (first 2 years), then every 3 months 9 months (first year and a half), then every 6 months 9 months/3 months for all four years month 3 months/6 months for all four years 6 months (first year), then every 12 months (second and third years), then every 6 months (fourth year) Programs that did not respond

TOTAL

23 5 3 2 2 2 1 1 1 1 1 1 1 1 1 1

2 49

JOURNALOFGENERALINTERNALMEDICINE, Volume 2 (Nov/Dec), 1987

;379

Median

Range

Intern Medicine Pediatrics

6 8

6-12 6 - 12

tional training b e y o n d their residencies, nine a r e in c o m b i n e d practices, o n e is practicing pediatrics, o n e is practicing medicine, a n d o n e is in e m e r g e n c y medicine. Further follow-up information a b o u t residents who t r a i n e d at the University of North Carolina a n d the University of Rochester c a n b e found in a r e c e n t article7

Supervising Medicine Pediatrics

15 15

6 - 18 4 - 18

DISCUSSION

Inpatient Medicine Pediatrics

12 10

6 - 22 4 - 18

Ambulatory care Medicine Pediatrics

3 6

0- 8 0 - 12

Critical care Medicine ICU Pediatric ICU Neonatal ICU Coronary Care Unit

2 1 4 2

0-6 0- 6 1- 6 0-4

TABLE 3 Numbers of Months Spent on Required Rotations

Table 4 reports the m a n n e r s in which continuity clinics a r e scheduled. Thirty-five p r o g r a m s required o n e h a l f - d a y continuity clinic p e r w e e k a n d 12 prog r a m s required two h a l f - d a y clinics p e r week. Methods u s e d b y most of the p r o g r a m s to evalua t e c o m b i n e d m e d i c i n e / p e d i a t r i c s residents include some combination of the following: e n d of rotation s u m m a r y e v a l u a t i o n forms; v e r b a l f e e d b a c k on a n o c c a s i o n a l basis; written n a r r a t i v e of residents' p r o g r e s s at the e n d of the rotation; a n d face-to-face c o n f e r e n c e s on a r e g u l a r basis. E a c h p r o g r a m director r a t e d the quality of the c o m b i n e d m e d i c i n e / p e d i a t r i c s trainees c o m p a r e d with their traditional counterparts in medicine a n d pediatrics on a five-point scale, with 5 b e i n g the highest rating. For medicine the m e a n rating w a s 3.36; for pediatrics, 3.79. T h e s e findings a r e similar to those of a s u r v e y at o n e institution that found that faculty r a t e d c o m b i n e d m e d i c i n e / p e d i a t r i c s residents the s a m e a s or slightly better t h a n their traditional counterparts. 6 Follow-up d a t a for c o m b i n e d p r o g r a m g r a d u ates w e r e a v a i l a b l e from two programs: the University of North C a r o l i n a a n d the University of Rochester. The University of North C a r o l i n a r e p o r t e d that of 20 g r a d u a t e s of their c o m b i n e d program, ten h a d subspecialized (nine a r e in a c a d e m i c medicine a n d o n e is in private practice). Of the r e m a i n i n g ten g r a d u a t e s , eight a r e currently in private practice (six a r e practicing in both fields, o n e is in medicine, a n d o n e is in pediatrics), a n d t w o a r e in transient positions. The University of Rochester r e p o r t e d 16 prog r a m g r a d u a t e s . Four h a v e subspecialized (one in a d o l e s c e n t medicine, o n e in b e h a v i o r a l pediatrics, o n e in adult endocrinology, a n d o n e in g e n e r a l internal medicine). Of the 12 w h o r e c e i v e d no addi-

Very little h a s b e e n published a b o u t c o m b i n e d m e d i c i n e / p e d i a t r i c s r e s i d e n c y training programs. Their growth h a s b e e n similar to that of family practice r e s i d e n c y training p r o g r a m s in the 1970s. In the 198 7- 88 Directory, 77 c o m b i n e d m e d i c i n e / p e d i a t rics p r o g r a m s a r e listed. The Directory continued to list two of the eight p r o g r a m s that r e p o r t e d t h e y w e r e not c o m b i n e d training programs. Despite these inaccuracies, the 1987- 88 Directory shows the addition of 21 p r o g r a m s not listed at the time of our survey. Fifty-eight of the current 77 p r o g r a m s a r e l o c a t e d e a s t of the Mississippi River. The literature on c o m b i n e d m e d i c i n e / p e d i a t rics r e s i d e n c y training consists of p r o g r a m discriptions 8 a n d proposals for other c o m b i n e d training p r o g r a m s . O n e interesting article b y Christiansen et al. 9 discussed a p r o p o s a l for a c o m b i n e d family practice a n d internal medicine r e s i d e n c y without mentioning or e v e n a c k n o w l e d g i n g the existence of c o m b i n e d m e d i c i n e / p e d i a t r i c s r e s i d e n c y training p r o g r a m s . The article w a s followed b y s e v e r a l editorials10, n which also failed to a c k n o w l e d g e the exist e n c e of c o m b i n e d m e d i c i n e / p e d i a t r i c s r e s i d e n c y training programs. In a s u b s e q u e n t letter to the editor 12 the omission of c o m b i n e d m e d i c i n e / p e d i a t r i c s residencies a n d the erosion of pediatrics training in a c o m b i n e d internal m e d i c i n e / f a m i l y practice resid e n c y w e r e questioned. T h e r e is a n obvious lack of recognition of c o m b i n e d m e d i c i n e / p e d i a t r i c s resid e n c y training p r o g r a m a n d a n e e d for dissemination of information a b o u t them. Despite the c o n s i d e r a b l e variability found among combined medicine/pediatrics residency

TABLE 4 Continuity Clinics

Continuity Clinic Structure One half day medicine and one half day pediatrics per week One half day clinic per week in medicine, then one half day clinic per week in pediatrics on alternate weeks Combined one half day medicine/pediatrics clinic staffed by an internist and a pediatrician One half day medicine (while on medicine) and one half day pediatrics (while on pediatrics) Other TOTAL

Number of Programs 17 12 11 6 3 49

380

Shumwaj/, Ferrari, MEDICINE/PEDIATRICSRESIDENCYTRAINING

training programs, s o m e trends a p p e a r to b e emerging. Even though the majority of p r o g r a m s w e r e offered in six month blocks, the three-montha n d eight-month-block a p p r o a c h h a v e a d v a n t a g e s o v e r the curricular structures d e s c r i b e d in Table 2. O v e r the f o u r - y e a r s p a n of these programs, residents rotate on e a c h discipline through all the s e a sons of the y e a r . This c a n b e e s p e c i a l l y important for s e e i n g patients with s e a s o n a l infectious diseases. Those p r o g r a m s in which the disciplines a r e altern a t e d m o r e frequently t h a n e v e r y six months h a v e the d i s a d v a n t a g e of not allowing residents to feel comfortable a n d c o m p e t e n t with o n e specialty before t h e y switch to the other discipline. P r o g r a m s that h a d residents do either two y e a r s of pediatrics or two y e a r s of medicine a n d then switch w e r e not conside r e d b y the investigators to b e truly c o m b i n e d prog r a m s b e c a u s e a resident c a n essentially a r r a n g e this type of p r o g r a m at a n y institution that h a s a medicine r e s i d e n c y a n d a pediatrics residency. This d o e s not really allow for integration of the two disciplines. P a s s a g e rates for the A m e r i c a n Board of Internal Medicine e x a m i n a t i o n w e r e a b o u t the s a m e for c o m b i n e d p r o g r a m g r a d u a t e s a n d traditional g r a d uates. The d i s c r e p a n c y b e t w e e n the n u m b e r of those w h o h a d t a k e n the Boards a n d the n u m b e r of g r a d u a t e s m a y b e e x p l a i n e d b y s e v e r a l factors. G r a d u a t e s do not n e c e s s a r i l y take both Boards simultaneously u p o n completion of the program, but often wait a y e a r b e f o r e taking the s e c o n d e x a m i n a tion. This results in a d e l a y in d u a l Board certification. Results of the S e p t e m b e r 1985 a n d S e p t e m b e r 1986 e x a m i n a t i o n s w e r e not a v a i l a b l e at the time of this survey. It a p p e a r s that c o m b i n e d training p r o g r a m s in internal medicine a n d pediatrics a r e h e r e to stay. Medical students a r e selecting c o m b i n e d m e d i c i n e / pediatrics p r o g r a m s a s a n alternative to family practice to deliver health c a r e that is not a g e - d e p e n d e n t . T h e s e p r o g r a m s offer the a d v a n t a g e of possible future subspecialization a n d fellowship training. Subspecialties such as infectious d i s e a s e a r e well suited for specialty c a r e of both children a n d adults. E v e n if g r a d u a t e s elect to practice solely in either medicine or pediatrics, their c o m b i n e d training b a c k g r o u n d s should assist them in their careers. Some important issues need to be addressed. Continuity clinic time a p p e a r s to b e well established in c o m b i n e d programs. What is the ideal m e t h o d of providing continuity of c a r e e x p e r i e n c e ? Are corn-

b i n e d clinics feasible or should t h e r e b e a weekly clinic in e a c h discipline? What is a n ideal a m o u n t of time spent in block a m b u l a t o r y rotations (in addition to w e e k l y continuity clinics) without diluting inpatient a n d a c u t e c a r e training? Should individual prog r a m s continue to d e t e r m i n e their o w n curricula or should a s e p a r a t e r e s i d e n c y review committee b e formed to e v a l u a t e curricula a n d a p p r o v e p r o g r a m s s e p a r a t e l y from their traditional counterparts? Should the curriculum guidelines s u g g e s t e d b y the A m e r i c a n Board of Internal Medicine a n d the Ameri c a n Board of Pediatrics b e a l t e r e d to a c c o m m o d a t e the n e e d s of t h e s e p r o g r a m s ? W h e r e do g r a d u a t e s of m e d i c i n e / p e d i a t r i c s p r o g r a m s fit into the h e a l t h c a r e delivery structure? Does m e d i c i n e / p e d i a t r i c s function a s a p r i m a r y c a r e discipline, or as a subspecialty? Is its p l a c e in a c a d e m e or in private p r a c tice? C a n m e d i c i n e / p e d i a t r i c s provide the "gatek e e p e r function" for both children a n d adults? How c a n p r o g r a m s b e structured to minimize the effects of a " s e c o n d - c l a s s r e s i d e n c y " b e c a u s e residents a r e training in two specialties in a shorter period of time? T h e s e a r e but a few of the questions that n e e d to b e a d d r e s s e d . More will b e l e a r n e d a b o u t these prog r a m s as the practice patterns of their g r a d u a t e s a r e observed.

REFERENCES 1. Graduate Medical Education National Advisory Committee. Final Report, Vol. 1. Hyattsville, MD: Health Resources Administration, 1980 (DHHS Publication No. 1 81-651) 2. Steinwachs DM, Levine DM, Elzinga DJ, Salkever DS, Parker RD, Weisman CS. Changingpatterns of graduate medical education: analyzing recent trends and projecting their impact. New Engl J Med 1980;306:10-4 3. Perkoff GT. General internal medicine, family practice or something better? N Engl J Med 1978;299:654-7 4. American Medical Association. 1985-86 Directory of residency ,training programs accredited by the Accreditation Councilfor Graduate MedicalEducation. Chicago:American MedicalAssociation, 1985 5. American Board of Internal Medicine. Policiesand procedures. Philadelphia: American Board of Internal Medicine, 1980:19 6. Shumway JM, Wible KL, Powers RL, Blum FC, Howland PA. Analysis of faculty opinion toward primary care medicine/pediatrics residents. Clin Res 1986;34:837A 7. Greganti MA, Schuster BL. Two combined residency programs in internal medicine and pediatrics. J Med Educ 1986;61:883-92 8. PetersonSE, GoldenbergK. A combinedinternal medicineand pediatrics residency program. J Med Educ 1986;61:688-9 9. Christianson RG, Johnson LP, Boyd GE, KoepsellJE, Sutton K. A proposalfor a combinedfamily practice-internal medicineresidency. JAMA 1986;255:2628-30 10. Colwill JM. Education of the primary physician:a time for reconsideration? JAMA 1986;255:2643 11. Geyman JP. Training primary care physicians for the twenty-first century. JAMA 1986;255:2631-5 12. Ferrari ND. Hybridization of the primary care disciplines. JAMA 1986;256:2345