Double duty

Med-peds: What medical students should know

Theotonius Gomes, DO, shares insight into the unique world of med-peds: the combination of internal medicine and pediatrics.

If you were a third-year medical student completing your core rotations and had to choose between your passion for adult medicine or pediatric medicine, what would you choose? Why not both! Back in 1949, the combined internal medicine-pediatrics residency, or med-peds for short, began to blossom into what we now see as a four-year residency program.

Usually, internal medicine and pediatrics are two completely separate specialties; each typically requires a three-year residency. As of 2021, there are 5,701 active med-peds physicians across the United States.

So what really is med-peds? This month, we discuss med-peds residency with Theotonius Gomes, DO, program director for the medicine-pediatrics residency program and an assistant professor in the departments of pediatric and adolescent medicine and medicine at Western Michigan University Homer Stryker M.D. School of Medicine (WMed). Following is an edited Q&A with Dr. Gomes.

Tell us about your background and your journey to osteopathic medicine.

Theotonius Gomes, DO

I grew up in Maryland, pretty close to the nation’s capital, and went to the University of Maryland, College Park for my undergraduate degree in neurophysiology. I learned about the osteopathic profession through an AACOM medical school fair held at the university.

I took several years off between undergrad and medical school. During that time, I completed several years’ worth of research, first at the Walter Reed Army Medical Center, performing research in neuroscience while also serving as a summer science counselor to spark others’ interest in careers in science and medicine. I then spent three years working at the National Institutes of Health in the National Heart, Lung and Blood Institute performing research in gene therapy.

I started my career in research but with a strong interest in clinical medicine. While working at the NIH, I met an osteopathic physician who was a fellow in the hematology/oncology department, whom I had the opportunity to shadow. I also volunteered at the Burtonsville Volunteer Fire Department, certifying as an EMT Basic, Firefighter 2 and Paramedic. All of these experiences helped shape my passion and drive for academics, medicine and devotion to using my hands as an osteopathic physician.

When I gained an interest in pursuing med-peds, there was only one osteopathic program available. Since then, after the profession transitioned to a single GME accreditation system, our WMed med-peds program is the sole med-peds program with osteopathic recognition through the ACGME. It’s great to be part of a program that highlights osteopathic medicine within an MD institution.

Can you explain what med-peds is?

The way to think about med-peds is that it combines three years of internal medicine training and three years of pediatrics training and crunches them into a four-year program with the ability to gain board certification in both. Many have thought that med-peds is a “newer” specialty, but looking back at its history, it has been around for as long as, if not slightly longer than, family medicine.

There are roughly 600 internal medicine programs and 300 peds programs across the country, but there are only around 75-80 med-peds programs. Combined medicine-pediatrics programs are well-suited to provide training encompassing the entire breadth of medicine from birth to death, the “cradle to grave” notion. Med-peds residents gain more inpatient experience and are well-equipped to take care of the sickest adult and pediatric patients. Beyond that, med-peds physicians are treated as both internists and pediatricians and are held to the same standard and expectations for each.

What kinds of exposure and experiences can med-peds residents expect?

The curriculum for med-peds programs is roughly similar from one program to another, most splitting time evenly on internal medicine and pediatrics. Residents switch between the two, acting similar to internal medicine and pediatric residents working with the categorical residents side-by-side every three to six months.

They also have the ability to work with a wide array of physician colleagues and departments. Many times, other residents and providers may not even realize they are working with a med-peds resident or faculty member, as they are just as competent on either side. Med-peds residents have the unique ability to offer insights that span the “other side”; they can offer insight to their colleagues who are less familiar with caring for adults or children (some examples are blood pressure management in pediatric patients or congenital disease in adults).

Most med-peds programs do not incorporate surgery or obstetrics and gynecology, which is a key differentiating factor relative to family medicine.

As far as hospital medicine goes, most med-peds clinics see a good mix of adult and pediatric patients. Med-peds trainees also typically receive significant ICU experience by spending time in the NICU, PICU and adult ICU(s).

How does med-peds differ from just pursuing internal medicine or pediatrics alone?

In general, the differences are few, but important. Keep in mind that med-peds training is four years rather than three years in internal medicine or pediatrics alone. If the ultimate career goal is to go into one specialty, med-peds will increase the time needed to complete training. Having said that, most graduates who choose one specialty still find value in the additional training; for some, it gives a greater training experience to feel more confident in their management. For others, it allows them the opportunity to gain a greater exposure to subspecialty experiences to make a more informed decision into their ultimate career path.

As a med-peds specialist, what are the various options residents can pursue post-residency?

Med-peds physicians have the opportunity to delve into a wide array of careers, including primary care fields and subspecialty fields. Graduates have the entire spectrum of available fellowships that are offered to internal medicine as well as pediatrics, but also the additional possibility of combined fellowships. We have had graduates from our program go into pediatrics subspecialties or internal medicine subspecialties. Many have also decided to go into med-peds hospitalist positions, spending their time caring for hospitalized patients and splitting their time in various ways.

Many med-peds residents pursue fellowships in sports medicine, sleep medicine or allergy and immunology. These fellowships are shorter than pursuing combined fellowships that may span closer to five years after residency.

In addition, there are specific fellowships that are unique to med-peds, including transitional care fellowships. What you will find with many med-peds physicians out there is the ability to hold positions that reflect diverse interests and span a multitude of responsibilities; almost no two med-peds physicians in a combined role are alike, and many change over time. For example, I myself, outside of being a program director, practice inpatient adult and outpatient adult and pediatrics in addition to directing an undergraduate medical education course.

For medical students interested in med-peds, what different rotations in medical school are beneficial before a med-peds residency?

There really is no set of required rotations other than internal medicine and pediatrics that make one more competitive in med-peds. There are opportunities to do combined med-peds rotations, but it is not required. The med-peds GME community realizes that many students interested in med-peds are likely to not have a med-peds program at their institution. In general, it is recommended that students build solid foundations in both internal medicine and pediatrics and engage in experiences that highlight their personality and interests. Many of the recommendations that make one a well-rounded applicant, including diverse experiences, volunteerism, global health and scholarly research, are always helpful. 

Is there anything you’d love to share about med-peds?

Med-peds definitely attracts intellectually curious and motivated individuals. After all, why else would someone be willing to devote four years and crunch two specialties into one? When you combine the motivation of tackling complex disease as an internist with an inner fun-loving child, you get a very personable physician who is able to deal with the most complex and wide array of patient pathologies. Many residents have mentioned that their interview trail was an affirmation they chose the correct path, as those they interacted with just met their personalities. I would encourage those who want to know more about med-peds to check out the National Med-Peds Residents Association (NMPRA).

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