Finding a Med-Peds Position: Med-Peds Career Options
What are the career paths of Med-Peds physicians?
What is the scope of Med-Peds practice?
What practice settings are Med-Peds physicians in?
What are the implications of a solo practice?
What are the implications of a multispecialty group practice?
What are the implications of a Med-Peds group practice?
What are the implications of partnering with Family Practitioners?
What are the implications of working in an institutionally owned practice?
What are the implications of working in an academic setting?
What are the implications of an ER career path?
What are the implications of an Indian Health Service or National Health Service Corps career path?
What are the implications of a hospitalist career path?
What are the career paths of Med-Peds physicians?
Med-Peds physicians have pursued a vast array of career paths. They include:
1. Academic generalist
2. Academic subspecialist
3. Primary care solo or group practice
4. Subspecialty solo or group practice
5. Emergency room physician
6. Urgent care physician
7. Hospitalist
8. International health
9. Indian Health Service or National Health Service Corps
10. Administration
What is the scope of Med-Peds practice?
Med-Peds physicians as a group practice in all the settings in which they train. That includes various ambulatory settings including nursing homes, general medicine and pediatric wards, delivery room coverage, newborn nurseries, PICUs, MICUs, and CCUs. Few report practicing in NICUs. The scope of individual physician’s practices varies widely, depending largely on their practice setting and partnership arrangements. Some have developed a practice that includes a specific specialty or interest niche that transitions the two disciplines, such as cystic fibrosis or adolescent medicine.
What practice settings are Med-Peds physicians in?
The setting has in part reflected the career path.
Academic Med-Peds generalists or subspecialists have usually found their ‘academic home’ within a single department. This has promoted career growth, and helped limit the need to be responsive to two department chairs with administrative needs. Their practice setting has usually been hospital based or sponsored.
Practitioners have practiced solo, or with a variety of partners that have included other Med-Peds physicians, categorical internists or pediatricians, family practitioners, and surgical specialists/subspecialists. Practices may be independently owned, partially subsidized by hospitals or systems, or wholly owned by hospitals or systems. Patient demographics vary with the setting.
Urgent care, emergency room, and hospitalist physicians have worked as independent contractors or within a single or multi-specialty group. Patient spectrum varies, and may be single discipline or dual.
What are the implications of a solo practice?
When last surveyed, 10% of Med-Peds graduates reported being in solo practice. Though the only physician in the group, many report working with physician extenders.
Advantages:
1. You get to make all the decisions
2. Office style, hours fit your image
3. Office staff accountable to one physician
Disadvantages
1. You have to make all the decisions
2. Need cooperative call schedule to avoid burnout
3. Financial responsibility entirely yours
4. No leverage with insurers
5. Resources for ‘big ticket’ items (EKG machine, office billing systems, etc.) more limited
6. CME breaks and vacations can be a challenge
7. Rounding at more than one institution difficult
What are the implications of a multispecialty group practice?
When last surveyed, about 50% of Med-Peds in group practices have multiple specialties within the group.
Group practices in general provide some economy of scale for administrative costs. Physician administrative responsibilities (e.g. personnel, call schedule, finances, physical plant) can also be divided. Each group has it’s own dynamic. They require communication structure, administrative structure, decision-making structure, compensation structure, and patient distribution and flow structure. The details of how well these are conceived and implemented may vary greatly from group to group, and significantly flavor the functionality of the group.
Advantages of a multispecialty group practice
1. Marketing to the community
2. Financial resources are pooled
3. Shared staff resources
4. Complimentary specialties can benefit patients and practitioners
5. In-house referrals have convenience and financial advantages
6. Contracting leverage with insurers if adequate size
Disadvantages
1. Division of call can be complicated
2. Compensation equity can be an issue
3. Requires attention to the details of structure of group practice
4. Sometimes cultures of different disciplines clash
5. Assignment of new patients can be a source of discord.
What are the implications of a Med-Peds group practice?
When last surveyed, 30% of Med-Peds graduates reported practicing with another Med-Peds physician.
Advantages
1. Similar training
2. Patient’s expectations become tailored to a Med-Peds practice
3. Easiest hospital, on-call, and vacation coverage arrangements
4. The advantages of scale of a group practice
5. Compensation issues may be more easily made equitable
Disadvantages
1. Fewer strictly Med-Peds practices available
2. No categorical specialty partners to enhance learning
3. Marketing as a dual specialty remains a challenge in some locations
4. Requires attention to the details of structure of group practice
What are the implications of partnering with Family Practitioners?
When last surveyed, 30% of Med-Peds physicians reported practicing with Family Practice physicians.
Advantages
1. Complimentary training
2. Name recognition
3. Abundance of FP practices
4. Dual specialty coverage
5. May serve as in-house referral source
Disadvantages
1. Philosophy may be different
2. Hospital, ICU, nursery coverage may be problematic
3. Complicated patients may migrate/be referred to Med-Peds, with financial disadvantages if compensation not properly structured
4. Requires attention to the details of structure of group practice.9
What are the implications of working in an institutionally owned practice?
When last surveyed, 5% of Med-Peds physicians worked for government agencies, HMO groups, or student health clinics. An unknown percentage have their practice partially or completely subsidized in some fashion by hospitals and academic institutions. Such subsidies usually are coupled with a component of corporate/institutional control, which may impact hours of operation, staffing, patient population, compensation, capital expenditures, additional patient care or teaching responsibilities, etc.
Advantages of an institutionally owned practice
1. Defined patient population
2. Generally low financial risk, at least for first couple years
3. Potential financial support
4. Purchasing power
5. Identity can be good
Disadvantages
1. Financial risk may accrue
2. Often lack flexibility
3. Often lower compensation
4. Productivity expectations not always tied to compensation
5. Bureaucracy
6. Identity can be bad
What are the implications of working in an academic setting?
When last surveyed, 50% of Med-Peds physicians had a faculty appointment, with one third of those being full-time salaried positions.
Advantages
1. Teaching and research opportunities
2. Academic mentoring
3. CME resources
4. Institutional resources
5. Stimulating environment
Disadvantages
1. Teaching time may not be protected
2. Need to learn to teach efficiently
3. Productivity expectations may be escalating
4. Need to know the recipe for success in each institution
5. Need to find an academic mentor
6. Few Med-Peds researchers have developed as role models
7. Call partners may be assigned not chosen
8. Bureaucracy
What are the implications of an ER career path?
When last surveyed, 2% of Med-Peds physicians worked in urgent care centers or emergency rooms. Many more are thought to work in these locations part time. The durability of an ER career varies. Some cite a tendency to burn out in 3-6 years, but others have sustained this career path for 2 decades. The number of hours worked and adequacy of surgical and critical backup are mentioned as mitigating influences. Patient demographics and responsibility will vary with community size and site. It is possible to be triple "certified" by adding ER boards through the American Association of Physician Specialist (http://www.aapsga.com). Sitting for the AAPSGA Board requires passage of either the ABP or ABIM, practicing Emergency Medicine for 5 years, and accumulating at least 7000 hours of practice in Emergency.10 Medicine. Passing provides Board Certification in Emergency Medicine but not that of specifically ER trained physicians who may take a Board exam through the ACEM. AAPSGA certification is recognized by many, but not EM academia.
Advantages
1. Set hours
2. No call
3. Partnerships unnecessary, if present focus largely on schedule and compensation
4. Instant gratification
Disadvantages
1. No continuity of care
2. Walk in patient population
3. Burn out
4. Credentialing
What are the implications of an Indian Health Service or National Health Service Corps career path?
Created in 1970, the National Health Service Corps is a program of the federal agency: the Bureau of Primary Health Care. The NHSC serves to encourage health providers to provide care in underserved urban and rural communities. The Indian Health Service, created under the Snyder Act of 1921, serves members of federally designated Indian tribes in the United States. Both of these programs offer opportunities for physicians to practice primary care in medically underserved communities. Each NHSC and IHS site is unique. Some of the larger programs operate as group practices with internists, pediatricians, FP’s, and med-peds working together. Other sites resemble solo practice arrangements. Some sites are purely outpatient and others offer both an inpatient and an outpatient practice.
Advantages:
1. Care to the underserved is ethically satisfying.
2. Loan repayment (above and beyond your salary) is often available through federal programs.
3. Continuity of care is good.
4. Benefits often mirror the federal system: good health care and retirement is available.
Disadvantages:
1. Bureaucracy and politics.
2. Burn out.
For more information about the HIS, visit their web site at: http://www.ihs.gov/.
For more information about the NHSC visit their site at: http://bhpr.hrsa.gov/nhsc//.
What are the implications of a hospitalist career path?
The term "hospitalist" was first coined in 1996 in an article in the New England Journal of Medicine. It refers to physicians whose practice focus is patients admitted to a hospital. The National Association of Inpatient Physicians (NAIP) reports 89% of Hospitalists are Internists and 5% Pediatricians. The corollary is that Med-Peds Hospitalists may be more likely to work with adults than children. Some of the most commonly cited reasons for choosing hospitalist practice are as follows:
1. The opportunity to focus on inpatient care - some find it more rewarding and stimulating than ambulatory care
2. Many hospitalists feel like their training provided better preparation for inpatient care than ambulatory care
3. Hospitalist practice may be a simpler business to manage than outpatient private practice
4. A hospitalist can be busy on the first day of work and doesn't need to spend months or years building a practice, as can be the case for office-based practice
5. Greater flexibility in scheduling, e.g., many hospitalists don't follow a typical Monday to Friday schedule Hospitalist practice may be a 24-hour a day, 7 day a week enterprise. That creates some challenges in scheduling, and can result in a schedule that requires working more nights and weekends than in outpatient based practice. This may be offset by more weekdays off.
Hospitalist incomes vary widely. According to the NAIP, it is similar or slightly higher than a doctor with the same training working in a traditional (inpatient and outpatient) practice in the same market. There are a number of common models for hospitalist practice. They differ primarily in who employs the hospitalist. In order of approximate prevalence, hospitalists are employed by (most to least common):
1. Hospitals
2. Managed care organizations
3. Local medical groups, usually large multispecialty groups
4. Geographically diverse, for profit, hospitalist companies
5. Academic hospitalist practice
6. Self-employed Hospitalist positions vary widely in scope. Hospitalists may occupy a small service niche within an institution, or cover the majority of patients admitted. Coverage may exclude or include ICUs. Some comment that every Hospitalist position is different. There may be teaching, research or administrative components. The challenge of working with or within two departments mirrors those with academic career paths. It is not currently known for how many Med-Peds physicians a Hospitalist position is a durable career path, or an intermediate step to something else. Information on Hospitalists is available at the WEB sites of the NAIP: Http://www.naiponline.org or the AAP Provisional Section on Hospital Care http://www.aap.org/sections/hospcare/.12