The History of Med-Peds
By Dale Newton, MD, & Allen Friedland, MD
Introduction
In 1967 the American Board of Pediatrics(ABP) and the American Board of Internal Medicine(ABIM) created the training option of dual internal medicine and pediatrics and the ability of qualified candidates to take both board examinations after four years of residency. Now approximately 8,000 physicians have completed this dual training. How and why did the Boards create this training pathway and did it almost not happen?
American Board of Pediatrics and American Board of Internal Medicine
During this conversation about how to train primary care physicians, leaders in internal medicine and pediatrics thought a combination of their two fields would result in physicians with the depth and breadth of training to provide excellent primary care for children and adults. Such training would not include the experiences in surgery, psychiatry and obstetrics-gynecology included in the FP curriculum but would include ambulatory training and more depth in hospital care, intensive care and the categorical sub-specialties. The American Board of Pediatrics(ABP) and American Board of Internal Medicine(ABIM) already accepted candidates for certification after completion of a rotating internship followed by two years of categorical training.
In a joint meeting of the boards in 1967, the ABP and ABIM approved dual training. Minutes of the ABP note this was “the recognition by both Boards of the importance of defining standards for the education and training of family practitioners.” The minutes go on to note the expectation that this training path would be for small numbers of trainees and “unusually good candidates,” but would “do little to meet the overall need for physicians of first contact.” The boards subsequently issued a memo approving dual board eligibility upon completion of 2 years of training in each field. However, the memo explicitly stated that candidates for dual training had to complete categorical internships and one year of residency in each field as the route to the four-year option. According to that memo, completing a rotating internship would require 2 more years of categorical training in each specialty (5 years total).
A Tale of Two Schools
Although having approved dual training, the Boards surprisingly didn’t publicize this training option! In the absence of publicity, dual training eked out an existence by word-of-mouth at two institutions, the University of North Carolina (UNC) and University of Rochester (UR). In 1962, and reflecting the national conversation about primary care training, Lawrence Cutchin, a medical student at UNC was told by the respective chairs that dual training would be possible in the future and he should start with a “mixed” internship (6 months of each specialty). After his training was interrupted by military service, he completed combined dual training in 1969 (totaling 5 years).
As at UNC, several individuals at UR did some combined training, but the first to complete combined training was Dr. Frank Geoffrey Marx in 1975. He had matched into the “Rotating 4” internship at UR. A “Rotating 4” internship was defined by the Directory of Approved Internships and Residencies, 1972-1973, (the “Green Book”) as an internship with an “emphasis on pediatrics” even though it consisted of 6 months each of medicine and pediatrics. During his internship year, both the Medicine and Pediatric chairs made him aware of the possibility of dual training and encouraged him to follow that path. He subsequently trained in both fields and by splitting his fourth year of residency completed dual training in four years. This latter option was not included in the original memo from the joint boards, but Dr. Marx was allowed to obtain dual board certification. Dr. Dale Newton completed a similar path at UNC in 1977.
Until 1975, medical students could still match into a rotating internship that did not specifically lead into a categorical residency. While training as an intern, the trainee would request the desired residency for the following year. The Directory contained no information about institutions that supported dual training, but did include the original language from the boards about the possibility of dual training. Information about where a physician could train in both fields was being communicated only by word-of-mouth(author’s personal experience; DAN). In 1976, the ABP Booklet of Information included the statement that the agreement with ABIM for dual training was still in place. The ABIM Booklet of Information for that same year does not even mention the option of combined training. Formal combined residencies still did not yet exist but were quickly developing.
By the late 1970s, several more physicians had completed dual training in four years, so it was clear the boards accepted this different paradigm of training contrary to the initial memo. In 1980, the ABP was aware of 5 programs with a total of 9 first-year residency positions. More institutions began offering the dual training track, but the Directory didn’t include any information until 1981-82, when there is a comment to contact the ABP for more information. Finally, in 1983-84, the Directory included an Appendix A with a listing of 62 available dual training programs. Even this may have been incomplete since the following year, the ABP sent a memo to all categorical pediatric program directors asking to be informed if they offered combined training.
During this time, the terminology for trainees in dual tracks had varied between “R-4,” “flexible,” and “rotating.” In 1976, the UR Internal Medicine Resident composite photograph shows 5 first-year residents identified as “Medicine-Pediatric.” The term was quickly adopted and often shortened to “Med-Peds.”
Combined Training Begins to Grow
With the visibility of residents remaining in dual training tracks and the knowledge of role model physicians practicing in both fields, more residents remained in the combined programs rather than moving into one of the parent categorical programs. During the late 1970s and into the early 1980s, the training programs had as their only requirements that the trainees have progressive responsibility for patient care and spend 24 months on each service. There was no requirement for any degree of coordination and integration between the two specialties. In 1981, the program directors at UR (Dr. Barbara Schuster) and UNC (Dr. Andy Greganti) made the first steps toward a more integrated and educationally sound curriculum. Specifically,these changes limited time in the intensive care units and increased time in ambulatory settings. By the mid-1980s, the number of programs had exploded nationally. By 1986, data from the ABP indicated that they were aware of 67 programs and 62 dual eligible physicians took the ABP certifying examination that year. The ABP also noted that Med-Peds candidates’ exam scores for both specialties were comparable to physicians completing categorical pediatrics or internal medicine programs.
The Boards Revisit Combined Training
The parent boards (ABP and ABIM) had never revised the initial requirements for dual training, allowing for significant variation in training between different programs. In 1986, they again had a joint meeting and reviewed data from a survey of the 67 programs. The survey data revealed remarkable variations in program requirements. Notable examples included: large continuous blocks of time in one specialty (up to 2 years), marked variability in number of sub-specialty rotations, lack of continuity clinic training, limited ambulatory training, lack of training in adolescent medicine (an explicit requirement for pediatric programs), and excessive requirements for intensive care training.
In 1987 Dr. Carole Lannon (the first Med-Peds trained combined residency director and now UNC program director) presented proposed curricular guidelines to the second annual meeting of Med-Peds program directors (as an interest group meeting with the Association of Program Directors of Internal Medicine). With Drs. Tim Oliver (ABP) and Joe Johnson (ABIM),program guidelines were developed and implemented specifying educational content, integration and continuity. Since combined programs underwent limited review by the categorical Residency Review Committees (RRCs), the combined programs were now required to file annual reports detailing compliance with the respective board requirements. Listing in the Directory was contingent on receiving annual program approval from both boards(by agreement with the editor of the Directory.)
Dual training Matures
Now well established as a training option, the career path began to mature. Professional organizations and subgroups/sections of professional organizations (e.g.,National Med-Peds Residents’ Association, Med-Peds Program Directors’ Association, Med-Peds Section of the American Academy of Pediatrics)were developed for Med-Peds trained physicians and residents. Federal funding was approved for the fourth-year of residency training through the Balanced Budget Act of 1997. As well, insurers were encouraged by national organizations to list Med-Peds providers dually. The number of Med-Peds Programs and residents continued to grow during the 1990swith a peak of 106 programs with 456 positions offered in the match in 1998.
Other combined training paths (e.g., Internal Medicine-Emergency Medicine, Internal Medicine-Psychiatry) were now in existence and none of the combined programs were accredited by the Accreditation Council for Graduate Medical Education (ACGME). The related categorical programs were ACGME accredited. Med-Peds was by far the largest combined track and as such now received more attention about residency program issues (e.g., curricula, duty hours, resources for both specialties). As a response, in 2003 the ACGME established a mechanism for oversight of Med-Peds programs with implementation 3 years later. The unintended consequence of accreditation requirements (stringent sponsorship, hospital alignment and resource allocation requirements) resulted in the closure of several programs. Others used the requirements to obtain additional institutional resources.
Where We Are Now
The physician training track of combined Med-Peds now celebrates 55 years since inception. The initial lack of visibility and support resulted in only about 5 physicians completing dual training during the first decade after approval by the boards. This pathway then exploded into a viable training option resulting in depth and breadth of training in adult and pediatric medicine. Medical educators often note that Med-Peds residents enhance categorical program education by bringing their experience and perspective on diseases that cross the pediatric and medicine continuum.
Med-Peds physicians now provide medical care in primary care, hospital medicine and often find niches in sub-specialties providing care to both age groups(e.g. infectious disease). A very significant recent development has been the leadership of Med-Peds physicians in transitional medicine; especially focusing on adults surviving with complex chronic childhood conditions(e.g., care of adults with cerebral palsy or congenital heart disease). So after 55 years, Med-Peds has overcome the initial hurdles to survival and recognition and now contributes significantly to the cadre of highly trained physicians providing health care to patients of all ages.
As we reflect on the journey of Med-Peds and its remarkable evolution over the last 55 years, it’s fitting to mark another significant milestone. On October 5th, 2023, the Association of Med-Peds Physicians celebrated its inaugural anniversary, the very same day its membership officially reached 500 dedicated professionals. The convergence of our first anniversary with the achievement of this membership landmark is a testament to the increasing recognition, dedication, and commitment of Med-Peds professionals.