What is Private Practice Internal Medicine-Pediatrics?

Session 64

Dr. Lauren Kuwik is a Med-Peds specialist in upper New York. She shares with us her desire to go into Med-Peds vs other specialty and so much more.

Check out all our other podcasts on MedEd Media Network. We are constantly looking for people to guest here on our podcast. If you know a physician whom you think would be a great guest, reach out to them and give them my email address ryan@medicalschoolhq.net and have them contact me and we will get them on the show.

Today’s guest is a private practice Med-Peds doctor. Med-Peds is internal medicine and pediatrics combine specialty. Lauren is now practicing for five years in Buffalo, New York area. And she talks all about her journey with us today.

[01:50] An Interest in Med-Peds

Lauren grew up knowing a doctor who was a family friend who ended up being her internist when she transitioned from her pedia rotation and she was Med-Peds.

Having always wanted to be an archaeologist and a teacher, she feels that Med-Peds allows her to be both. With internal medicine, in terms of the archeology part of it, you’re always putting together clues to figure out what’s going on with the patient. She loves the mental tenacity involved in internal medicine. While for the peds part, she loves children and thinks they’re fun. She loves taking care of kids. And as with the teaching aspect, she loves educating patients on a daily basis. So she gets to do all the things she wanted to do together in one specialty.

[03:08] Is Med-Peds Going Away Soon? And How It’s Different from Family Medicine

With the generality of it with both internal medicine and pediatrics, she doesn’t really see any risk of the Med-Peds going away over time. There’s a need for primary care doctors and specializing in both really gives you the opportunity to be a better pediatrician and a better internist. People really like to have someone that they can see themselves and their kids. They’re both the doctor to the mothers and kids. So Lauren thinks this specialty is really here to stay.

How is the specialty different from family medicine then? Lauren explains it’s similar to family medicine or family practice where they take care of the whole spectrum from babies all the way to patients in their 90s or 100s. But they don’t do OB, so they don’t deliver babies. They take care of pregnant patients but they’re not involved in their prenatal and delivery care. They do very little surgery. And while family medicine may do a couple of months in pediatric training, Med-Peds would have to do a full residency in pediatrics and they’re board-certified in pediatrics. They can subspecialize if they want to. So any specialty comes out of internal medicine, out of pediatrics.

You can either subspecialize in the pediatrics and adults subspecialty or you can specialize in both. There are those that may want to take care of patients with compact heart disease as a kid. They’re then repaired and now they’re in their 30s. So there are people who will do a longer fellowship and combined internal medicine and pediatrics, cardiology and then they can take care of those people throughout their whole life. It’s longer. If each fellowship in internal medicine or pediatrics three years, that’s usually about a five-year fellowship.

Other people just do adult cardiology but because they’re pediatric certified, they feel very comfortable with those cases. There are other ways to do that without doing it for five years. Nevertheless, it’s a lot of training.

[06:00] Traits that Lead to Being a Great Med-Peds Doc

Lauren explains that you have to be willing to talk to people. You have to be willing to build relationships and be comfortable speaking with specialists. This will help your patients out in the future.

Additionally, you have to be able to apply knowledge to things that don’t seem very straightforward. Some people like to have one specialty where they get a lot of deep knowledge in a very narrow pocket. You have to know a little about everything and be really willing to work hard.

Alternately, if you’re someone that doesn’t like to do a lot of procedures or like to be in an operating room, this is where you can do minor procedures that are not heavy. So this is a good fit as well.

Aside from Med-Peds, another specialty that actually drew her was Emergency Medicine. In fact, she thinks most people in Med-Peds, at some point, considered a career in Emergency Medicine. For her, a couple of things impacted her decision. First being was that her mother was an emergency medicine nurse practitioner. She spent a lot of time volunteering in the emergency department. She found it to be so much fun with a lot of variety. But ultimately, she likes controlling her time. She doesn’t mind an emergency every once in a while or dropping everything to take care of it. But she doesn’t lots of emergencies going on at the same time. She doesn’t like feeling flustered.  She really likes having control over her schedule in deciding the hours she wants to work without someone assigning those to her so she gets more time with her family.

[08:05] Types of Patients and Typical Day

Lauren sees a mix of patients from a one-day old baby to a 91-year old patient. She sees a mix of well visits or annuals. She sees people who are getting ready to go for surgery or those who come in for chest pain or for fever. It’s just a variety of things.

A typical day for Lauren is getting to the office 30 minutes before she starts her day.  She’d do a lot of things between seeing patients like talking to her nurses, answering calls, checking labs, reviewing many documents, images, and sometimes prepping her notes in the morning. She sees patients in the morning for about three to four hours. And then she also sees patients in the afternoon. She has a late day where she’s in the office until 7 at night, but she comes in at noon when this happens. So it’s basically the same day just pushed forward.

Lauren explains that where she lives, she does more of outpatient care. But for most outpatient primary care doctors, are having their patients taken care of in hospital by hospitalists. So she only goes to the hospital for babies born to her practice at the newborn nursery. Most pediatricians have their hospitalists and the nursery sees their patients. That said, she reckons it at 95% out patient for her.

[10:22] Taking Calls and Work-Life Balance

Lauren takes calls one day a week. She might get one phone call usually. In fact, one time, she went almost three months with no phone calls on that day. Sometimes, she gets two or three. And every fifth weekend, she’s on call. She gets an average of ten phone calls.

She doesn’t necessarily have to be somewhere. She just has to be available by phone. If patients hear her kids talking, they know she’s living her life. But it’s not as time-consuming.

Lauren has three kids and two of them, she had during residency. However, with the kind of schedule she has, she feels like she has a lot of time with her kids.

[12:05] The Training Path

As a Med-Peds doctor, you’re taking a three-year pediatric residency and a three-year internal medicine residency. Then you’re mushing them together into four years. Because of that, there’s a lot of overlap especially in the first year about learning how to be an intern. A lot of the things that you learn are not really specific to one specialty or another.

There’s not a lot of time for electives or research months. They have a lot of inpatient and intensive care unit months compared to a traditional pediatric or traditional internal medicine residency.

For Med-Peds, there’s a national guideline that you have to hit to both finish your pediatric requirements and finish your internal medicine requirements. And Lauren doesn’t think this is a modifiable thing. She feels lucky though because her clinic “assignment” was at a private practice and a community where the other doctors are really happy in primary care. It gave her a great introduction to life as outpatient primary care doctor and talked her into that role.

Lauren goes on to explain that Med-Peds programs are usually pretty small. She’s from the east coast and most programs were 2-4 residents per year. Most people who graduate from her program would be one in the primary care. They only did dev specialty in internal medicine or pediatrics. And sometimes, they overlap stuff such as sickle cell care or cystic fibrosis care. She has seen people do both although she has no knowledge of the actual data. But speaking of her program, most people went into primary care.

Lauren doesn’t think Med-Peds is competitive. She went to state school and interviewed at top programs but she didn’t think it was particularly competitive. Primary care in general, she thinks, is not as competitive too. Although she wished it was more competitive, but she assumes it has more to do with salary.

[16:30] Bias Towards DOs, Special Subspecialties, and Working With Other Specialties

Lauren doesn’t really see any bias towards DOs. A lot of times, she forgets when she thinks about her colleagues that she did training with as to who went to DO school and who went to MD school.

As to what’s not available to a Med-Peds doc to do a fellowship in, there might be people who do a Med-Peds residency and then do a fellowship that is just within one sphere, for instance, pediatric ICU. But the practice both in the pediatric and adult realm, she does see this happen. But there’s not anything that’s cut out. When she was rotating in pediatrics and internal medicine, most of the attendings are happy to have Med-Peds on their teams knowing they’re pretty academic and they work hard.

Other specialties they work very closely with Cardiology, Oncology, Surgery, and sometimes Nephrology. Outside of clinical medicine, special opportunities would be telemedicine, college health, reviewers on different journals, etc.

[18:55] What She Wished She Knew that She Knows Now

Although not specific to Med-Peds, Lauren wished she knew so much more of how the business in medicine. Being a private practice owner and actively learning, she wished they taught this in medical school. She wished she got a wiser advice about her student loans before entering attending shift, although it’s coming around and she plans on them being gone in a couple of years.

What she likes the most about being a Med-Peds doctor is being someone’s doctor. She likes taking care of families and she loves taking care of older adults in their 80s and 90s. She thinks there’s so much to learn from them and she loves taking care of first time babies of families and guiding them through the process.

On the flip side, what she likes the least is the reimbursement compared to specialists. Although there’s not a lot to complain about, it seems like it’s a fact that they pay more for procedural specialties than they do for those people who hold their patient’s hands and talk to them when something’s going on. And she really thinks the reimbursement playing field must be evened out.

[20:15] Private Practice versus Academics

The reason she chose private practice over academics is having control over her own schedule and over how things run where she is. Additionally, you get paid more, you get to have a better schedule, and so you get a better quality of life. You get to have more say over how your practice runs and you’re not having an administration telling you what to do.

Lauren recalls that in her particular practice for five years, the first four years, she was an employed physician. And then she became a Partner last year. And she basically realized she would never work for someone else for the rest of her life.

[21:35] Major Future Changes in the Field

Lauren mentions this thing called, capitation. It doesn’t impact students but there’s a change in the way that they’re paying private practice. This is on a regional level, but a lot of insurance companies are interested in incentivizing in order to provide really good care to their patients. But then they pay you per month to be someone’s doctor and they pay for sick visits when patients come in.

Overall, with the Affordable Care Act, this has not affected her practice in a negative way. So she’s interested to see what happens in the new healthcare plans. Moreover, the one population she loves taking care of which are 80-year-old patients are on Medicare. They’ve worked so hard so you would want those to be available to those patients.

[22:55] Final Words of Wisdom

If she had to do it all over again, she’d still choose the same specialty 100%. Lastly, Lauren would like to impart to students that it’s important to network and connect with attending physicians. Shadow them to see if this is something you’re interested in. Most of them are really excited to share their specialty with people. So if you know someone that’s a family friend or your pediatrician, or someone you met at a networking event for premeds, really take them up on the offer if they offer for you to shadow. Or reach out to them. Because they want to share that with other people who may be interested.


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