Patient Care

Split Personality


 

By the fourth year of residency, most in combined internal medicine/pediatrics (commonly known as “med-ped”) residencies come to realize that their training is heavily weighted toward inpatient and ICU settings. After all, med-ped residency programs require that all the inpatient and ICU requirements of both the American Board of Internal Medicine (ABIM) and the American Board of Pediatrics (ABP) be met. This allows med-ped graduates, numbering just over 300 each year, to sit for both boards, and potentially to be able to obtain admitting privileges for both adults and children. This seems to be the perfect training for a hospitalist-to-be, if one so desires.

But for hospitalists, there comes the dilemma: Should you concentrate on the adult or the pediatric population, or is it possible to be a med-ped hospitalist? By far, most HM job opportunities are for either purely adult hospitalists or purely pediatric hospitalists, although there are an increasing number of “off the shelf” med-ped hospitalist positions. Building a med-ped career as a hospitalist from shifts in adult and pediatric programs is a possibility but requires extra attention to scheduling, salary, and benefits.

Med-ped physicians are used to being creative about their work, but some might begin to ask themselves whether the additional effort is worth it. Seeking out knowledgeable administrators and department/division chiefs, following other med-ped hospitalists who have already blazed a trail, and being realistic about your “mix” of work are some solutions for the hybrid hospitalist.

Academia Fosters Cooperation—and Lack Thereof

An ever-increasing number of med-ped physicians seem to think being a med-peds hospitalist is possible, even desirable. Heather Toth, MD, program director for the med-ped residency program at Medical College of Wisconsin and a hospitalist at Children’s Hospital of Wisconsin, both in Milwaukee, doesn’t regret her decision to put in the extra work required to be a hospitalist for all age groups.

“[It is] absolutely a wonderful career and worth the effort to establish a combined position. There is much to be learned from each world [medicine and pediatrics] to enrich our patients’ care,” says Dr. Toth, who was a former chief resident for the med-ped program at the college. In her case, being close to the administrators of both departments played to her advantage and allowed her to craft her job “from the inside,” she says.

It is the hospital that derives the most benefit from a [combined] hospitalist program. And as such, they were easy to convince of the benefits of a med-peds model and expansion into pediatrics.—Allen Liles, MD, director, hospital medicine program, UNC Hospitals, Chapel Hill, N.C.

“The process was much smoother than anticipated,” Dr. Toth explains. “One concern was which department would own my time. This was overcome by splitting my time by months. For example, January is medicine wards, February is pediatric wards, etc., with corresponding overnight shifts/call.”

Others have experienced obstacles in carving out an academic med-peds hospitalist position. Susan Hunt, MD, a hospitalist at Brigham and Women’s Hospital in Boston, finished her med-ped residency at Duke University in 2008 and began her career as an adults-only hospitalist. However, the desire to work in pediatrics still burned, leading Dr. Hunt to seek pediatric hospitalist work within the Partners HealthCare system. Initially, her efforts were to no avail. More recently, she has been able to break into hospitalist work through the Children’s Hospital Boston’s outreach program at local community hospitals.

“Pediatric programs tend to be small and, in Boston, had very little turnover,” Dr. Hunt says. She also has a warning for pediatric hospitalist hopefuls. “Increasing pediatric time invariably results in decreased pay.”

For the most part, med-ped hospitalist positions in academic hospitals tend to be crafted from a combination of time from two distinct departments. But an academic setting does offer potential med-ped hospitalists a few advantages, such as:

  • Typically more hospitalists in each department, leading to greater scheduling flexibility;
  • Larger pediatric hospitalist programs that often encompass not only the “main” hospital, but also community hospitals; this leads to increased availability of hospitalist work; and
  • The possibility of a med-ped residency program at the same site, which allows for the possibility of being a role model to med-ped residents.

Although the trends might be changing, there are multiple barriers to an academic med-ped hospitalist job. Often, the IM and pediatric departments are not used to working together. Determining who will pay the hospitalist’s salary and benefits, how the schedule will be coordinated, and to whom the hospitalist is responsible can be tricky. Moreover, it’s not always clear which department will take the lead in the promotion process. Departments expect hospitalists to act as good citizens by serving on committees, and it can be difficult to serve two masters.

As a result, many academic med-peds hospitalists have a primary appointment in one department and have their clinical salaries “bought down” by the other. A handful of hospital committees, including quality-improvement (QI) and information technology, allow med-ped hospitalists to serve on one committee and receive citizenship “credit” from both departments. Leonard Feldman, MD, FAAP, FACP, and Carrie Herzke, MD, have walked this tightrope at Johns Hopkins Hospital in Baltimore. Their successes in this arena have created more clinical and research opportunities for med-ped hospitalists, as the administrators and physicians have learned how to negotiate their relationship. One example of this success has been the Johns Hopkins Hospitalist Scholars Program, which provides up to $12,000 of annual funding to hospitalist faculty.

Although rare, the academic med-ped hospitalist program under a single administrative structure does exist. Allen Liles, MD, program director for the hospital medicine program at the University of North Carolina (UNC) Hospitals in Chapel Hill, has brought together a group of 17 hospitalists, six of whom are med-ped-trained.

“Both the pediatric portion and the medicine portion are administered within this one program,” states Dr. Liles. “I think this is a huge advantage to actually making it work. If I was not the director being med-peds-trained, I am not sure this would have happened.” According to Dr. Liles, it took six months of working closely with the CFO of UNC Hospitals to establish a program that he felt “managed to change the paradigm.”

“It is the hospital that derives the most benefit from a [combined] hospitalist program,” adds Dr. Liles. “And as such, they were easy to convince of the benefits of a med-ped model and expansion into pediatrics.”

The Community Setting: Challenges and Successes

Academic settings aren’t alone in their battles putting together med-ped hospitalist positions. Jacques-Bret Burgess, MD, MPH, FAAP, a hospitalist with Traverse City, Mich.-based Hospitalists of Northwest Michigan (HNM), began in April 2009 to establish a pediatric hospitalist program within his group of adult hospitalists. Since that time, med-ped-trained hospitalists have increased to five from just one out of the 30 hospitalists employed by HNM. But there have been growing pains.

“The majority of administrators and physicians just do not understand the potential, nor the efficiency, of a [med-ped] physician,” Dr. Burgess says. “Most frustrations come from trying to explain what an IM-ped physician is, what we are capable of, and then obtaining adequate support to practice both disciplines while at the same time maintaining some sense of self and family.”

In fact, it is not uncommon for med-ped hospitalists to work full time in one discipline—usually adult—and moonlight or work part time in pediatrics. Jeff Whittall, MD, a hospitalist for MultiCare Inpatient Services in Tacoma, Wash., works primarily as an adult hospitalist at Tacoma General Hospital but provides pediatric urgent care at Mary Bridge Children’s Hospital in Tacoma as well. “It is a fantastic mix,” Dr. Whittall says.

Table 1. Pros and cons of a career in med-ped hospital medicine click for large version

click for large version

That said, other med-ped hospitalists consider such combinations to be a compromise. Many yearn for that perfect mix of adult and pediatric hospitalist work, and have even taken on additional training to do so.

Oliver Medzihradsy, MD, was a half-time adult hospitalist at Barton Memorial Hospital in South Lake Tahoe, Calif., with the other half spent in outpatient pediatrics for Tahoe Carson Valley Medical Group, until this year. In August, be became a first-year fellow at Rady Children’s Hospital in pediatric hospital medicine.

“Having been out [of] hospital-based peds for four years now, I decided that, if I wanted to get back into … [pediatrics] as a hospitalist, it would serve me well to go back for a peds hospital medicine fellowship,” said Dr. Medzihradsy. “Economically, it’s rather foolhardy to take such a salary cut, not to mention the philosophical change of becoming a trainee again, but from a clinical passion standpoint, it’s what I wish to do.”

In some cases, community hospitalist programs, many of which offer a less territorial work environment and organizational structure, have been more successful at establishing full-fledged combined med-ped hospitalist programs. Elliot Hospital in Manchester, N.H., has built from the ground up a hospitalist program utilizing both internal medicine and med-ped-trained hospitalists. Currently, Elliot Hospital employs four med-ped-trained hospitalists, who staff the pediatric inpatient unit but are available for adult inpatients when pediatric volume is low. Other community hospitalist programs utilize the pediatric skills of their med-ped hospitalists in urgent-care or ED coverage in times of low pediatric volume.

“From the perspective of our med-ped physicians, they feel that this is a unique employment opportunity that allows them to have a truly balanced 50-50 medicine/pediatrics inpatient experience,” said Anita Ritenour, MD, assistant vice president for medical affairs at Elliot Hospital. Although trained in internal medicine, her familiarity with community med-ped physicians made her an early advocate of med-ped hospitalists.

Amy Stone, MD, director of Elliot Hospital’s pediatric hospitalist program and a med-ped-trained physician, typically starts her day at 7 a.m. with sign-out from the overnight provider, then touches base with nurses about overnight events. Family-centered rounds follow, with the afternoons being occupied by ED or direct admissions and family meetings. Given their training, however, the med-ped-trained pediatric hospitalists can get called upon to help out on the internal-medicine side.

“As a med-ped hospitalist on the peds service, we get pulled occasionally to help with the internal-medicine service to admit, both during the day and at night,” adds Dr. Craig Widness, another med-peds-trained hospitalist at Elliot.

But the scope of practice and volume has ramped up for the pediatric hospitalist service at Elliot, as many community pediatric groups have opted to utilize their services. In addition, a new pediatric ICU has recently been established, managed by the pediatric hospitalist service.

As a result, the opportunities for the med-ped-trained pediatric hospitalists to help out on the adult hospitalist vortex have been increasingly rare, which seem to be a welcome development to the pediatric hospitalists.

When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them.—Jacques-Bret Burgess, MD, MPH, FAAP, Hospitalists of Northern Michigan, Traverse City

Building the Perfect Beast

So how does a med-ped physician entering hospital medicine build a job that satisfies the need to care for both adults and children? In some cases, the perfect med-ped position is already available. More likely, however, hospitalist jobs in a specific location are limited to either one discipline or another.

In many, if not most, cases, practice in one discipline will have to be somewhat compromised to fulfill the staffing needs of the “primary” job, at least initially. In the interview and hiring process, however, hospitalists wishing to pursue med-peds must make known their desire to work in both medicine and pediatrics. The transparency will allow hospital and group administrators to build into your schedule time to work in both pursuits.

“Start trying to arrange for pediatrics early. I started before I finished residency and it took me over a year to set up,” Dr. Hunt says, noting her current position is in the academic arena. “Discuss your plans with any medicine group you intend to join. See if your FTE would be flexible or if they can help arrange things. Get in touch with local med-ped program directors, if possible, as they often know people on both sides and might be able to help get you in touch with the right people.”

When looking at community hospitalist jobs, it is critical to ensure your administrators are familiar with med-peds residency training. It helps them better understand your skills, your goals, and allows them to put you in position to care for patients in all age groups.

“When one finds administrators and leaders that understand and respect the concept [of med-peds], hold on to them,” Dr. Burgess advises. “Do not let anyone take your unique training for granted and try to categorize you as one or the other; rather, we are both. We have two sets of boards, with separate training and a unique overlap that provides synergy with our abilities. Find a group that understands the level of training you possess.”

Call Protection

As uncommon as it is to find med-ped hospitalist jobs that feature built-in coordination of work in both disciplines, one should pay attention to coordinating salary, call, vacation, and CME between the two disciplines.

“Talk with potential groups about how they cover you for call, how you will be reimbursed, and what data will they base your pay and incentives on,” Dr. Burgess says. “What will they base your CME on—two disciplines or one? What is your depth if you have a sick child and sick adult at the same time?”

Most important, med-peds must make sure administrators of both disciplines are aware of your activities on both sides. “We do not want double-call days,” Dr. Burgess adds. He also warns that overcoming the frustrations of med-pedwork “takes a great deal of patience and discussion.”

Salary might be an issue, especially as one tries to mold a position. SHM and the Medical Group Management Association (MGMA) State of Hospital Medicine: 2010 Report Based on 2009 Data lists the median national annual compensation for adult hospitalists as $215,000, and $160,038 for pediatric hospitalists. This also has implications when IM time is bought down by pediatrics in academic centers, as pediatrics might not pay as much for clinical time as medicine will.

Back Where You Belong

Either by necessity or choice, med-ped-trained hospitalists all across the country have taken jobs in one setting or another and now yearn to get back into the other discipline. It might not be as difficult as you think.

If hospitalist work in the other discipline is available in your institution, you could consider a reduction of FTE in your current job to expand into the other discipline. Keep in mind, however, the interdepartmental coordination difficulties (i.e. scheduling, benefits, maintaining privileges). Those can be even more pronounced if two or more employers are involved.

Additionally, a reduction of FTE in your current job could lead to increased clinical time on the part of your colleagues, or perhaps even hiring additional staff, so this change needs to be discussed thoroughly with administrators and colleagues well in advance of any changes.

Less dramatic changes can enable a med-ped hospitalist to get a taste of the other discipline without wholesale changes in salary and schedule. Moonlighting as an intermittent hospitalist or nocturnist, taking call in the other discipline’s call schedule, or filling in for urgent-care slots can keep skills and knowledge from getting rusty.

It also can prevent the loss of pediatric admitting and procedural privileges. A patchwork approach also could lead to a steady hospitalist job in the other discipline.

“I discussed my desire to do pediatrics with friends and acquaintances who worked as pediatricians in local community hospitals through Children’s Hospital Boston,” Dr. Hunt says. “Eventually, [it led] to the peds work.”

As is often the case in HM, med-ped programs tend to follow the tenet “if you build it, they will come.” Once a hospitalist director discovers the flexibility and skill set a med-ped hospitalist provides the group, they often look to expand—especially to staff smaller pediatric units.

Such was the case at Elliot Hospital; familiarity with med-ped moonlighters eventually led to a full-time med-ped hospitalist hire. Following the full-time hire, the HM group realized a dramatic increase in local pediatric groups referring patients to Elliot’s hospitalist group, including the largest pediatric group in Southern New Hampshire, Dartmouth-Hitchcock Clinic.

“Initial referral base from the community was sluggish as community [pediatricians] wanted to hold onto their patients,” Dr. Ritenour says. “As the acuity of what we could support as hospitalists grew, more referrals were made for kids that might have previously been transferred.”

The Future of Med-Ped Hospitalists

At the dawn of combined med-ped residencies in the early 1960s, the hospitalist movement was only a twinkle in the eye of house physicians of yore. Now that both movements have matured, will we see this hybrid of a hybrid flourish?

“I think med-peds is well suited for hospital medicine, based on solid training that includes numerous inpatient wards and critical care in both internal medicine and pediatrics,” says Dr. Toth, adding she hopes to bring additional med-ped hospitalists to her group in Milwaukee in the future.

It seems inevitable that the med-ped movement, which has grown into the largest combined residency specialty in the country, and the hospitalist movement, which has exploded as the fastest-growing medical specialty, will continue to intertwine, branch out, and evolve.

And every year, some of those med-ped residency program graduates will continue to climb those twisted trunks, as challenging as it might seem. TH

Dr. Chang is a med-peds hospitalist at the University of California at San Diego and Rady Children’s Hospital. He is a member of Team Hospitalist.

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