MED-PEDS PERSONAL STATEMENT
She was 74 year old and presented with abdominal pain and dysuria that had been ongoing for two months. A CT scan was eventually done which showed multiple liver metastases with a pancreatic mass. Gina had incurable metastatic pancreatic cancer. But she still found a way to smile through it all.
She was the most angelic little girl, only four months old. Yet in those few months she had already been through a lifetime of trials and tribulations. By the time I met Leslie she had been diagnosed with biliary atresia and a Kasai procedure had been performed. She had her good days when she smiled as I walked into her room, ready to play. Then there were the days when her eyes looked yellow and sad and all she wanted to do was take a very long nap. I felt helpless; all I could do was rock her to sleep but I knew that somewhere in that little girl was a tremendous will to survive.
These experiences among countless others have helped influence my decision to pursue a career in Internal Medicine and Pediatrics. I cannot relieve the ailments of every patient that crosses my path. What I can do, however, is provide a comfortable safe haven and a listening ear. Every encounter is an opportunity to learn. It may not always be about science or the advancement of health care. It may be something as simple as learning that a little boy has a dog named Ponce. These simple nuances that foster a good doctor-patient relationship that is so vital to the practice of Med/Peds.
The essence lies in the journey, not the destination. My journey started in a very distant land. Born in a small country on the West coast of Africa, I spent my formative years where I saw limited medical resources put to tremendous use and stretched a long way. My experiences in these countries exemplified from an early age, the vitality of primary care. As a child, the only physician I knew was an uncle. In my mind he is the epitome of a physician. He not only treated many people in the community from the very young to the very old. From malaria to cholera, hypertension to diabetes, he handled it all. This was my vision of what a physician was supposed to be: the center point of care; one who could treat any ailment across all ages and remain an integral part of the community. In medical school, I found these qualities in Med/Peds. One of the beauties of medicine is the opportunity it renders to meet people of various backgrounds and cultures. The beauty of Med/Peds is that you not only meet people across all ages and walks of life, but that
you actually build a relationship with all of them.
Early on, I knew I was interested in primary care. In my first year of medical school, I was accepted into the Primary Care Track program. Over a two year period, I spent one
afternoon a week with a Family Medicine physician. The moments I treasured the most were walking into the room of a two year old for routine well child care immediately after having seen a woman with depression and substance abuse. I valued the interchange and the opportunity to not only examine the physical but also the mental and social aspects of their lives. However, the moment I felt most alive was being a part of a team on the wards and solving the myriad of complexities that is inpatient medicine. I was as intrigued by the seven year old girl in the PICU with an asthma exacerbation as I was by the forty year old man with cellulitis presenting in diabetic ketoacidosis.
I want to be intellectually stimulated and to learn something new each day. No field in medicine can provide me with such an immense wealth of knowledge as Med/Peds. I welcome the challenge of a combined residency and look forward to a lifetime of learning. Patients like Leslie have taught me about the will to fight, and to know at the end of the day that I have given my very best and nothing less. From Gina, I have learned to smile in adversity. My goal is to receive superior training in Internal Medicine and Pediatrics that will lay the foundation for a meaningful career in both an academic and community setting. From my family I have learned the values of hard work, determination, dedication and versatility and from my patients I have learned perseverance and compassion. These qualities will serve me well as an internist and a pediatrician.
Med-Peds began in the late 1960s at the University of Rochester (NY), Tufts University (Baystate), and University of North Carolina. These schools played a large role in the formation of early Med-Peds residency programs. Many new programs were organized in the 1980s and 1990s, and there are now 78 in the nation. In the 2017 Match, there were 405 total applicants (342 US seniors) and 381 residency positions offered. The largest programs take 14 residents per year, but most take between four and eight. Several Med-Peds programs are expanding to accommodate an increased interest in the field.
Med-Peds continues to be a small (but rapidly growing) field, with more than 6,500 graduates around the country. Residency programs are accredited by the ACGME. According to the National Med-Peds Residents Association (NMPRA) 50% of graduates are practicing primary care with 77-93% of those treating pediatric and adult patients and 40% of those working in academic positions. About 25% go onto fellowships, and 50% of this group pursue combined fellowships. Another 15% pursue hospitalist careers.
There are many Med-Peds fellowships available. The fraction of graduates pursuing fellowship opportunities has recently been reported to be 18-25%, including Pediatric, Medicine, and combined fellowships. Some subspecialties translate easily to Med-Peds practice, including rheumatology, allergy/immunology, endocrinology, and infectious disease. Many physicians with combined training are now developing a niche in the long-term follow-up of patients with "childhood" diseases such as congenital cardiac disease, adult survivors of childhood cancers, and cystic fibrosis. Many graduates of Med-Peds residencies have worked with programs to “create their own” fellowships to accommodate broader interests. In addition, an increasing number of Med-Peds physicians are pursuing careers as hospitalists, where combined training and their ability to serve a broader spectrum of patients makes them especially marketable and valuable to smaller communities. Med-Peds training also translates well into work in global health, and many programs now offer electives or tracks in this area.
The Med-Peds program is a four-year residency, with a total of two years spent in each discipline. Upon completion of the program, graduates are eligible to become board certified in both specialties. Most programs rotate between the Pediatrics and Medicine departments every 3-4 months. The Med-Peds residents are members of both departments, though the number of dedicated Med-Peds faculty and infrastructure varies greatly between programs. The internship experience varies from 12-18 months. Approximately 7 months are spent on the ward services per year, and a total of 6-8 months are spent in intensive care units over four years. Since the programs essentially compress six years of training into four years, the combined program is rigorous and offers less time for electives. However, many programs now offer combined Med- Peds subspecialty electives to maximize your elective time.
Med-Peds is sometimes compared to Family Medicine, and deciding between the two is often a difficult choice. In general, Med-Peds provides more hospital-based training (including more time in intensive care units), while also providing residents with the opportunity to pursue subspecialty careers. In contrast, Family Medicine offers broader training in more outpatient focused primary care. As a result, Family Medicine residents spend time during their intern year on OB/Gyn and Surgery, and Family Medicine programs offer more exposure to outpatient procedures (e.g., colposcopy) and Psychiatric elements of primary care. In addition, while Med- Peds-trained primary care physicians may provide routine gynecological care (e.g., Pap smears), they do not provide obstetrical care. There is also a significant geographic bias between the two fields, since Med-Peds is far more established in the East and Midwest, while programs are less common further west. If you are deciding between Family Medicine and Med-Peds, you should consider the type of practice in which you are interested, the location in which you’d like to practice, whether you wish to sub-specialize, your interest in obstetrical care, the length of residency training you desire, and the demands of becoming board-certified in two fields.
How to get started
The FREIDA website lists all of the Med-Peds programs and basic information, such as program directors’ names, address, number of residents, etc. Begin researching programs in June and July. A program map is available with links to each program's website. Ask questions of as many residents and faculty members as possible. Drs. Robert Habicht, Ronald San Juan, and Leah Millstein (the Maryland Program and Assistant Program Directors, respectively) - all Med-Peds trained faculty- are always willing to talk with interested students. Additionally, Dr. Erin Giudice (Peds) and Dr. Susan Wolfsthal (Med), the Program Directors of Maryland’s categorical programs, are also great resources. Information about Maryland's program can be found here.
- Check out National Med-Peds Residents' Association and the AAP site. The NMPRA publishes a medical student guide that addresses many common questions.
- Write your CV and Personal statement: Have your advisor and other people review them. If you are torn between specialties, write a personal statement for each, ask other people which sounds the most genuine, and think about which was the most natural to write. Some applicants choose to apply to one or both categorical programs in addition to Med- Peds. However, you should discuss this with your faculty advisor
- Request letters of recommendation: Most programs require 4 letters, including one from the chairmen of each department (Medicine and Peds). Meetings will be held by each department over the summer for students interested in applying to each field; how to obtain your chairman letter and other matters will be discussed at these meetings. You should attend both the Medicine and Peds meetings. Your other letters should come from faculty with whom you have worked closely, preferably one from each department (and better yet, a Med-Pedser). Choose people who know you well and will write strong letters. The MSPE (Dean's Letter) is also required.
- It is now generally recommended that you take Step 2 in time for scores to be available before rank lists are due. This usually translates to taking Step 2 by mid-December. However, if your Step 1 score was weaker than you’d like, you probably will want to take Step 2 earlier. It is important to discuss this timing with your adviser.
- Consider scheduling a sub-I in each discipline early in the year. This may help you in the decision making process and allow you to interact with faculty who may write your letters. If you are only able to schedule one sub-I in the first two blocks of the year, schedule an elective in the other field during the first two months. This way, your application will contain evaluations and possibly letters from both disciplines. Faculty advisors can help you decide which electives are best for this purpose.
- Get involved with the Med-Peds interest group. They hold activities to help students learn about Med-Peds training and offer access to residents and faculty.
Med-Peds is on ERAS. You should schedule meetings with Drs. Habicht, San Juan, Wolfsthal and Giudice to discuss programs and recommendation letters in July/August. They are all willing to discuss programs, their reputations, and your chance of being offered an interview. Individual program requirements are available on their respective websites. Get your applications in early (September), since the interview slots fill quickly. You should be prepared to certify on the first day possible.
Save November, December, or January as a free month for interviewing if you can. Interviews start in mid-late October and continue through mid-late January. December tends to have the most Med-Peds interviews. It is best to schedule electives during this time, as time off is very limited on sub-I’s. Take notes during or shortly after your interviews and get phone numbers/emails of residents in case you have questions later. Be sure to come up with a list of questions to ask of each interviewer. It is sometimes helpful to ask the same questions of different people to verify consistency. After your interview, write thank you notes or emails to the program director and your individual interviewers. Maryland students have historically interviewed at 8-20 programs depending on their personal preferences, individual academic strengths, couples-matching, geographical restriction, etc. It is best to discuss the total number of programs to which you should apply with the Med-Peds faculty at Maryland.
Things to look for
- Curriculum: Because Med-Peds training is essentially condensed from 6 to 4 years, the ACGME has fairly stringent curriculum guidelines to be followed by residency programs. As such, curricula do not vary much between programs with regard to the number of months spent on wards, in ICUs, and in the ambulatory care setting. However, what may vary between programs are the structure of ambulatory months (e.g., sporadic 4 week blocks vs. multiple consecutive blocks of ambulatory medicine), possibility of second ½ day of clinic during upper level years in certain programs, whether there are combined Med-Peds electives and/or clinics, and whether there is a transitional care curriculum or transitional care clinic. When viewing programs, consider those that structure their curriculum in a way that is conducive to achieving your own personal career goals. For example, if you are interested in primary care: Are the residents well prepared for outpatient medicine? Do they have a primary care curriculum? How much time is spent on units vs. in clinic? If you are interested in subspecialty, you will want to ask yourself whether the program has adequate subspecialty training. Look at the careers chosen by the program’s graduates – does the program prepare residents well for the path you would like to take? Also note that some programs are beginning to develop specific tracks for residents interested in primary care, subspecialty, global/public health, advocacy/policy, research, and even business. The opportunities available through these tracks can vary greatly between programs, and if interested in a special track, be sure to ask about it when you interview.
- Residents/Faculty: Many people cite the folks they would be working with as the deciding factor in which residency they chose. What type of people does this residency attract? What are the dynamics among residents and between residents and faculty? Are all subspecialties represented, especially in Pediatrics? Are the residents happy? Do they appear overworked? Do they spend any time together outside of the hospital? Have many people dropped out of the program, and if so, why? Do people stay to be on faculty upon completion of their residency? Can you picture yourself there? How well do Med-Peds residents blend into the categorical programs? What are the demographics of residents in terms of relationship status: single, married, engaged/serious relationships?
- Med-Peds “identity”: How many dedicated Med-Peds faculty are there? Is Med-Peds its own entity at the institution, or is it still split between Medicine and Pediatrics? Is there a Med-Peds trained program director…Chief Resident? How do the Med-Peds residents interact with each other, the program director, and the categorical residents? Are there combined conferences or journal clubs to address Med-Peds issues? Do Med-Peds faculty practice combined Medicine and Pediatrics? Are there fellows pursuing combined fellowships, or is the institution willing to work with incoming fellows to form opportunities for combined fellowship training?
- What do graduates do upon completion of the program: What percentage go into primary care vs. subspecialty training vs. academic medicine? (Look at this in the categorical programs too). How competitive are the residents when pursuing fellowships?
- Facilities: Is there a free-standing children's hospital? Note that a free-standing children’s hospital may or may not be important/attractive to you. Are there Pediatric specific services? Is there an electronic medical record (including electronic order entry)? How many hospitals/clinics will you rotate through and where are they located?
- Continuity Clinic: How much time is spent in clinic per week? Is it a combined clinic or do you alternate between Medicine and Pediatrics clinics? (There are pros and cons to each of these.) Will you have to attend clinic post call? Are there subspecialty clinics available for residents? How does the program maintain a balance of Medicine and Pediatrics in resident clinics?
- Academics: What is the quality of teaching? What is the conference schedule? Is teaching a priority? Is there formal board preparation? What are the pass rates? Are the categorical Medicine and Pediatrics programs equally strong? Any recent changes in program or departmental leadership?
- Call schedule and vacation: This varies from program to program. Most programs have mostly q4 call. This may change as new work hour requirements are instituted via the iCompare trial. It is completely acceptable to ask whether or not an institution will be changing their duty hour requirements. The average vacation is 3-4 weeks/year.
- Responsibility: Do house officers write all the orders? Are there private attendings, and how does that impact your training? The less “scut” you need to do, the more time you have for learning and patient care (look for “resident assistants,” or some variation, who help with discharge planning including appointment scheduling). How much autonomy do you have on Medicine and Pediatrics? (Note: Pediatrics is traditionally a more "hand-holding" field, so do not be surprised if you hear that everything you do is supervised, even as a senior resident).
- Procedures: Will you get sufficient exposure to outpatient procedures? Are units "fellow driven" or "resident-driven?"
- Electives: Are there electives available in women's health, orthopedics, community medicine, advocacy, or in your other areas of interest? Is there a limit to the number of "off campus" electives? Are there international opportunities in place? If you do an international elective, do you still get your paycheck? Does the program help to fund international trips?
- Patient Population: Is it a diverse population? Will you get exposure to the patient population you plan to work with?
- Location: Is it an area you want to live for four years? If you have a significant other, is it a compatible location for them? Do residents live close to the hospital? Could they afford to if they wanted? Are there opportunities for rotations away from the main site? Through how many different hospitals will you rotate?
- Residents/Faculty: What type of people does this residency attract? What are the dynamics among residents and between residents and faculty? Are all subspecialties represented, especially in Pediatrics? Are the residents happy? Do they appear overworked? Do they spend any time together outside of the hospital? Have many people dropped out of the program, and if so, why? Do people stay to be on faculty upon completion of their residency? Can you picture yourself there? How well do Med-Peds residents blend into the categorical programs? What are the demographics of residents in terms of relationship status: single, married, engaged/serious relationships?
One Final Word of Advice: During the process you will hear lots of positives and negatives about programs from classmates, colleagues, faculty, and people you meet on the interview trail. It is important to realize that not everyone is the same (or has the same criteria for a program) and as such, you should really check out each program for yourself and assess whether you like it; ultimately, you decide whether the place/program is the right fit for you.
There is no one factor that will determine which program is best for you. After evaluating what is most important to you, much of it will come down to the general feeling you had on your interview day.
Enjoy the process and good luck!
If you'd like to speak to some of the students from the Class of 2018 applying to Med-Peds, feel free to contact:
Leila Bahmani Kazeroon
Last Revision: March 8, 2018