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Why Med-Peds?

Trying to figure out what kind of doctor you should become? Wondering what specialty you should choose? Then SheMD's Why Specialty Series is perfect for you! We're bringing you female physicians sharing WHY they chose their specialty. Today's post is on why Dr. Kuwik chose the Med-Peds!

For years, my family and friends were confused every time they heard about me seeing an adult patient. They thought I was a pediatrician. Just last week, I saw saw a longtime patient in the office and she has an important question for me. She had been noticing the many children in my waiting room, and asked me with great concern, “I’m 70. Is it still okay that I come to you or are you just seeing kids now?” I understand the confusion. I am a pediatrician. But, I am also an internist who takes care of adults because I completed a dual residency in internal medicine and pediatrics. Combined internal medicine and pediatrics, or “med-peds” as it is affectionately called, is a unique residency program that offers robust training in the care of adults and children, offering a deep scope of practice that open the door to a variety of career opportunities.

In medical school, we spend two years in the classroom learning about medicine then embark on two years of “rotations” in the hospital, exposed to certain core clerkships including internal medicine and pediatrics. Internal medicine is traditionally the care of adults above age 18; pediatricians by contrast care for children from birth to young adulthood. Internal medicine and pediatrics residency training programs are both 3 years. The first year in any training program is similar, with a focus on simply learning how to be a doctor, rounding on patients, recognizing a “sick” patient and learning the system. Med-peds is like an internal medicine and pediatrics sandwich, where we smush it all together, completing lots of ICU and inpatient ward months, cutting out some elective time, and get all the requirements done in 4 years.

As a child, I had an interesting progression in my planned careers--from budding archaeologist in my early youth to teacher (how I loved lecturing my younger brothers and correcting their papers!) to doctor. A good internist encompasses all of these. We are expert at taking a good history, looking for subtle clues that lead us to a diagnosis and conveying that information to our patients. We are often referred to as the “doctor’s doctor” due to our diagnostic and management skills. It is fitting that physicians and their families encompass a large part of my patient panel. Why would we choose to take care of children as well? Honestly, kids are just super fun. One time, I spent ten minutes of a two year old well visit listening to nursery rhymes and songs on a portable karaoke machine. You can be sure I was also evaluating speech and development at the same time. Pediatricians fawn over the cute babies on their schedule. As med-peds docs, most of us can’t decide who is more of a pleasure-the babbling 6 month old or the incredible 87 year old telling us about her 15 great-grandchildren and prize-winning garden. We have the opportunity to take care of not only the beautiful newborn baby, but her parents, her grandmother and her uncles. Most pediatricians are passionate about prevention, education and advocacy. Internists share this interest as well. We have an incredible breadth in med-peds.

Our training in both internal medicine and pediatrics gives us excellent subspeciality perspective. A common med-peds axiom is “Do not refer to a specialist unless you need an intervention”; we sharpen our thinking skills over the course of our rigorous training. This leads us to really scrutinize the need to refer our patients out, and if we have to, we usually start the diagnostic workup or treatment prior to the subspecialty evaluation. For example, between medical school and residency, I did two pediatric cardiology rotations, took care of cardiology patients while in the pediatric intensive care unit, neonatal intensive care unit and the wards, did two adult cardiac care unit rotations and an inpatient cardiology elective. I got to see many angiograms and stress tests. I worked on preoperative cardiovascular evaluations. I rotated through the adult congenital heart disease clinic. There was no lack of chest pain or congestive heart failure in my daily management on the adult inpatient wards. After residency, It is my patients who directly benefit from this deep cardiology training. If a patient calls with chest pains or palpitations, instead of referring them without thought to cardiology or the ER, we can often see them in the office, run EKGs, labs, place event monitors, and get cardiology involved if needed. Periodically, an ED evaluation is warranted and we need to call EMS for an ambulance. But I don’t need to refer out to simply get an EKG, or know if a patient needs a stress test.

Med-peds doctors are expertly qualified to take care of children with chronic disease as well as adults that have sequelae of childhood illnesses. Chronic disease management is a cornerstone of internal medicine and this positively impacts how we care for children with chronic illness. Our training makes us comfortable taking care of adults with type 1 diabetes, cystic fibrosis, intellectual disabilities and any medical condition typically identified in childhood. Our training has opened our eyes to the unique role of their primary care doctor, and we often co-manage our patients with our subspecialty colleagues. For example, I did a med-peds transitional care elective in residency that included time spent each week in the cancer survivorship clinic. I learned about surveillance for the delayed effects of chemotherapy, long term concerns about decreased fertility and the very common psychiatric sequelae of anxiety and depression. Again, my patients directly benefit from this extra fund of knowledge. Even better, my med-peds training they don’t have to transition over to another provider when they “age out” of pediatrics.

Med-peds challenges you to a match of mental gymnastics daily. It is a mix of cognitive work, relationship building and pure joy. In pediatrics, there is a focus on family centered care, involving the patient and their family in medical decisions. Similarly, shared decision making is essential in the care of adults as well. I find that being an adult doctor makes me a more calm and calculated pediatrician. Most of our younger patients’ parents are also under our care, leading to an enhanced sense of trust. Med-peds is for those who want to know “a lot about a lot.” Our scope of practice is huge. There are training programs that require you to know a lot of information about a narrow field of practice; med-peds is different.

Let me walk you through a typical day:

I talk about potty training. Did you try wrapping presents up on the back of the toilet? What about a sticker chart? What was that about early introduction of peanuts to avoid allergies? Now time to look in a 2 year old’s belly button for frogs.

On to patient phone calls: Can rabies vaccine cause a false positive syphilis test? What vaccines does a person need once their spleen is taken out? How to fix fluid overload in diabetes insipidus with permissive polyuria? Time to call the endocrinologist.

Next door opens: A 6 year old and 2 year old quack at me and dance like ducks. We turn out the lights and look for smiles with my “doctor flashlight.” They reach for my ophthalmoscope, “Dr. Lauren, can I play with your telescope?” Mom and I laugh.

Triage: New MRI finding. Looks like it could be cancer. Order tumor lysis labs and set up with the cancer institute. Talk with the patient, then later with the family, offer any reassurance I can.

Next door: My 89 year old patient comes in for a visit. We talk about her grandchildren, the light of her life. Now time to get that squirmy febrile baby to let me look at her ears...

Med-peds, there is nothing better. Our training uniquely positions us to care for patients with complex medical issues, especially childhood illnesses and their sequelae. This is an incredible career that allows me to care for a brand new 5 day old baby and her 95 year old great grandmother. Med-peds training challenges us to be archaeologists, teachers, investigators, friends and team members on a daily basis and to me, there is nothing more fun, mentally challenging and rewarding.

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