Opportunities in Pulmonary and Critical Care Medicine for Dual-trained Medicine and Pediatric Physicians

Abstract

Combined internal medicine–pediatrics (med–peds) training has been recognized as a unique, Accreditation Council for Graduate Medical Education–accredited residency pathway since 1967, resulting in more than 10,000 graduates. Med–peds graduates have the option of pursuing combined med–peds fellowships with a 1-year reduction in training time compared with pursuing such fellowships separately. The typical med–peds resident spends 8–9 months in the intensive care unit during residency, with additional rotations in pulmonary medicine; not surprisingly, residents are increasingly inquiring about combined med–peds fellowship training within the fields of pulmonary and critical care medicine. In this review, we outline both the advantages and challenges of such training and present various pathways and considerations to achieve board certification.

Case Presentation

A 28-year-old woman presented to the emergency department with palpitations and fatigue, as well as new-onset lower extremity edema and dyspnea. Her medical history was notable for surgical correction (Fontan procedure) of tricuspid atresia 25 years prior, and she was admitted to the intensive care unit (ICU) with new-onset atrial fibrillation and decompensated heart failure. Although typical patients with heart failure often benefit from a combination of diuretics and increased intrathoracic pressures to offload the left ventricle and redistribute pulmonary edema, this patient’s pulmonary blood flow was passive and preload dependent; elevated intrathoracic pressures and diuresis might have decreased pulmonary blood flow and worsened her heart failure. Thus, the ICU team opted to avoid invasive mechanical ventilation, placed her on a high-flow nasal cannula, performed cardioversion, and provided inotropic support in an attempt to lower pulmonary pressures and augment cardiac output. In this circumstance, having a dual-trained intensivist familiar with pediatric congenital cardiac surgery might improve the care of such patients, especially in rural areas or community hospitals, which might lack access to congenital cardiac specialists.

Introduction

Combined residency training in both internal medicine (IM) and pediatrics, often referred to as “med–peds,” has been recognized by the Accreditation Council for Graduate Medical Education (ACGME) since 1967, with more than 10,000 physicians successfully completing four-year programs granting them eligibility to qualify for both IM and pediatric board certification (1). From this training, med–peds physicians choose a range of careers; most continue to see both adult and pediatric patients in their practice, in either outpatient primary care or inpatient hospital medicine settings (2). In addition, the American Board of Internal Medicine (ABIM) and American Board of Pediatrics (ABP) permit med–peds graduates to pursue combined med–peds subspecialty fellowship training, allowing them to reduce the length of training by overlapping the research completed during fellowships toward graduation requirements for the individual specialties (3, 4). The reduction in training time relies on successful petition of one or both boards, which can be quite onerous to trainees and to programs. However, guidance on the decision to pursue dual training and on how to create such fellowships for med–peds residency graduates is sparse (5). The purpose of this review is to describe the advantages, challenges, and pathways for combined med–peds training in the fields of pulmonary and critical care medicine (CCM).

Justification for Combined Med–Peds Training in Pulmonary/CCM

The first question a med–peds resident must consider is “why.” Why undergo additional prolonged training on top of an already longer residency, compared with a categorical IM medicine or pediatrics fellowship? For some, there is interest in caring for patients with diseases that have their onset in childhood but must be managed well into adulthood, such as asthma, congenital heart disease, and cystic fibrosis (CF). Indeed, the median survival time of patients with CF rose from 28 years in 1990 to more than 48 years in 2019, and there are now more adults with congenital heart disease than children; when these patients transition to adult providers, they likely benefit from specialists who understand the full spectrum of their disease (6–8). For others, there is a recognition of the similarity in disease between children and adults: most core principles of management of sepsis do not vary between adults and children, with exceptions arising more from differences in comorbid conditions and risk factors for specific infectious syndromes rather than specific differences in physiology. Similarly, the expertise of dual-trained intensivists is important, as seen recently in the coronavirus disease (COVID-19) pandemic, in which dual-trained experts provided insights to categorical colleagues (9, 10). For those planning clinical or basic science research-oriented careers, an increasing realization that many diseases (including chronic respiratory diseases) have their origins early in life drives an interest in a broad-based clinical training that will allow them to follow children into adulthood to understand disease pathophysiology without constraint by arbitrary age cutoffs. Several large cohort studies have demonstrated that adult lung function trajectories are determined by experiences in infancy and childhood, and the developmental origins of health and disease is a field well suited for those with med–peds training (11–13). An additional impetus for combined training is the potential to provide care for a wider range of patients in an underserved community lacking resources for dedicated categorical subspecialty expertise. Regardless of the reason, a med–peds resident should be clear on what motivates the desire to train in both adult and pediatric pulmonary/CCM.

Challenges

There are several challenges that must be considered before undertaking combined training. First, the training is time intensive (Table 1). Although IM fellowships typically combine pulmonary disease and critical care training in a 3- to 4-year program, pediatric training separates these two disciplines into distinct 3-year fellowships. Thus, even with the ABP and ABIM agreement to reduce training time by 1 year, combined med–peds pulmonary/CCM fellows are typically training for at least 4 additional postgraduate years beyond residency to meet minimum requirements for board certification.

Table 1.

Duration of combined internal medicine–pediatrics subspecialty fellowship training

Training Program	Standard Duration (yr)
Pediatric critical care (16)	3
IM pulmonary–critical care (17)	3–4
IM critical care (18)	2
IM pulmonary (17)	2
Pediatric pulmonary (19)	3
Combined IM pulmonary–critical care/pediatric critical care	5–6
Combined IM critical care/pediatric critical care	4
Combined IM pulmonary/pediatric pulmonary	4
Combined IM pulmonary–critical care/pediatric pulmonary	5–6

Definition of abbreviation: IM = internal medicine.

Second, no ACGME-accredited combined med–peds fellowship training programs currently exist. If a resident seeks to take advantage of the ABP/ABIM reduction in training time by 1 year, the training curriculum must be developed on a case-by-case basis, and both the ABP and ABIM must be petitioned to allow the training to proceed. In applying to fellowship programs, a resident may need to participate in the subspecialty fellowship match for one program but be offered a position outside the match for the other. In addition, because programs often have a limited number of ACGME-accredited, Centers for Medicare and Medicaid Services–funded positions for fellowship training, a med–peds combined fellow may need to be considered for an additional, nonaccredited position with funding provided internally. Alternatively, if a med–peds resident is accepted into an accredited position, the program may need to make significant schedule accommodations that adversely affect training for categorical fellows. Coordination of clinical training (such as continuity clinic across departments or determination of minimum required clinical experiences) across two programs can be difficult as well.

Third, creating protected research time within a clinical-heavy training program spread between two distinct departments can be quite challenging. For most academic physicians, fellowship training provides the opportunity to build the foundation for an academic career and should lead to intramural and extramural grant funding; navigating research time between two departments is not easy.

Fourth, the challenge of maintaining excellence in multiple domains (e.g., board certification, research, clinical skills, clinical education, administration, leadership) while balancing a personal life should not be underestimated, and a dual-trained subspecialist may ultimately need to focus on a single discipline or career path. Finally, although med–peds has been a recognized discipline for more than half a century, there are still significant challenges in identifying job opportunities that readily allow dual-trained physicians to practice to the full extent of their training. Although several institutions have created mechanisms for hiring dual-trained physicians within a single department (e.g., the University of Pittsburgh, Baylor College of Medicine), academic dual-trained med–peds physicians typically need to identify an “academic home” in either the department of medicine or the department of pediatrics to provide mentorship, career guidance, resources, and funding support.

Approach to Combined Fellowship Training

If a graduating resident desires formal training (and board eligibility) in both IM and pediatric subspecialties, there are two basic mechanisms by which this may be achieved. First, the resident may simply complete the individual fellowships sequentially. In this scenario, the resident need not complete both fellowships at the same institution, nor is it necessary to “double count” research experience or petition the ABIM and ABP for combined training. In effect, the resident applies and matches into one fellowship and then, during the last year of that fellowship, applies and matches into the other. Although this approach may be simpler to navigate, it necessarily involves a minimum of 5 years of postresidency training. Furthermore, maintaining a single research project between both fellowships may be more challenging, leading to difficulty with focus and progress and delays in productivity. Alternatively, the resident may create a combined training program within a single institution, integrating a single research project in to both fellowships and reducing overall training time (Table 2). Notably, the administration of med–peds residencies typically depends on the categorical IM and pediatrics programs’ contributing equal resources for each resident, counting a single resident as a 0.5 full-time equivalent within a given year for a given program; thus, most med–peds residency programs have an even number of residents, simplifying administration. However, because there are so few applicants pursuing combined fellowship training, this training is usually divided by year, rather than switching between pediatrics and IM every 3–4 months, as is the case for med–peds residency. For instance, a fellow may alternate years, being a pediatric fellow in Years 1 and 3 and an IM fellow in Years 2 and 4 (or vice versa). Alternatively, a trainee may choose to “front load” the clinical portion of training in the first 2.5 years of fellowship between both IM and pediatrics departments, dedicating the final 1.5 years of training primarily to research (with occasional call or continuity clinic). Regardless of the approach, this second strategy requires coordination at a single institution, with agreement of both the department of pediatrics and medicine and petitioning of the ABP and ABIM. Such coordination may be facilitated by a program with ACGME-accredited training in IM–CCM only or IM–pulmonary only (as opposed to combined pulmonary/CCM), as these programs are typically only 2 years long; the integration of a med–peds fellow may be less disruptive and a curriculum more straightforward than coordination with a combined IM pulmonary/CCM program.

Table 2.

Timeline for combined internal medicine–pediatrics subspecialty fellowship training

PGY1	In planning for PGY2, consider prioritizing elective experiences in pulmonary or critical care to provide exposure and assist with decision making.
	Identify mentors from among both IM and pediatrics faculty.
PGY2 (early)	Draft a letter of intent describing interest in pursuing this type of training, including a potential timeline for accomplishing it.
PGY2 (late)	Send letter of intent to potential training programs, particularly those that have successfully dual trained pulmonary/CCM physicians (for reference, see the NMPRA fellowship guide) (https://medpeds.org/fellowship-guide).
	Discuss logistics of the application process (inside or outside the match, using ERAS) with potential program directors.
PGY3 (late)	Prepare fellowship application materials.
PGY4 (early)	Submit fellowship application (through ERAS if necessary) and interview at potential programs.
PGY5	Consider completing board certification examinations in IM and pediatrics.
PGY7–PGY8	Complete board certification examination in the first subspecialty.
PGY8–PGY9	Complete board certification examination in the second subspecialty.

Definition of abbreviations: CCM = critical care medicine; ERAS = Electronic Residency Application Service; IM = internal medicine; NMPRA = National Med-Peds Residents Association; PGY = postgraduate year.

Critical Care

Formal combined critical care training is often attractive to med–peds residents because the typical residency training includes at least 2 months each in the medical ICU (MICU), cardiac ICU, and pediatric ICU (PICU), as well as 2–3 months in the neonatal ICU; thus med–peds residents have significant critical care training upon the completion of residency. Given the significant overlap in the management of critically ill patients between the MICU and PICU, there are numerous examples of med–peds residents’ completing fellowships in PICUs but being granted privileges (upon the completion of fellowship) to practice in MICUs as well, and vice versa. In addition, trainees may develop specific expertise that applies to both the MICU and PICU, such as with extracorporeal membrane oxygenation; they may be able to continue practice as extracorporeal membrane oxygenation experts supporting both children and adults. The primary drawback of this approach is that these physicians are eligible only to sit for the boards in the fields for which they completed fellowships, which may limit opportunities depending on the requirements of the hospital or university at which they practice. Physicians who are dual boarded in IM–CCM and pediatric CCM have undertaken a range of training pathways: some have alternated MICU and PICU training by year, others have completed both fellowships sequentially, while still others have combined training at a single institution with front-loaded clinical experience and back-loaded research time.

Pulmonary

The majority of IM–pulmonary training occurs in conjunction with CCM training, which may necessitate the completion of both CCM and IM–pulmonary in addition to pediatric pulmonary, for a minimum of 5 years. Combined training in adult and pediatric pulmonary may be ideal for managing patients with chronic lung diseases (such as CF, asthma, interstitial lung diseases, and bronchopulmonary displasia), as well as for managing pediatric lung transplantation patients over the life course. In addition, in less populous regions, there may not be demand for a full-time pediatric pulmonologist; however, a physician trained in both adult and pediatric pulmonary would be able to cover as much pediatric pulmonary as necessary, with the remainder of care provided for adults with pulmonary diseases for which there remains a substantial need (15). Many skills and approaches are shared between the pediatric and adult specialties, including pulmonary function testing, bronchoscopies, and the management of chronic lung diseases. IM–pulmonary/CCM/pediatric pulmonary–trained physicians typically have additional expertise in ventilator management and the management of severe respiratory failure (compared with those trained solely in pediatric pulmonary medicine), congenital or progressive neuromuscular diseases (compared with those trained solely in IM–pulmonary/CCM), and advanced lung disease (compared with those with either IM–CCM or pediatric CCM training).

Conclusions

To the best of our knowledge, there are at least 5 med–peds physicians currently in fellowship and 23 med–peds physicians who have completed combined training in med–peds pulmonary/CCM, resulting in board certification in both IM and pediatric subspecialties. Of these 23 physicians, 15 were dual trained in both IM and pediatric pulmonary (with or without IM–CCM), and 8 were dual-trained in IM and pediatric CCM. Anecdotally, at least half of these physicians maintain a clinical practice that includes the care of both pediatric and adult patients in addition to having active National Institutes of Health–funded research careers, roles in administration, and/or serving as clinical educators. This review draws on the experience of several of these dual-trained physicians to provide guidance to graduating med–peds residents and residency/fellowship program directors who may be considering such training pathways.