Internal Medicine-pediatrics Residents Research Articles

Current Practice in End-of-Residency Handoffs: A Survey of Internal Medicine–Pediatrics Program Directors

End-of-residency outpatient handoffs affect at least 1 million patients per year, yet there is no consensus on best practices. To explore the use of formal systems for end-of-residency clinic handoffs in internal medicine-pediatrics residency (Med-Peds) programs, and their associated categorical internal medicine and pediatrics programs. We surveyed Med-Peds program directors about their programs' system for handing off ambulatory continuity patients. Our response rate was 85% (67 of 79 programs). Thirty-one programs (46%) reported having a system for end-of-residency handoffs. Of the 30 that offered detailed information, 22 (73%) formally introduced the program to residents, 12 (40%) standardized the handoff, and 14 (47%) used multiple methods for information exchange, with the electronic health record and oral transfer of information (15 of 30, 50%) the most common. Six programs (20%) indicated they did not offer residents protected time to complete end-of-residency handoffs, and 13 programs (43%) did not identify a specific postgraduate year level for residents to whom patients were handed off. Programs were more likely to have a system for end-of-residency handoffs if another categorical program at their institution also had one (P < .001). Fewer than half of responding Med-Peds programs have outpatient handoff systems in place. Inclusion of end-of-residency handoff information in the electronic health record may represent a best practice that has the potential of enhancing continuity and safety of care for patients in resident continuity clinics.

Integrated Care of Refugees in a Primary Care Residency Clinic

Providing quality health care for refugees requires cross-cultural competence and unique medical knowledge.1,2 While the Society of General Internal Medicine called for the development of longitudinal training for residents in refugee care in 2004,3 most residents do not feel prepared to care for new immigrants.4 We describe the experience of the Yale Combined Internal Medicine-Pediatrics Residency Program in providing integrated care for a population of Burmese refugees. This model presented numerous challenges but we believe it represents a viable, rewarding alternative to one in which refugees are cared for in a distinct clinic. In 2007, our patient-centered medical home practice serving a multiethnic, largely poor and underserved community began caring for 66 newly resettled Burmese refugees, most of whom were members of the Karen ethnic minority. We developed 3 distinct interventions that helped us provide quality care to this group. We first organized an introductory community meeting that brought together faculty, residents, and office staff with representatives of the community. We held home visits during which we led health education discussions, reviewed common health concerns, and held pediatric acute care and catch-up immunization clinics. Connecticut, like many states, lacked comprehensive guidelines for refugee health care. Since our Karen patients were randomly distributed between physicians, we devised a standardized instrument to provide guidance during the initial visit. It prompted the clinician to gather information relevant to refugees and provide recommendations regarding infectious disease screening. The provision of efficient, quality care was limited by a vast cultural divide and by unreliable telephone interpretation. Taking medical histories, eliciting symptoms, and comprehending and following through on management plans were challenging. The extended time taken by visits with our Burmese patients affected patient flow and clinic efficiency. An integrated care model offers several advantages. Serving as a medical home to this population created a sense of trust between patients and providers. We focused on refugee-specific matters and general health issues concurrently and could effectively coordinate care with the resettlement agency and community. However, this model of care also presented distinct challenges. Varying degrees of cultural competence meant different levels of comfort in caring for this population. Our screening protocol was developed in parallel with home visits and ongoing primary care, limiting its effective, widespread implementation. We were faced with the question of when and how to shift the focus from fulfilling the needs of the newly arrived refugee to those of the primary care patient. Finally, though this vulnerable population merited special attention, we struggled with how to balance their needs with those of our other patients. With tens of thousands of refugees being resettled annually in the United States,5 exposure to their medical care needs is a vital component of residency training and one that fosters cultural competency. Our interventions provided structure and built trust as we cared for this population. Though rife with challenges, we believe a residency clinic can provide effective, comprehensive care to refugees.

A Simulation-Based Curriculum To Address Relational Crises in Medicine

Preparing health care professionals for challenging communication tasks such as delivering bad news to patients and families is an area where a need for improved teaching has been identified. We developed a simulation-based curriculum to enhance the skills of health care professionals, with an emphasis on the communication of difficult or bad news, which we termed relational crises. Our approach was based on a review of existing simulation-based curricula, with the addition of unique features, including a learner-focused needs assessment to shape curriculum development, use of 360-degree evaluations, and provision of written feedback. Development and implementation of our curriculum occurred in 3 phases. Phase I involved a multidisciplinary needs assessment, creation of a clinical scenario based on needs assessment results, and training of standardized patients. In Phase II we implemented the curriculum with 36 pediatric and internal medicine-pediatrics residents, 20 nurses, and 1 chaplain. Phase III consisted of the provision of written feedback for learners, created from the 360-degree evaluations compiled from participants, observers, faculty, and standardized patients. Participants felt the scenarios were realistic (average rating of 4.7 on a 5-point Likert scale) and improved their practice and preparedness for these situations (average rating, 4.75/5 and 4.18/5, respectively). Our curriculum produced a statistically significant change in participants' pre- and postcurriculum self-reported perceptions of skill (2.42/5 vs. 3.23/5, respectively, P < .001) and level of preparedness (2.91/5 vs. 3.72/5, respectively, P < .001). A simulation-based curriculum using standardized patients, learner-identified needs, 360-degree evaluations, and written feedback demonstrated a statistically significant change in participants' self-perceived skills and preparedness for communicating difficult news in pediatrics.

An Intervention to Improve Ambulatory Care Handoffs at the End of Residency

The medical literature shows evidence of numerous initiatives to improve inpatient physician handoffs. In contrast, handoffs of ambulatory patients to incoming interns or junior residents at the end of residency are an area of potential concern that has been overlooked. To examine handoffs of high-risk ambulatory patients by outgoing residents to junior colleagues and to compare current practice to a standard handoff process. We hypothesized the intervention would lead to increases in the number and quality of ambulatory care handoffs. Fourteen graduating internal medicine and combined internal medicine-pediatrics residents who practiced at an academic continuity clinic were randomized to an intervention or a control group. E-mail instructions were sent asking the intervention group to write a handoff note using the clinic's electronic medical record system. The e-mail included a detailed outline of information to incorporate and highlight features of the electronic medical record that would facilitate the process. The handoff notes of the intervention and control group were independently evaluated and scored for quality using a predetermined point system. Six of the 7 residents (86%) in the intervention group completed 19 handoff notes; none of the residents in the control group completed handoff notes. Most of the handoffs provided a brief paragraph or 2 of background information on the patient and then focused on issues needing short-term follow-up during the coming months. The standardized handoff process implemented via simple e-mail instructions increased the number of outpatient handoffs at the completion of residency. Further study with a larger number of residents, identification and removal of barriers to the handoff process, and correlation of handoffs to clinical outcomes are key next steps.

Correlates and Trends in Training Satisfaction on Completion of Internal Medicine-Pediatrics Residency: A 5-Year Study

To examine trends in training satisfaction in graduates of combined internal medicine-pediatrics (Med-Peds) training programs and whether curricular elements designed to enhance the integration of the two disciplines have been successful. We conducted a cross-sectional survey of all graduating Med-Peds residents (years 2003-2007). Responses across survey years were analyzed to identify trends. Data for all survey years was analyzed for correlations among curricular elements, perceived adequacy of training, and preparation for future activities. Overall, residents rated training time as just right for all areas except neonatal intensive care unit training, outpatient procedures, career planning, and office management. There was a significant upward trend in availability of board examination reviews, Med-Peds noon conferences, and mentoring. Residents' ratings of their preparation for most activities increased across the years. More residents reported being satisfied with preparation for internal medicine than pediatric primary care practice (86% versus 83%). Career planning seminars, mentoring, and board reviews correlated with the greatest increase in satisfaction. Med-Peds graduates report a high and increasing level of satisfaction with their preparation in multiple educational domains. Curricular elements designed to enhance integration of the two disciplines have a broad positive impact. Perceived pediatric practice preparation lags behind that of internal medicine.

Validated Ovid Medline Search Assessment Tool

OPEN ACCESSJuly 27, 2011Validated Ovid Medline Search Assessment Tool Gurpreet Rana, MLIS, Doreen Bradley, MILS, Monica Lypson, MD Gurpreet Rana, MLIS University of Michigan Medical School Google Scholar More articles by this author , Doreen Bradley, MILS University of Michigan Google Scholar More articles by this author , Monica Lypson, MD University of Michigan Medical School Google Scholar More articles by this author https://doi.org/10.15766/mep_2374-8265.8588 SectionsAbout ToolsDownload Citations ShareFacebookTwitterEmail AbstractAbstract Introduction: The ability to successfully search Medline and other online databases is a critical component to sustain lifelong learning among health care professionals. Given the fact the ACGME has phased in competencies for graduate medical education such as practice-based learning and improvement, the importance of this skill has only grown. As a result, medical education needs a validated assessment instruments to adequately measure graduate and undergraduate learner abilities to search Medline for appropriate and relevant information. Methods: The University of Michigan MEDLINE Search Assessment (UMMSA) tool for Ovid Medline is a matrix that measures the use of identified search elements and other criteria of importance, and may be customized to apply to a specific question. Since the first step in effectively searching the medical literature is to identify a “searchable question,” the searcher is expected to identify an appropriate search question, based on an introduced clinical scenario, as well as an appropriate search strategy. There are 11 search criteria for which points are awarded and two search elements for which points are deducted. Results: This tool has been used in collaborative teaching settings facilitated by physicians and health sciences librarians. The tool has been used across the continuum of medical education: undergraduate, graduate and faculty development showing its use in lifelong learning. In 2004, the instrument was piloted with fourth-year medical students. To validate the instrument, Medline search strategies were obtained and scored from residents at various points in their training and from faculty identified as experts in evidence-based medicine. Discussion: The UMMSA has been successfully deployed with fourth-year medical students, first- through fourth-year pediatrics and internal medicine-pediatrics residents, and clinical faculty from varying disciplines. It allows educators to demonstrate evidence of competence in searching the Medline database in order to locate relevant medical literature for patient care and lifelong learning. Educational Objectives By the end of this session, learners will be able to: Demonstrate evidence of student competence in searching the Medline database in order to locate relevant medical literature for patient care and lifelong learning.Gain access to outcome evidence in the area of practice-based learning and improvement. Sign up for the latest publications from MedEdPORTAL Add your email below FILES INCLUDEDReferencesRelatedDetails FILES INCLUDED Included in this publication: Instructor's Guide UMMSA.docx UMMSA-Medline Search Assessment Tool.pdf To view all publication components, extract (i.e., unzip) them from the downloaded .zip file. Download editor’s noteThis publication may contain technology or a display format that is no longer in use. Copyright & Permissions© 2011 Rana et al. This is an open-access publication distributed under the terms of the Creative Commons Attribution-NonCommercial license.KeywordsLiterature SearchDatabasePubMedMEDLINE Disclosures None to report. Funding/Support None to report. Loading ...

End of the "see one, do one, teach one" era: the next generation of invasive bedside procedural instruction.

Traditionally, an apprenticeship model has been used for the instruction of invasive bedside procedures. Because this approach is subject to nonuniform application, a new model was established to determine the impact of a standardized curriculum on medical students' and residents' medical knowledge and technical skills. A procedural instruction curriculum for medical students and residents was developed, and a pilot program with the curriculum was incorporated into an internal medicine residency program. Five common procedures in osteopathic and allopathic internal medicine training programs were included: central venous catheterization, knee arthrocentesis, lumbar puncture, paracentesis, and thoracentesis. An initial assessment of participants' baseline knowledge and skills was obtained. Teaching methods included video instruction; discussion of key concepts; faculty-led, hands-on, simulation-based instruction; and individual deliberate practice. Postinstruction knowledge and skills were evaluated, respectively, through a written test and a quantified assessment (ie, checklist) using direct observation. Participants were asked to provide written feedback at the conclusion of each instructional module. A total of 60 participants, all in allopathic medicine, underwent the training component. Fifty-two participants were internal medicine residents (including 2 from an outside program); 4 were trainees in a combined internal medicine-pediatrics residency; and 4 were medical students (1 from an outside program). Participants demonstrated a statistically significant improvement (P<.001) in medical knowledge, as evidenced by preinstruction vs postinstruction test scores. Comparison of initial baseline procedural checklist scores with postinstruction checklist scores, during participants' performance on the first live patient, also showed statistically significant improvement (P<.001). A simulation-based, standardized curriculum in invasive bedside procedural instruction significantly improved the medical knowledge and technical skills of novice physicians.

A Web-Based Assessment of Pediatrics Resident Medical Knowledge in Childhood Hereditary Gastrointestinal Cancer Predisposing Syndromes

Pediatricians need to competently care for children with hereditary gastrointestinal cancer-predisposing syndromes. Pediatrics resident education on this subject has hithertofore never been studied. Forty-five US pediatrics/internal medicine-pediatrics program directors allowed their residents to participate in an anonymous questionnaire. The survey-questionnaire was administered as a hyperlinked interactive Web page through e-mail to all consenting residents. Thirty-eight sites including 290 of 1327 residents (21.5%) and 33 internal medicine-pediatrics participated in the study. Knowledge on polyposis syndromes varied by syndrome (14% to 84% correct) but not by year of training. Internal medicine-pediatrics residents were more likely to inquire on family history including polyposis, early colorectal cancer, than pediatrics residents. This study suggests that familiarity with cancer syndromes does not accrue during resident training in pediatrics. The observations suggest that greater emphasis on resident education on these syndromes may improve outcomes in this vulnerable group.

Religion, Spirituality, and Depressive Symptoms in Primary Care House Officers

The arduous nature of residency training places house officers at risk for depression. We sought to determine the prevalence of depressive symptoms in pediatric (PED), internal medicine (IM), family medicine (FM), and combined internal medicine-pediatric (IMPED) house staff, and spiritual/religious factors that are associated with prevalence of depressive symptoms. PED, IM, FM, and IMPED residents at a major teaching program were asked to complete a questionnaire during their In-Training Examination. Depressive symptoms were measured with the 10-item Center for Epidemiologic Studies Depression Scale. Independent variables included demographics, residency program type, postgraduate level, current rotation, health status, religious affiliation, religiosity, religious coping, and spirituality. We collected data from 227 subjects. Their mean (SD) age was 28.7 (3.8) years; 131 (58%) were women; 167 (74%) were white; and 112 (49%) were PED, 62 (27%) were IM, 27 (12%) were FM, and 26 (12%) were IMPED residents. Fifty-seven house officers (25%) met the criteria for having significant depressive symptoms. Having depressive symptoms was significantly associated (P< .05) with residency program type, inpatient rotation status, poorer health status, poorer religious coping, and worse spiritual well-being. In multivariable analyses, having significant depressive symptoms was associated with program type, poorer religious coping, greater spiritual support seeking, and worse spiritual well-being. Depressive symptoms are prevalent among house officers and are associated with certain residency program types and with residents' spiritual and religious characteristics. Identifying residents with depressive symptoms and potentially attending to their spiritual needs may improve their well-being.

Internal Medicine???Pediatrics Physicians: Their Care of Children Versus Care of Adults

Purpose To determine how practicing physicians who graduated from internal medicine-pediatrics residency programs allocate their practice time and professional activities between adult and child patients, and to investigate whether there are predictors of the extent to which a particular physician's practice is more or less focused on one or the other of these patient groups. Method In 2003, the authors mailed a questionnaire to the 1,300 generalists and 472 subspecialists who, as of 2003, had completed internal medicine-pediatrics training since the inception of the program in 1980. Results The response rate was 73% for the generalists and 65% for the subspecialists. The vast majority of the generalist physicians stated that they provide care to all ages of patients. However, the proportion of care they provided to different age groups was not uniformly distributed, with more care provided to adults than children. Both generalist and subspecialist respondents were more likely to feel better prepared by their residency training to care for adults than for children. Those who felt less well-prepared to care for children were less likely to do so in their practices (odds ratio, 0.68; 95% confidence interval, 0.48-0.96). Fifty-four percent of the subspecialists pursued subspecialty training in internal medicine only, while 38% completed a combined internal medicine-pediatrics subspecialty program. These respondents, like the generalist respondents, also were more likely to focus clinical efforts on adults than children. Fewer than half (43%) provided any care to children zero to one year of age, while 54% provided at least some care to children aged two to 11 years. Conclusions Internal medicine-pediatrics physicians are more likely to spend a majority of their clinical care focused on adults and to perceive that they stay more current in the care of adults than of children. Potential reasons for this disparity may include training issues, greater reimbursement for the care of adults, perceptions of the impact on the medical market of the demographic shifts to older adults, and employment opportunities following training. These results also demonstrate the need for a more detailed and comprehensive assessment of the adequacy of pediatrics training in these programs.

A clinical performance exercise for medicine--pediatrics residents emphasizing complex psychosocial skills.

To assess the skills of internal medicine-pediatrics (med-peds) residents in evaluating and counseling patients with complex psychosocial problems using a clinical performance exercise (CPE). The authors designed a 13-station CPE [nine standardized-patient (SP) stations and four non-SP stations]. Eight of the SP stations focused on counseling or assessing complex psychosocial needs, and three were videotaped and analyzed for specific verbal and nonverbal communication skills. Residents completed a written task for each station and SPs completed a checklist on interviewing and communication skills and a 52-item patient's-satisfaction survey. All first- and third-year residents (n = 25) from two academic years participated. The range of the average scores on the nine SP stations was 43-75%. The residents performed better with common problems (newborn hospital discharge instructions and cardiac risk-factor counseling) than with more complex problems that are less often encountered in the institution (HIV counseling), or problems less often recognized (adult survivor of childhood sexual abuse). As expected, third-year residents scored better than did first-year residents on the written "plan" part of the SP stations and on the non-SP stations. Third-year and first-year residents had similar scores, however, on measures of verbal and nonverbal communication and patient's satisfaction, and for gathering data and providing information. This is the first performance-based evaluation of residents in a combined med-peds residency program. The stations addressed more complex clinical skills than those reported for objective structured clinical evaluations of residents.

Internal medicine-pediatrics combined residency graduates: what are they doing now? Results of a survey.

While the number of internal medicine-pediatrics (med/peds) residency training programs has increased considerably in the past decade, questions continue to be raised about career paths of the graduates of these programs. It is uncertain whether med/peds graduates follow a generalist career path and whether they continue to practice both specialties. To determine the career outcomes of graduates of med/peds residency programs. A survey questionnaire of graduates of med/peds residency programs. The computer databases of the American Board of Pediatrics and the American Board of Internal Medicine were used to identify 1482 individuals who had completed training in combined med/peds residency programs between 1986 and 1995 and who had applied to either board for certification. The survey questionnaire was mailed to all graduates identified. Time spent in professional activity (patient care, teaching, administration, and research), site of principal clinical activity, ages of the patient population, types of hospital privileges, practice organization, subspecialty activity, night and weekend coverage arrangements, community size of practice, involvement in teaching, and membership in professional organizations. Of the total group of 1482 graduates, 87.3% are certified by the American Board of Internal Medicine, 91.3% by the American Board of Pediatrics, and 81.6% by both boards. The survey was completed by 1005 graduates (67.8%). The principal activity of almost 70% of the graduates was direct patient care. Most graduates cared for patients of all ages. More than half of all respondents noted that their principal clinical site is a community office practice. Eighty-five percent managed patients who require hospitalization. Approximately 50% of respondents had a medical school appointment. This study, the largest survey to date of med/peds graduates, provides strong evidence that most med/peds graduates are practicing generalists who care for adults and children. In addition, the fact that 80% of graduates achieve dual board certification suggests that these physicians are well qualified to care for the spectrum of health care needs of children and adults. Because the changing US health care system mandates a strong primary care base, these physicians will play a small but important role in providing high-quality generalist care.

Effects of an educational intervention on residents' knowledge and attitudes toward interactions with pharmaceutical representatives.

To assess primary care resident and faculty knowledge and attitudes concerning interactions between physicians and pharmaceutical representatives (PRs) and to measure changes in residents' knowledge and attitudes after an educational intervention, we conducted preintervention and postintervention surveys with a causal-comparative group in a university-based primary care residency program. All primary care internal medicine and internal medicine-pediatrics residents and faculty were given the voluntary survey. In general, residents and faculty demonstrated similar responses for the preintervention survey. Differences between faculty and resident opinions were seen in two areas. Faculty were more likely than residents to believe that PRs sometimes use unethical marketing practices (p < .05) and that the amount of contact with PRs in the outpatient clinic is excessive (p < .01). The postintervention survey of residents demonstrated significant differences between the control and intervention groups for three attitude scales. After the intervention, residents showed an increased belief that PRs may use unethical marketing practices (p < .01), that marketing gifts with no patient benefit may be inappropriate (p = .05), and that other physicians' prescribing patterns could be negatively influenced through the acceptance of gifts (p < .05). A brief educational intervention can change resident attitudes concerning physician interactions with PRs.

The Perspectives of Current Trainees in Combined Internal Medicine—Pediatrics

To gather information from combined internal medicine-pediatric residents about their application process for residency, their perceptions of the stressors during residency, and their future plans. Survey of all combined internal medicine-pediatric residents-in-training in the 1989-1990 academic year. Fifty-four percent of residents-in-training responded to the survey, representing 70% of the programs. Combined residents often investigate and rank other generalist residences. However, internal medicine is significantly (P < .005) considered more often than pediatrics or family medicine. Sixty percent of combined residents do not anticipate further training beyond the 4 years and expect to practice both specialties. The majority of those interested in a subspecialty expect to continue to combine internal medicine and pediatrics in their subspecialty practice. Switching services during the residency engenders stress. Factors that decrease stress include more frequent switches and increasing seniority. Switching from pediatrics to internal medicine is more stressful (P < .0001) than switching to pediatrics from internal medicine. The residents considered ambulatory training sites and a specific coordinator for the program to be the most important features of the residency. Combined internal medicine-pediatric programs continue to attract a small cohort of well-qualified US medical school graduates, the majority of whom intend to practice as generalists in both pediatrics and internal medicine.

Surveying Graduates of Combined Internal Medicine - Pediatrics Residency Programs

Graduates of all U.S. combined internal medicine-pediatrics residency programs were surveyed in 1987 regarding a variety of demographic information about their residencies and current practices, the residency curricula they had followed for both specialties, and recommendations for modifications in training. The 71 responding graduates (from a total of 112) reported patient care as their major involvement (mean of 42.9 hours per week), with a majority (83%) seeing patients in both pediatric and adult age groups. Most were involved in primary care only (64%). The graduates reported that during both pediatrics and internal medicine training, they had had too many inpatient and intensive care rotations and too few elective and ambulatory rotations. The most important subspecialty rotations in internal medicine were considered to be cardiology, dermatology, and pulmonary medicine; and in pediatrics, infectious disease, cardiology, and adolescent medicine. The graduates recommended more outpatient subspecialty rotations, ambulatory rotations in medicine and pediatrics, and a combined medicine-pediatrics continuity clinic.

Guidelines for Combined Internal Medicine-Pediatrics Residency Training Programs

The objectives of a combined residency in internal medicine-pediatrics include the training of general physicians for practice or academic careers addressing the spectrum of illnesses in the newborn, children, adolescents, and adults. Graduates of a combined residency may function as generalists in practice and academic environments or enter subspecialty training. This clinical training can also prepare graduates to undertake research in areas shared by internal medicine and pediatrics, including adolescent medicine, medical genetics, clinical epidemiology, medical decision making, and health care delivery. The strengths of the residencies in internal medicine and pediatrics should complement each other to provide the optimal educational experience. Combined programs include components of independent internal medicine and pediatrics residencies that are accredited respectively by the Residency Review Committee for Internal Medicine and by the Residency Review Committee for Pediatrics, both of which function under the auspices of the Accreditation Council for Graduate Medical Education. Although combined programs will not be independently accredited, the accreditation status of the parent internal medicine and pediatrics programs influences a combined program resident's admission to the certifying examinations of each board. The boards will not accept training in a newly established combined program if the accreditation status of the residency in either discipline is provisional or probationary. If the residency in either discipline is accredited on a probationary basis, residents should not be appointed to the combined program. At least two residents must be enrolled in each year of the 4-year program to ensure peer interaction. GENERAL REQUIREMENTS A combined residency in internal medicine-pediatnics must include at least 4 years of coherent training integral to residencies in the two disciplines that meet the special requirements for adcreditation by the Residency Review Committee of Internal Medicine and Residency Review Committee of Pediatrics, respectively.

Demographic features and attitudes of program directors of combined internal medicine and pediatrics residencies.

Combined residency training in internal medicine and pediatrics has proliferated greatly in the last ten years. This survey of program directors (N = 55) of such residency programs reports their personal and professional demographic characteristics as well as their perceptions about aspects of combined training. The directors were more often affiliated with Internal medicine (33 directors [60%]), 47 (85%) were men, their mean age was 44 years, they had been out of medical school for a mean of 19 years, the mean time served as program director was 2.6 years, and 32 (58%) had completed a fellowship. The programs had existed for an average of 4.2 years, the mean entering class size was 2.8 persons, and the mean number of graduates per program was 4.2. We report directors' perceptions of why students choose combined training, why the programs have proliferated, and how these residents differ from family medicine residents. We comment on curriculum design and the goals of combined internal medicine-pediatrics residency training programs.