A Med/Ped in Family Practice
by Norman E. Toy
Med/Peds Recruiter

When I first spoke with William Feldmann, MD, he was in search of a Med/Ped opportunity in Southeastern New Hampshire. I was able to find him a practice which he was satisfied with, and where he has been working for the last year and a half. We spent some time recently talking about aspects of his search, and the results.

NT: When we first spoke in July of 1995, you had just finished your residency program, and were beginning your chief residency in pediatrics. Before you actually began your job search, what was your original idea of what kind of practice you were looking for?

WF: I was looking very clearly at primary care practice. I saw myself as "Old Doc Feldmann", where everybody brought their problems, from lacerations to MI's, and whatever. I was definitely looking to set up an office and take all comers. In large measure, that's how it worked out.

NT: Did you have an idea what the composition would be of the group you would work with?

WF: No, not really. When I first started residency, the thought of call coverage and having partners, really wasn't something that I thought too much about. I certainly didn't think at all about the business aspect of it. All I really knew was that I loved taking care of kids, but I felt the pediatrics alone would not be sufficiently stimulating. But it's an awful lot of fun. So, I added in the medicine to keep things a little more interesting.

NT: When you first talked to me, you were looking for a practice where there was a predominance of children. Is that the case where you are?

WF: It is now. It wasn't when I started. In fact, when I joined, I joined essentially just one family practitioner, and he was distinctly uninterested in doing pediatrics. So he had a very small pediatric practice, and was perfectly happy to give me all of his patients. But when I started, probably only ten percent of the practice was pediatrics. And in a year and a half, I would say it's probably sixty percent now.

NT: What does the group consist of now? Is it still just you and one family practitioner?

WF: No. It is myself, and two family practitioners. One is sixty-four years old. Very sharp. And really keeps up. And is very open to learning new things. This has been his practice for years and years. We have kids coming in who are grandchildren of people he took care of. And then there's another family practitioner who came out of residency about a year ago now. We also have a family-practice trained Nurse practitioner. So there are three doctors and a nurse practitioner.

NT: Being the only Med/Ped within a group of family practitioners and mid-level family practice-trained staff, are there distinct advantages and disadvantages?

WF: There are both. The main things that I find lacking in my training, and which I'm fortunate enough to be able to pick up from the family practitioners, are certain procedures that we don't often get to do. In particular, dermatological procedures that I never really did during my residency. And I knew during residency that I wasn't getting enough Orthopedic training to be a primary care person, so I actually used some of my very precious elective time during residency to do orthopedics. And that was probably the smartest thing I ever did in residency. I actually spent another month doing dermatology as well, for the same reason. So I've been able to pick up some procedural tricks, because the family practice people get to do more surgery, derm, and ortho than we do. The flip side, of course, is that I'm just more intensely trained in the things that I do, and we sort of have a division of labor in our practice. I pretty much take over how we do pediatrics. The other family practice people do see some well-child stuff, but I totally revamped how we did immunizations, well-child checks, routine blood testing, TB testing, etc. Basically, just getting them up to speed with what the current recommendations are. There are other things that they just don't feel as comfortable with. For instance, I'm the only one in the office who will do official readings of EKG's.

NT: Concern over pediatric coverage seems to come up the most when Med/Peds consider working with family practitioners. How has this been handled in your group?

WF: Our group is unusual in that forty to fifty percent of the total group practice is urgent care. And we are open extended hours. So, given the volume of people, and the fact that we cannot control the flow of patients, this group does not do any admissions. We have a group of cardiologists in town who do all of the internal medicine admissions, and we've arranged with a pediatric group to do the pediatric admissions. That is not how I would like to do it. I would prefer to do my own admissions, but given the way this office is set up, that's not feasible right now. As you probably know, the way pediatrics is going these days, there's very little in-patient. Most things are taken care of on an outpatient basis. In the year and a half I've been here, I think I've admitted six or seven pediatric cases. So, it has not been as big a deal as I thought it would be.

NT: Within the office itself, do you all pretty much equally handle pediatric patients?

WF: Oh, no. I have the vast majority of pediatrics in the office. The older physician that I joined hasn't much interest at all. He hears someone coming into the office crying... (laughs)

NT: (calling) William!

WF: Absolutely!

NT: Were you the first, and are you the only MedPed physician within the hospital system that you are a part of?
WF: Yes, and yes.

NT: How did you, and how did the hospital, handle either marketing you, or communicating to the community how your training in the two disciplines could fulfill their need?
WF: How did the hospital do it? Badly!

NT: Really?
WF: Yeah. ...When I initially got here, we were short a doctor, so it didn't make a whole lot of sense, I guess, to advertise this to the public, because we already had more patients than we could handle at the time. But it would have been very helpful had they gone to some effort to educate the other doctors in the area, as to who I was and what I was. ...But they really didn't expend any effort in that direction at all.

NT: Did you make any request, or did you propose any strategy for them?
WF: Unfortunately, [for] most of... the people who finished my year who went out and joined other groups, the hospitals did a significant amount of education in the community. I just assumed they would go ahead and do that. We actually talked about a couple of things, briefly, and to me it just seemed like, Oh, yeah, every hospital that hires you is going to do the advertising, and that didn't happen. ... I'm very clear [now]... when I send out correspondence, like, I'm sending you this patient to evaluate him for such and such. I'm very clear that I sign it William Feldmann, M.D., board certified in Internal Medicine; board certified in Pediatrics. It says that very specifically on my business card because the name of the practice is Salem Family Practice, so it's important. But I would have preferred that [the hospital] sent off some fliers, at least to the other doctors. They're in the process of doing that now, because we're up to full strength.

NT: Do you think the key to MedPeds being successful in a community is, not so much communicating to the patients, but to the other doctors?
WF: ...I thinks it's both. The way things are right now, some people are changing insurance plans, sometimes yearly, or in some large companies, they're often picking a new primary care doctor. So, getting out the information to them that I do both [Medicine and Pediatrics] is extremely important, and I've had a hell of a struggle getting the insurance companies to understand it. And that's a big deal, because when some one switches and they pick up the book of providers, Family Practice, Internal Medicine and Pediatrics are listed separately. ... Sometimes I'll get on the phone personally and explain it to them, and they'll say, "Well, you can only be listed in one place."

NT: That's going to take a little doing then, for them to comprehend.
WF: It does...but eventually you can explain it to them.

NT: Are there any objectives, or hurdles within your practice that you feel remain to be overcome?
WF: I have a delightful practice. ...We're making a transition from urgent care to primary care, and that requires a different level of support staff, a receptionist, secretary, and that sort of thing. In addition, it has been quite the struggle for me to get them to understand that internist approach things in a different way than family practitioners do. And when we do a complete physical, we do a complete physical. It takes more time. We do more testing. We're looking for more trouble basically. ...I have seen family practioners book fifteen minutes for a complete physical. And it's in my mind, completely inappropriate, but it's sometimes hard to make them understand that, Yes, I'm working with family practioners, but I don't do things the same way. And the difficulty is compounded by trying not to offend your family practioner colleague.

NT: Is there any general advice that you would give to a MedPed resident who is coming out into the job market.
WF: Think very hard about the things you're willing to compromise on, and be accommodating about. ...In residency, we all thought things were going to be golden once we were the attending, once we were private physicians, once we go "out there." It doesn't get easier, it's just a different set of challenges. The other incredibly important things is, keep up. Don't let yourself fall behind, because it's a long distance to fall. They kept telling us that in residency , and we kept saying, "Yeah, yeah, I'm just trying to survive the days," but you have to keep reading, you have to keep learning, and you can learn something from anybody. Just keep your eyes and your ears and your mind open.

NT: What about if a MedPed physician is considering becoming the first MedPed doctor within a community, or practice, like you did. Is their any general advise that you would give to that person?
WF: Yeah, you have to be sure that during the interview process ...assuming you are going to do what I did, which is, join a family practice group, you have to make very clear to everybody that your interviewing with, how your training is different than theirs. It's important that they understand that you're trained in something different, so that if there's any possibility for friction between you and the other [doctors] in the area, that it's addressed before you take the job. If the medical community you are joining is not flexible, and not open, you may find yourself banging your head against the wall, and it can be a real problem. I, fortunately, have not had that difficulty. I'm in the department of medicine at the hospital, and the department of pediatrics, but I only take service call for medicine. ...But you have to make sure that the bylaws of the hospital will accommodate this, because a lot of hospitals, their bylaws are very rigid, and there need to be changes to accommodate this.