Madelyn Schimmel of River Forest was just 3 when her parents learned the value of pediatric specialists for the treatment of certain children’s health problems.
In May of 1998, Madelyn had a seizure from a high fever and landed in the community hospital with a severe kidney infection. She was given antibiotics to dissipate the infection, then sent to radiology for a CAT scan of her kidneys to look for possible physical abnormalities that may have caused her health problem.
The experience was a distressing one, says her mother, Ann.
“The technician kept having to call someone; he didn’t have the right equipment. And he seemed uncomfortable with the fact that she was just a 3-year-old,” she says.
“The staff seemed very insensitive to our concerns as parents.”
That test and a second one turned up negative, so Madelyn was sent home.
Six months later, she was back in the community hospital with an equally bad infection in the same kidney. This time, after the infection was stabilized, the family’s pediatrician urged the Schimmels’ HMO to allow Madelyn to be tested at Children’s Memorial Hospital, Chicago. “The pediatric nephrologist who tested her there found the problem immediately. Madelyn’s infection was caused by a high grade of reflux from her bladder into her kidney,” says her mother. “It wasn’t found the first time because the test at the community hospital had been done improperly. The (pediatric subspecialist) put Madelyn on a different daily antibiotic, and she has done great ever since.”
There is no question that pediatric subspecialists offer a great deal of expertise in children’s health care issues. A problem arises, however, when there are no pediatric subspecialists available to take on a case. Today, many managed health care plans and certain geographic areas have few if any pediatric subspecialists to whom they can refer patients. In addition, some insurance plans simply are reluctant to make the referrals, believing that, in many circumstances, a pediatric generalist can deliver the appropriate care.
In the last decade, medical students in pediatrics have shifted away from careers in the subspecialties such as pediatric nephrology, gastroenterology and pulmonology and back to primary care or general pediatrics. It was thought for a time that there were too many subspecialists and not enough generalists, says Dr. Stephen Berman, president-elect of the American Academy of Pediatrics, headquartered in Elk Grove Village.
However, the tide has turned, and critically so.
“In the last three or four years, we have seen that we really don’t have enough specialists in the pipeline, and I’m very concerned about this,” says Berman, professor of pediatrics at the University of Colorado Health Sciences Center and The Children’s Hospital, Denver. “In the rush to shore up the gaps in primary care, there are emerging significant gaps in the numbers and availability of pediatric subspecialists.
“The important thing is that if you have a child who is really sick with a complicated case, you want someone with a lot of experience to take care of him.
“They will provide a higher quality of care to your child. There’s no question in my mind that it’s the pediatric subspecialists who have that experience,” Berman says.
He adds that if a parent has a choice, he or she “definitely should insist on a pediatric subspecialist rather than a subspecialist (who treats adults).”
Pediatric subspecialists are critical because children aren’t simply little adults, says Berman. Their diseases and their physiology differ. Consider cardiology as an example, Berman continues. Although adults have more coronary artery disease, children have more congenital heart malformations.
Dr. Dan Fintel, director of the coronary care unit at Northwestern University Medical School and associate professor of medicine, agrees. He says, “Although an adult cardiologist may be able to approach the specialized heart problems of a child, the very best care in terms of diagnosis and therapy would be provided by a pediatric subspecialist. They have the special skills and insight needed to provide the best treatment for children with significant illness of body systems, like the heart, the stomach or the bones.”
In addition, general pediatricians don’t have the advanced training to keep up with the vast amount of knowledge required of a subspecialist.
“The capability to help children with a variety of medical problems is greatly increasing with the advances in genetics and technology. These give physicians more powerful tools, but they require more and more expertise to apply,” says Dr. Thomas Green, head of the department of pediatrics at Northwestern University Medical School.
Green also serves as physician in chief and head of the department of medicine at Children’s Memorial Hospital.
“As a parent, I would rather have my child go to someone who spends all of his professional time focused on taking care of children and their particular problems,” he says. “The problems of children are not just a matter of size. The diseases are different, the physiology of children is different, the type of equipment and facilities needed are different.”
Specialized pediatric training programs grew in the 1950s through the 1970s as new treatments and medical techniques emerged. Medical schools soon realized that additional training and experience would be needed for pediatricians to deal with the children’s special health concerns.
Some of the earliest pediatric subspecialties to arise were in cardiology, hematology, oncology and nephrology. In the ’90s, pediatric subspecialties in adolescent medicine, emergency medicine, rheumatology and infectious diseases grew.
Today, nearly two dozen pediatric subspecialties exist. “Neonatology is far and away the biggest area,” Green says. Other specialties popular with pediatrics students are cardiology, hematology and oncology, emergency medicine and critical care.
However, in some geographic areas across the United States, especially small towns, there is a dearth of critical pediatric subspecialists.
“They just can’t recruit people,” Green says. “That poses a risk for the health care of those children,” particularly in problems relating to neurology, gastroenterology and pulmonology.
Green adds to that wish list of doctors the subspecialties of endrocrinology and nephrology (kidneys). Some 59.3 percent of all non-metropolitan counties and 11.8 percent of metropolitan counties didn’t even have a general pediatrician in 1992, according to data from the American Academy of Pediatrics.
There are several reasons medical students have moved away from the pediatric subspecialties, Green says.
“One overwhelming reason is the change in the way health care is organized,” he says. “In the ’80s, the message was that primary or generalist care was the wave of the future in managed care.”
Today’s health providers often have a limited supply of pediatric subspecialists on hand. Even when the providers do employ them, Green says, they sometimes throw up a barrier, preventing patients from seeing them without first jumping through a lot of hoops. The American Academy of Pediatrics hopes that current legislation on managed care reform will rectify that situation.
“The House version of that modified patient bill of rights has specific language that seeks to guarantee children access to pediatric subspecialists,” Berman says.
H.R. 2723, the Bipartisan Consensus Managed Care Improvement Act of 1999, would ensure children access to appropriate specialists and guarantee families the option to choose pediatricians to be primary care providers for their children. The next step is for the House-Senate Conference Committee to craft a final set of managed care protections and rights for American families.
Compensation is another reason medical students are shying away from pediatric subspecialties. In a 1995 comparison of mean net physician incomes, the American Academy of Pediatrics found that pediatricians make an average $140,500 compared to $185,700 for general internists and $195,500 among all physicians.
Berman notes that many patients of pediatric subspecialists are Medicaid patients.
Among this group of people, “there tend to be children with lower birth weights, higher degrees of prematurity and infectious disease,” says Berman. Pediatric specialty care is required to deal with many of these complications, but few subspecialists are adequately reimbursed for the medical care they provide, he adds.
“Medicaid reimbursement nationally is 57 percent of what Medicare is. My contention is that we are in a society where value is reflected by what we pay for things. We undervalue our children when we pay them half of what we pay for the elderly.”
A third problem with pediatric subspecialties as a career choice is that it takes a long time to get there. Specialty care involves an extended period of training, Green says.
Subspecialists must train for three years beyond residency, or a total of six years beyond medical school, and do some research and publishing on the way, all for compensation that isn’t substantially different from what generalists make.
“People coming out of medical school often have a huge debt and must start paying off loans,” he says. “Many of them can’t wait three more years to do that.”
Karen Emerick, 32, is an exception to the trend. Emerick finished her fellowship in pediatric gastroenterology 1 1/2 years ago and is a board certified pediatric gastroenterologist at Children’s Memorial Hospital (this sentence as published has been corrected in this text).
“I chose this subspecialty because it’s an excellent blend of different skills,” she says. “There’s a lot of general pediatrics as well as the ability to do procedures. There are endoscopies, colonoscopies, liver biopsies — procedures through which you can develop skills that are enjoyable.”
Although she is thrilled with her career choice, Emerick understands why some of her peers may have chosen not to take the plunge. “It is very expensive to be a subspecialist such as a gastroenterologist. You need . . . hundreds of dollars worth of equipment, a trained staff experienced in pediatric life support and hospital affiliation. Few people can afford to practice independently.”
In short, physicians and medical schools are becoming concerned about a future with a low supply of pediatric subspecialists. Parents should sit up and take notice too.
“This is a problem with multiple sources, and it’s having a significant impact now,” Green says. “There will be more worries in the future if the trend continues. It will impact the health of children everywhere.”
