PEDIATRICS Vol. 123 No. 1 January 2009, pp. 413-416 (doi:10.1542/peds.2008-3254)
COMMENTARY |
The Rebirth of Pediatrics
Center for Policy, Outcomes and Prevention, Department of Pediatrics, Lucile Packard Children's Hospital and Stanford University School of Medicine, Stanford, California
Abbreviations: SCHIP, State Children's Health Insurance Program
Any close examination of the epidemiologic trends in childhood suggests 2 fundamental findings. First, pediatrics has been among the most successful specialties in the history of modern medicine. Second, pediatrics must change. At the heart of this seeming paradox is the recognition that pediatrics has so altered the clinical threats to the well-being of children over the past 50 years that new structures of care will be required. The epidemiology presents a ruthless logic: one cannot take pride in pediatrics' remarkable record of impact and at the same time defend the status quo.
The challenge to the pediatrics community is to ensure that the changes that will inevitably come are exquisitely focused on meeting the needs of children. We must craft strategies that can protect what remains essential in pediatric practice and yet embrace a historic opportunity to craft requisite reforms. It is in this context that the recent initiatives by the American Board of Pediatrics1 [Editor's note: also see related supplement titled "Residency Review and Redesign in Pediatrics: New (and Old) Questions" with this issue of Pediatrics.] and the American Academy of Pediatrics2 to consider new training and practice needs should be welcomed. However, the nature and scale of the challenge will require a new level of direct engagement from pediatricians and a renewed progressive commitment to speak with a stronger and more coherent collective voice.
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CONFRONTING THE EPIDEMIOLOGY OF SUCCESS |
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It is useful to begin by recognizing just how much the epidemiology of childhood has changed over the past several decades. The likelihood that a child will get an acute illness, such as an upper respiratory infection, otitis media, or viral syndrome, has not changed very much over this time period. However, the likelihood that a child will get an acute illness and stay home from school has decreased dramatically.3 Although this phenomenon is almost certainly related to major increases in maternal employment, it also likely reflects the correct perception among American parents that an acute illness, even one associated with fever, is not likely to be serious.
Although serious acute illness has become increasingly rare, the prevalence of chronic disease has risen consistently over the past 4 decades. Estimates suggest that the percentage of children with a chronic illness has quadrupled between 1962 and 2005, now falling between 12% and 16% of all children.4 The juxtaposition of reduced serious acute disease and the rising prevalence of chronic disorders suggest a divergence, or dichotomization, in the epidemiology of childhood.5 The vast majority of children are generally well with only a small risk of ever becoming seriously ill, whereas a relatively small segment of the pediatric population accounts for a growing portion of morbidity, hospitalization, health-related costs, and mortality. Meeting the needs of this increasingly important group of children has helped fuel the wide acceptance of the "medical home"6 as a useful model for pediatric practice.
The problem has been, however, that despite multiple pronouncements and demonstration projects underscoring the utility of the medical home, it has proven exceedingly difficult to actually implement it in the real world of current pediatric practice. This is not because pediatricians are unaware of the need or are inherently resistant to change. Rather, it is because our current system of pediatric care and its financial foundation (an infrastructure developed in the 1950s and 1960s when serious, acute infectious disease was the principal concern) is just not designed to support the provision of high-quality, intensely coordinated care for chronically ill patients. Current incentives are forcing many practices to see higher and higher volumes of generally well children. It should not be surprising, therefore, that most pediatricians report that they are not able to schedule more time for chronically ill patients, that they do not have adequate staff to coordinate the care of these patients, and that they themselves spend 1 hour or less per week addressing these needs.7 Recent data have confirmed that the quality of care that children with special health care needs receive in primary pediatric practice is tragically deficient.8
At the same time that traditional pediatric practices are less able to care for children with complex problems, there is growing pressure to create alternative mechanisms of care for generally well children. The rapid growth of retail-based clinics in pharmacies and megastores such as Wal-Mart represents an effort to strip some of the central elements of well-child care out of pediatric practice. Although the development of these clinics can be problematic on a variety of levels, their emergence does, nevertheless, signal a basic shift in the public's appreciation of the risks and efficiencies of not seeking well-child care in a traditional pediatric setting.
These trends strongly suggest that there is a growing mismatch between current pediatric structures and emerging pediatric needs. This mismatch, together with unfavorable developments in health care financing and policy, imply that our current structure of pediatric practice in the United States will likely prove increasingly unsustainable. The task lies in identifying the core principles and pragmatic strategies that will be essential for creating a foundation for constructive reform.
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EMPHASIZING STRATEGIC MEDICAL EXPERTISE |
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Pediatrics was founded on the notion that the medical response to the illnesses of childhood required specialized medical expertise. The dynamic developmental needs and pathophysiologic cadences of childhood demanded child-focused research and clinical capabilities. Simply put, pediatrics was founded to address a fast-developing strategic need to provide medical expertise that no other medical group possessed. Despite the many changes that have taken place in medicine and society since the founding of pediatrics, the fundamental justification of pediatrics has never changed; it remains in its strategic expertise.
There can be no doubt that some of the greatest rewards of pediatric practice emerge from building trusted relationships with children and families as they experience the many struggles of growing up in an increasingly complex world. Characterizing well-child care as merely a series of immunizations, screenings, and bullet anticipatory guidance moments, therefore, does a disservice to both pediatricians and the families in their care. Nevertheless, reward is not the same thing as strategic expertise. Pediatric expertise may offer little strategic advantage given the proven capabilities of other health professionals to provide caring, high-quality well-child care.
The most pressing reason to reground pediatrics in its strategic medical expertise, and clearly my primary motivation for raising this issue, is the glaring inadequacy of our current pediatrics structures to meet the needs of all children, but particularly poor children, with serious chronic illness. This is the challenge against which all other potential pediatric functions must be judged. Caring for a child with sickle cell disease, cystic fibrosis, autism, learning disorders, serious obesity, or mental illness so clearly requires strategic pediatric expertise that it almost seems unnecessary to even mention this point except for the critical fact that pediatricians are finding themselves increasingly unable to provide such care in community settings across the country. Indeed, although the evidence is only anecdotal, I have been part of many conversations over the past year in which pediatricians have reported that time and fiscal constraints have become so debilitating that they have been forced to functionally close their practice to children with complex medical problems. If this becomes increasingly widespread, it represents an almost complete uncoupling of pediatrics from its justification as a legitimate, strategic medical specialty.
The need to urgently improve the care of chronically ill children will likely require pediatricians to reduce their direct involvement in well-child care and purposefully refocus their practices on the clinical, coordinative, and social needs of patients with more complex conditions. Successful models in which pediatricians supervise the provision of well-child care by other health professionals are in place in a variety of clinical settings throughout the United States. What is missing is any coherent analytic effort to assess the relative utility and financial requirements of implementing these models in different community settings. Nevertheless, it is useful to recognize that a more consultative role for pediatricians is, of course, precisely the structure that exists in virtually all other parts of the world. The concern is that current pediatrics preoccupations have drifted away from pediatrics' strategic expertise and have left the field relatively untethered from its original and enduring existential legitimacy. Indeed, this drift has become so commonplace that many do not even think of pediatricians as specialists anymore.
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THE DOMINANCE OF ADULT HEALTH POLICY AND THE DEREGIONALIZATION OF PEDIATRICS |
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Over the past decade in the United States, health policy has become cost-containment policy. This transformation is of special concern for the child health community, because most health care expenditures are generated by adults. Accordingly, child health needs have been pushed to the periphery of health policy deliberations, with children included rather haphazardly in policies defined on the basis of adult needs.
This dominance of adult health care concerns has put at risk one of the great triumphs of modern pediatric care: regionalized specialty care referral and hospitalization for children. Because serious chronic illness is far less prevalent in children than in adults, pediatrics must concentrate patients with a variety of relatively rare conditions into networks of regionalized specialty care centers, whereas adult care can tolerate far more decentralized services. However, these distinctions in epidemiology and care requirements have been all but lost in our current health policy environment. Poor children with complex medical needs have been routinely folded into state Medicaid managed care plans, although all the supporting studies were performed on disabled adults, and there remains little understanding of how chronically ill children actually fare in such programs.9 Without greater protection of our current systems of regionalized services, >40 years of progress in ensuring access to pediatric specialty care could unravel.
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THE PEDIATRIC IMPLICATIONS OF PERSONALIZED MEDICINE |
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The growing body of evidence linking genetic and epigenetic interactions in early life to the development of what traditionally have been considered adult diseases has the potential to profoundly reshape clinical pediatric practice. Despite many ethical and other concerns, it is likely that incentives for parents to seek individual or "personalized" genetic and biomarker risk profiles for their children will grow as new, more efficacious pediatric interventions are developed. In this manner, pediatrics may increasingly become an important clinical domain for personalized medicine, ultimately making the management of the precursors of adult-onset disease a central component of pediatric care.
The pediatrics community can provide national leadership in developing constructive, preventive ways to address the precursors of adult-onset disease. However, this will require greatly improved analytic support for assessing the clinical significance of identified risks and the utility of any clinical or community response. In addition, it is not at all clear how the current emphasis on improving quality through reducing clinical discretion and enhancing standardization of care will relate to highly personalized risk identification. Clearly, improved epidemiologic and informatics capacities will be needed, which in turn will require enhanced technical support networks for practices that do not have the capacity to create and implement stand-alone screening and precursor management systems on their own.
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CREATING A UNIFIED POLITICAL VOICE FOR CHILD HEALTH |
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The only guarantee that the coming changes in American health care will actually prove beneficial to children is a greatly expanded and smarter public engagement by the pediatrics community. The usual complaints regarding insurance companies, budget cuts, and complacent policy makers, although justified, provide little basis for meaningful action and serve as a reflective, mirror-like indictment of the current impotence of the pediatrics community in the public sphere.
The need for a more informed and aggressive pediatrics public presence is no better illustrated than by the discouraging veto battle over the reauthorization of the State Children's Health Insurance Program (SCHIP) in 2007. Despite overwhelming evidence for the effectiveness of the program in improving access to care for children in low-income families not eligible for Medicaid, efforts to expand the program over the next 5 years were defeated on the grounds of excessive cost and the intrusion of government into health care financing. As can be seen in Fig 1, however, the scale of the proposed expansion in SCHIP is dwarfed by the federal expenditures on adult health programs, including the Part D prescription coverage program that was added to Medicare by the Bush administration in 2003. The vetoed SCHIP funding amounted to the cost of 
12 days of the Iraq war. Observations such as this are often met by the reminder that children do not vote; the real question, however, is why should they have to vote? If nothing else, the SCHIP veto experience demonstrated the disturbingly weak political voice of the pediatric and broader child health community.
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This is a wonderful time to go into pediatrics. The next 10 years will usher in a unique historical moment for a specialty that has enjoyed unparalleled success but must now reinvent itself in ways that both protect its greatest strengths and address its emerging weaknesses. This process will not be easy; birth is always accompanied by a cry of pain along with a cry of joy. The nature of the challenge before us extends beyond representative committees, routine lobbying, and public rhetoric that no longer compels public action. It is essential that pediatricians begin to see more clearly that their growing frustrations in day-to-day practice are merely the daily expression of a larger set of trends and policy failures. It is hard to know when change is necessary and when it is time to act. However, the stakes here are both historical and personal, touching not only the quality of our care but also the course of our own professional narratives,11 the conviction that the sacrifices and rewards of a life in pediatrics do indeed contribute to a larger collective efficacy and, ultimately, an enduring legacy of humane and effective service to America's children.
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FOOTNOTES |
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Accepted Oct 28, 2008.
Address correspondence to Paul H. Wise, MD, MPH, Stanford University, Center for Policy, Outcomes and Prevention, Department of Pediatrics, CHP/PCOR, 117 Encina Commons, Stanford, CA 94304-6019. E-mail pwise{at}stanford.edu
The author has indicated he has no financial relationships relevant to this article to disclose.
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
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REFERENCES |
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1. American Board of Pediatrics. Residency Review and Redesign in Pediatrics Project. Available at: www.innovationlabs.com/r3p_public. Accessed September 24, 2008. [Editor's note: also see related supplement titled "Residency Review and Redesign in Pediatrics: New (and Old) Questions" with this issue of Pediatrics.]
2. Jenkins RR. AAP planning for future through Vision of Pediatrics 2020.
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3. US Department of Health, Education and Welfare. Acute conditions. Vital Health Stat 10. 1975;(98):18
4. Centers for Disease Control and Prevention, National Center for Health Statistics. Summary health statistics for U.S. Children: National Health Interview Survey. Vital Health Stat 10. 2007;(234):27
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8. American Academy of Pediatrics, Division of Health Policy Research. Periodic survey of fellows #44: health services for children with and without special needs—the medical home concept. Available at: www.aap.org/research/periodicsurvey/ps44aexs.htm. Accessed November 3, 2008
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PEDIATRICS (ISSN 1098-4275). ©2009 by the American Academy of Pediatrics
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