Pediatrics, then and now

As a pediatrician who retired after many years of solo pediatric practice and now volunteers at a clinic for the poor, I read with interest your article “5 ways your practice will change, and the 1 way it won’t (Contemp Pediatr. 2013;30(12):24-32)” about what is causing the stress and unhappiness of many of the now-practicing pediatricians.

Yes, pediatrics has changed over the past 50 years. Pediatricians always were and still are underpaid and now underappreciated, while nonphysician pediatric practitioners encroach upon our specialty. Using the electronic medical record (EMR) at the clinic where I volunteer takes more time to complete than the time I spend with my patients.

However, the article left out one of the most important changes that have taken place over the years, one that has a lot to do with the current unhappiness of pediatricians in practice. The fault for this change lies with the pediatricians themselves and the American Academy of Pediatrics, which is made up mainly of university professors who had (and still have) little or no insight into what goes on in the trenches and so do little if anything to make their pediatric members’ lives easier or better.

Many years ago, when I finished my pediatric training under Dr. Waldo Nelson in Philadelphia, it was drummed into us daily that we would be “specialists in the care of children,” taking care of almost all their problems. The few available pediatric subspecialists were so busy that they went out of their way to teach us, the general pediatricians in training, as much as they could of their own specialties so that we felt confident to handle most of the basic otolaryngologic, gastrointestinal, neurologic, orthopedic, and other subspecialty problems that we would encounter in a busy office practice. They didn’t need (or want) routine, simple referrals. They sent us out confident that we truly were specialists in the care of all children. Our sick patients were treated by us, hospitalized by us, and taken care of by us. There were no “hospitalists.” We took care of our own newborn patients and went to cesarean deliveries because there were no neonatologists or cesarean delivery teams of nurses and respiratory therapists.

Were we busy? Yes. Were we tired? Yes. Were we underpaid for much of the work we did? Yes. Did our patients get excellent care? Yes! I am not at all convinced that team care-a mix of subspecialists, hospitalists, and the family general pediatrician in the background-really gives superior care to most sick children. We knew our patients, their families, and their needs, and care was not fragmented among many. Were we appreciated? Yes! Did we have status? Yes, we did! Most families rated their pediatrician just a little below their God. We were not providers but their own family pediatrician. For the most part, they loved us and appreciated everything we did, and that in itself was rewarding, very satisfying, and made up for all the time spent being a good pediatrician.

Much of this has changed. Physicians have become providers, our child patients have become clients, and the insurance company stands between the physician and the patient. This has caused a loss of patient loyalty. If the insurance changes, often the pediatrician changes as well. It has also caused our remuneration to go down.

What caused this major upheaval in the way we practiced? It was partly the fault of the pediatricians themselves. Most of us were tired; many wanted more time off. Many were not happy with what they were doing, and so delegated more and more of their patient’s care to others. They did not realize that once the interesting part of pediatrics-taking care of the sick child patient-was lost, it could never be regained. Anything the least bit complicated was referred out. Hungry pediatric subspecialists were looking for more patients and encouraging pediatricians to refer. Yes, this made more time for the pediatrician, but at the cost of job satisfaction.

So that is the here and now. When I was training new pediatric residents, it soon became obvious how things have changed. For any child seen with even a minor problem, when the resident is asked ‘”What would you do next,” the response is “We need to call the subspecialist.” Will these residents, when finished with their training, be anything other than well-baby, upper-respiratory-infection, otitis-media doctors who refer out any slightly complex, but oh-so-interesting, problems or any child who is really sick and needs hospitalization? In the clinic where I mentor family practice residents in community pediatrics, when we encounter any problem and I ask a question, out comes the smartphone and the appropriate app is asked what to do. Is this a satisfying way to practice medicine? I am afraid of what will happen to the patients in the care of this new crop of physicians.

Practicing pediatricians who must battle the new government regulations have my sympathy. Yes, medicine has made many advances in the past few years. Most of these advances have been for treatment of the few, rare, really complicated medical problems and not the common, garden-variety illness that the pediatrician encounters daily. Gone are the patients with measles, chicken pox, polio, and Haemophilus influenzae meningitis crowding into the office in the winter months. This should have made the pediatrician’s life easier, not more stressful. Sadly, that is not the case. Government regulations, the EMR, and the referral out of anything interesting now cause much of the pediatrician’s unhappiness. These causes are stressful, yes, but they are not nearly as interesting as the multitude of illnesses and hospitalized patients that were our causes of stress. Getting efficient in the use of EMR and governmental regulations will never be as satisfying as solving a complex medical problem and having a child go home, cured.

I feel sorry for what has happened to the specialty I love, and I see no real solution that could be put into place to make the current pediatrician’s life better and more meaningful. Any ideas, anyone?

DR WEINBERG is a retired pediatrician who volunteers at Salud Clinic, West Sacramento, California.