A Pediatrician’s Dirty Little Secrets - Part 3
Robert P. Lindeman, MD, PhD
Natick Pediatrics, PC

This is the third in a series of articles that reveal what I refer to as ‘dirty little secrets’ about pediatrics in today’s world. The title is a joke, of course: there is neither anything dirty nor secret about the stories. I refer to them as secrets because if these stories circulated widely throughout the community and if enough parents believed the stories to be true, primary care pediatrics as we know it would vanish quickly. Most pediatricians don’t want to vanish quickly. That’s why these stories remain secret, until now that is.

Secret #3 – Your Child’s Health Care Provider Doesn’t Have to be a Doctor

There was a time in the not so distant past when it was hard to find a pediatrician. That is because pediatricians were sub-specialists found mainly in hospitals located in big cities. You went to a pediatrician only when your child had a problem that your general practitioner could not figure out, or if your child needed a type of surgery that required the services of a pediatric surgeon. General Practitioners (who today in the U.S. would be ‘Family Practitioners’) took care of adults and children alike. They performed well-child checks, gave injections, and treated most illnesses, major and minor.

General Practitioners (GP’s) still exist in the United States today, but they no longer serve as the foundation of the medical system as they continue to do in Great Britain. Today, internal medicine doctors (internists) and pediatricians divide the labor that was once performed by GP’s. There are several reasons for this divide, most of which are beyond the scope of this article. One of the major reasons, however is that there are simply too many pediatricians.

Too Many Pediatricians?

The 20th century saw an explosion of pediatric training programs. By the 1990s, the number of pediatricians was rising faster than the number of children in the U.S.! Nevertheless, some parts of the country have many more pediatricians than others. Massachusetts has one of the highest concentrations in the country, with around 84 pediatricians per 100,000 children. Wyoming has the fewest with 20 pediatricians per 100,000 children. Even in Wyoming, there are too many pediatricians to perform only specialty work in hospitals. Most of these pediatricians are what we refer to as ‘primary care doctors’. With the appearance of a large number of board-certified pediatricians practicing primary care in the communities as opposed to specialty care in hospitals, many parents began drifting away from GP’s and over to pediatricians.

As the number of pediatricians grew, so did the rumor that children needed a pediatrician. The logic was simple: there are experts in childhood medicine in my community; therefore I ought to take my child to one! Why not bring your child to an expert? Fairly soon almost every child had a pediatrician. Specialists in internal medicine, or adult medicine, essentially took over the care of people older than 18.

But as the role of the pediatrician transformed from that of sub-specialist to that of primary care provider, the way pediatricians are trained did not change. Pediatricians are trained in hospitals, where they are taught to care for ill children. The pediatric curriculum is largely based on the diagnosis and management of pediatric diseases. Only recently have pediatric training programs begun to teach primary care in any depth. As a result, pediatricians emerge from training programs well-prepared to care for sick children, and less-well prepared to care for healthy children. This type of training gives a young pediatrician a much skewed perspective on the health of children. It wasn’t until I began practicing in the communities that I discovered that the overwhelming majority of children are, in fact, quite healthy!

The ‘Sick’ Model

It follows naturally that pediatricians should regard children as essentially sick people. After all, pediatricians get the bulk of their training caring for sick children. This model of the child as ‘sick’ person doesn’t work well in primary care. Pediatricians are trained to find and treat disease, not to manage wellness. As the saying goes ‘when you have a hammer, the whole world looks like a nail’. Pediatricians are trained to wield highly-specialized hammers. They are over-equipped to practice well-child care.

If pediatricians are best suited to the care of sick children, who is best suited to care for well children?

If Not the Pediatrician, Then Who?

The GP has not vanished from the American landscape, he merely changed his name. In 1971 the American Academy of General Practice changed its name to the American Academy of Family Physicians (AAFP) and the Family Practitioner was born. The AAFP certifies doctors to care for families of adults and children. Several AAFP diplomates practice in Massachusetts. FP’s perform excellent work, and provide the advantage of comprehensive care to entire families. A pediatrician is often faced with the problem of an infectious illness in a family, but she must share the work of managing these outbreaks with parent’s physicians. Coordination of this type of care can prove difficult. An FP has no such difficulties.

Enter the Nurse Practitioner and the Physician’s Assistant

The last 20 years saw the rise of a specialized type of nurse known as the nurse practitioner (NP). NP’s are essentially nurse-specialists. There is now a sub-specialty for pediatric nurse practitioners. The NP in primary care provides essentially the same level of care as provided by pediatricians. In many states, NP’s can see patients independently with physician back-up. They can diagnose and manage illness, and they can write prescriptions. And they are compensated at a fraction of what a pediatrician earns.

Physician’s Assistants (PA’s) have also begun appearing in primary care offices. Like their colleagues the NP’s, PA’s diagnose and manage common pediatric problems with physician back-up if needed. Like NP’s, PA’s are much more cost-effective than physicians.

Many parents worry that NP’s and PA’s will be unable to spot problems that a pediatrician would find. This is an understandable worry. Happily, it is unfounded. Central to the training of NP’s and PA’s are the assessment skills necessary to diagnose, and in many cases to treat effectively the types of problems normally encountered in primary care. When they encounter problems that stretch beyond their expertise, NP’s and PA’s make referrals to specialists, even to pediatricians!

Whence the Pediatrician?

With the emergence of high-quality primary care delivered by non-physicians, someday we may see the return of the pediatrician to her place of origin, the pediatric hospital. There she can practice the kind of medicine she was trained to practice, the diagnosis, management, and care of acutely and chronically ill children. But first, for this to occur, there need to be fewer pediatricians. Pediatric training programs will have to cut back the number of graduates they produce, and some programs will have to close. If they do not do so voluntarily, the market, driven by low-cost/high-quality care provided by FP’s, NP’s and PA’s, will force them to do so.