The pediatrician now and in the future should be recognized as the specialist specifically trained to provide comprehensive, coordinated health care to infants, children, adolescents, and young adults throughout growth and development. This care, which can be described as primary care, encompasses problems of Level I, II, and III complexity. Although the majority of the pediatrician's practice time will be devoted to Level I and Level II services, the actual mix of a pediatrician's practice will be influenced by practice location, individual training, competency, interest, and the financial structure of the pediatric practice. The pediatrician will work with multiprofessional teams to coordinate and supervise comprehensive family-centered care for the child with multiple handicaps. The pediatrician should provide consultation to other physicians and various community child care programs.
The trend toward group practice will continue. The increasing number of women in pediatrics and the desire of almost all physicians for a more balanced lifestyle will enhance group practice (part-time and shared). Pediatrics lends itself especially well to this type of care. Shared overhead and expenses will decrease costs and may allow for specialized care by individuals within the group—a development that will enhance the competency of the group as a whole and individual practice satisfaction.
To ensure access of sophisticated medical knowledge and technology to all children, the number of pediatric subspecialists will continue to increase. Because of continued emphasis on education and research, most subspecialists will be located in tertiary care teaching centers, although multisystem subspecialists may also work in primary care settings. Pediatric subspecialists should diagnose and treat patients with complex illnesses and, after developing an ongoing therapeutic plan, return them to their pediatricians for ongoing care. A significant portion of the subspecialist's time should be spent in research. Enhanced networks of patient referral and regionalization of tertiary care should be encouraged to provide cost-effective care to the relatively small number of pediatric patients with complex diseases. New patterns of coordinated health care delivery for children should be considered.
Currently, there is a debate about whether or not we are training too many or too few pediatricians to meet the health needs of children in the United States. The following facts should be considered:
A. A large number of American children receive no health care. With better access to care, there will be an increased demand for practicing pediatricians.
B. The management of increasingly complex biomedical and psychosocial disorders by pediatricians requires extended professional time and knowledge.
C. An increasing number of adolescents will be seen by pediatricians.
D. Increased knowledge and technological support for diagnosis and treatment of complex pediatric diseases will require the services of pediatric subspecialists in addition to pediatricians providing primary care.
E. The increasing demand for a healthier lifestyle for both men and women will result in more realistic working hours for pediatricians.
Consideration of these factors leads to the conclusion that there will be a need for increasing numbers of pediatricians involved in pediatric care in the next decade.
Pediatricians and pediatric subspecialists have a common interest in the health and welfare of children. This should be the basis for further discussion by all pediatricians about child health needs and the type of delivery system that will provide quality health care to all children. Professional organizations interested in child health, such as the American Academy of Pediatrics and the pediatric research societies, should continue to monitor all issues related to children's access to health care, the quality of care, and the practice of pediatrics. With such monitoring and evaluation, rational decisions can be made about the number of pediatricians and subspecialists needed to provide comprehensive, quality health care. Dialogue must continue between practicing pediatricians and the academic community to ensure the relevancy of pediatric training programs in preparing pediatricians to deliver high-quality care to all children. Ongoing evaluation and research will be needed to define the role of the pediatrician and pediatric subspecialist further in meeting the future health needs of children of this nation.
A Primary Care System to Improve Health Care Efficiency: Lessons from Ecuador
