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The only constant in life is change, a well-known truism. Medical practice is no exception, with changes to funding models, care delivery models, health care problems and needs, and evolving roles of various health care providers. The survival of individuals, organizations or professions depends on the ability to adapt in times of change to remain relevant. The present article appraises community paediatrics with respect to training, practice and how practice activities are valued. I propose a way forward, proffering solutions to some of the problems raised.
To start, two complementary concepts – the community-based paediatrician and the community paediatrician – must be differentiated.
The community-based paediatrician, as the name implies, is a paediatrician based in the community, usually outside a tertiary centre, whose practice is focused on those who visit the clinic, including support for patients accessing needed services within the community. The community paediatrician, on the other hand, sees the community as the patient (1,2). The focus is on all children and youth rather than just those who come to the clinic. There is recognition that the social determinants of health go beyond medical care and that partnerships with other professions serving children and youth, cultural sensitivity and advocacy are ingredients for optimum health. The approach to diseases is also different. Those who come to the clinic reflect symptoms of health of the community. Thus, an unusual number of children with gastroenteritis may indicate a Rotavirus epidemic. Both the immediate and remote causes of the problem in the community need to be considered, and the community paediatrician has the skills to address these issues.
In Canada, the majority of those usually referred to as community paediatricians practice as community-based paediatricians. They do excellent work. Some do venture into aspects of community paediatrics. In the past, I have argued that community paediatricians, complemented by public health providers, should adequately serve the needs of children and youth. However, after gaining practical field experience, I now hold the view that we could do better.
Disease patterns demand a new approach (3,4). For example, in spite of our ability to control asthma in individual patients, the incidence of asthma is increasing (5). Approximately one-quarter of Canadian children are overweight (6). An increasing number of children have type 2 diabetes (7), and more children are being prescribed statins (8). For the first time, the current generation of children may have a life expectancy shorter than that of their parents (9). The increase in the survival rate of extremely premature neonates often also means more cognitive and behavioural difficulties by school age. Communities must be equipped to support them. Long-standing problems – injuries, chemical dependency, sexually transmitted diseases, unplanned pregnancies, school failures – still need to be contained. The social, economic and political environments in which children live and develop have been recognized as the most important contemporary determinants of child and youth health (10–12). The short- and long-term economic impact on society of not dealing well with these and other diseases will be severe.
The increase in disease burden, in spite of our success in treating the individual patient, requires that we implement new strategies. We cannot possibly hope to succeed in dealing with obesity one patient at a time, anymore than a forester would succeed in dealing with the pine beetle one tree at a time. (Tree beetle infestations of large swaths of forest in western Canada attributed to mild winters from global warming.)
This is where community paediatrics comes in. A community paediatrician has the skills to deal with the individual patient as well as think globally about diseases, and is able to evaluate, design and implement interventions that are sensitive to the unique characteristics of the community. Thus, from my perspective, there is a need for the paediatricians of the future to continue to deal with individual patients but also to acquire increased expertise in population-based interventions.
In the mid-19th century, doctors were primarily educated through preceptorships and apprenticeships in offices of community-based generalists (13). In 1910, the post-Flexner model shifted education to academic medical centres (13,14). Although Flexner emphasized the importance of social and preventive medicine, his biomedical model of teaching based in academic centres set the stage for the decline of community-based education. Many educators have since recognized the problem and have tried to increase community-based training (13,14).
Unfortunately the imbalance in training of paediatricians persists. Most programs are geared toward training subspecialty paediatricians or ‘general paediatricians with subspecialty interest’ who function primarily in tertiary centres or large urban hospitals. In most training programs, a few weeks of community postings either as an elective (for medical students) or required (for residents without any community-oriented curriculum) is usual. In both instances, the trainee ends up shadowing the community-based paediatrician and, at best, learns about some of the challenges of practicing outside a tertiary centre.
More recently, there have been attempts in several locales across the country to decentralize medical schools, perhaps with the hope that more training would be community based. Unfortunately, large urban centres with hospitals similar to the ‘academic’ core hospital are usually the chosen sites for training, undermining the aim of community-based training.
Let me illustrate this with a personal example. When I suggested that the University of British Columbia (Vancouver, British Columbia) accept Trail (British Columbia) (85,000 catchment population) as a community training centre for paediatric residents, on grounds that it has a rather sophisticated hospital in a rural setting with a full complement of keen, energetic staff in all the major departments, it was determined to be “too far” and to have “not enough infrastructure” to be suitable for training. Interestingly, these are some of the reasons newly graduated doctors give for not setting up practices in communities like Trail. In essence, many new physicians are primed to survive only in the shadows of teaching hospitals or in large urban communities where there is ‘infrastructure’, and are ill-equipped from the outset to deal with the challenges of smaller remote communities. While six metroplitan centres, namely Toronto (Ontario), Montreal (Quebec), Vancouver (British Columbia), Ottawa-Gatineau (Ontario-Quebec), Calgary (Alberta) and Edmonton (Alberta) have 45% of the population (http://www.chpc.biz/Census_Population.htm), there are many communities in Canada that are relatively far from a large urban centre.
A few medical schools, including those in Maastricht (The Netherlands), Newcastle (Australia), Havana (Cuba) and Ilorin (Nigeria) – where I trained – have strong community-based decentralized programs. Students had early and repeated community postings to a particular community with a curriculum sensitive to the needs of the area. In my experience, the teachers who are the products of the university-based biomedical model of learning unwittingly often became the obstacles to development of these programs due to a lack of skills, insight or interest in truly designing and implementing decentralized community-based training. Another obstacle is that the residents are a major part of the labour force in the teaching hospitals, making it difficult to release them for significant amounts of time for community postings.
Our training, mode of compensation and demographic imperatives determine how we practice.
A typical paediatrician with subspecialty qualifications practices in a tertiary centre. Where this is not possible or if he has a more general training, he becomes a community-based paediatrician, usually in a large urban centre. He is sandwiched between the family physician and the sub-specialty paediatrician, often with limited referrals because the family doctors refer directly to the subspecialist. Based on current trends in training, many paediatricians could not function as effective community paediatricians, especially in smaller communities.
The payment system also contributes to the patterns of practice. Many Canadian paediatricians are compensated on the fee-for-service model, which is tailored to the provision of one-on-one medical care (15). A sizable component of the suburban paediatrician’s income often comes from providing coverage for local paediatric emergencies. Any activities outside the fee guide are not compensated. Health-promoting activities of a community paediatrician, including advocacy, meetings with other professionals serving children and youth, healthy living campaigns, and lobbying for policy enactments or changes, all have to be voluntary.
Finally, demographics contribute to practice patterns. The younger generation of paediatricians has a more balanced approach to work; hence, they are unlikely to accept solo responsibilities in remote communities (16). The increasing proportion of female paediatricians with attendant parenting priorities creates an uneven distribution of work that makes it necessary for them to function in areas where flexibility is possible; often easier in large urban settings. In addition, the aging of existing paediatricians and the attraction of urban conveniences over smaller communities have led to more than 80% of paediatricians practicing in large urban and suburban centres, with a dwindling pool of paediatricians scattered in the smaller communities across Canada (15,16).
Generally, paediatricians are trusted by the parents of their patients because they are expected to be driven by the best interests of children. I find the level of trust to be even higher in smaller community settings. The goodwill of parents is perhaps the most untapped and underused force in the service of children and youth. Some paediatricians go to parents only at times of crises. In my experience, parents can be very effective advocates for children and youth, implementing health promotion campaigns, lobbying municipal politicians and raising funds for specialized equipment.
We live in a capitalist system; hence, monetary compensation is seen to reflect value; more remuneration, more valued. Among medical specialists across Canada, paediatricians are consistently among the least paid, and by implication, the least valued in spite of equally rigorous training requirements and equally onerous clinical responsibilities for a sick child or youth. While parents, as individuals, appreciate their paediatricians, policy makers and society are unwilling to pay equitably for their services. Perhaps paediatricians have been too shy about their contributions to society, including their interventions in prenatal care, premature newborns, vaccines, injury prevention, aiding the child with school difficulties, caring for the troubled teens, etc. We concentrate on child and youth health advocacy with the hope that appreciation of children translates to the appreciation of those who care for them. We must value our own efforts and demonstrate its impact on the larger society or we will continue to be undervalued by our medical contemporaries in other disciplines as well as by those who might consider becoming paediatricians. Ultimately, this will affect our ability to adequately care for children and youth.
I think the future paediatrician is to be versatile and have skills as an expert in dealing with individual as well as populations of children and youth. For consistency, I shall keep to the themes enunciated above.
I favour the distributed medical school model that is now being implemented in some jurisdictions, including British Columbia. Victoria, Prince George and Kelowna (British Columbia) have been chosen as medical school campuses of the University of British Columbia. My preference is for some of these campuses to be in smaller centres, such as (yes, you guessed it) Trail, to sensitize the students to the needs and opportunities of smaller communities. Given that small communities normally do not have the political clout to influence campus location, I suggest that there be teaching centres in smaller communities affiliated with these campuses. Distance education technology can ensure uniform standards across all training sites.
Further, medical school admissions should consider the fact that students originally from smaller communities are more likely than their urban counterparts to set up practice in smaller centres (17).
Curriculum change is also needed. The student should be introduced to the community early in his training because this positively affects attitudes to smaller communities (18). Return to the community in later years of training would allow the student to measure his own progress. In my experience, exposing medical students early to practical and relevant aspects of epidemiology and biostatistics makes them think more critically and globally about disease processes, rather than the usual mechanical approach to diagnosis and treatment. Giving them the skills to find answers engenders the courage to ask questions.
At the postgraduate level, community paediatrics should be treated as a distinct subspecialty discipline. The training should be for five years: the first three years dedicated to general paediatric training, and the rest split between further paediatric training and master’s level training in public health, medical education and administration. This curriculum equips the resident for different practice options: a consulting paediatrician, a public health officer for children, and a manager in academic/health or other health institutions.
As other medical disciplines expand their scope of practice, our roles as consulting paediatricians will also need modification and change. Referral patterns should be streamlined – from family doctors to paediatricians to subspecialists. In addition to providing care for individual children, we should be able to design and implement population-based interventions for them. Capabilities in medical education and managerial roles afford us the opportunity to have teaching/administrative responsibilities as life changes. Funding for community health projects remains a challenge. A national fund that individual paediatricians can access for specific projects in their respective communities would be helpful.
We will continue to enjoy public goodwill with new and expanding scientific discoveries that are of benefit to children and youth. Modern techniques in genetics and our expanding need for early population-based preventive strategies give us tremendous advantages over other disciplines. In addition, we must be relentless in our advocacy for child and youth health. Meaningful advocacy is based on the rights of children. The medical student, paediatric resident and paediatrician in practice should be educated in local child rights (if any) and the United Nations Convention on the Rights of the Child (10), thus providing a solid basis for advocacy, a most potent instrument in addressing the inequities ensuing from the adverse social, economic and environmental impacts on the health of children.
Within the paediatric community, the Canadian Paediatric Society should adopt a wider approach to acknowledging member efforts. Acknowledging community paediatricians is limited to sectional or regional awards; a major award is needed.
Because the capitalist system equates pay with value, we must strive for equal pay with other medical disciplines. This should form the basis for our negotiations. The Canadian Paediatric Society should engage those capable of ascribing monetary value to our activities. Where salaries are concerned, all fellows of the Royal College of Physicians and Surgeons of Canada with comparable training and responsibilities should earn comparable wages. The community paediatrician may need a hybrid of fee-for-service and alternative forms of payment.
Paediatricians should be more active participants in their own economic affairs, actively participating in important areas of medical organizations whose decisions impact our economic well-being. Where necessary, we should get professional representation for sensitive economic negotiations.
Membership of provincial paediatric societies is encouraged because in some jurisdictions, numbers determine voting rights, including in economic matters. Cooperation among regional paediatric societies across Canada is desired. When a regional society registers some economic success, the strategies for such achievement should be made available to other societies with similar challenges.
The quality that we bring to the care of children is not just a measure of our humanity, it is our humanity. I hope that the implementation of these ideas will show us the way forward to a sustainable future for paediatrics in the 21st century.