Letters to the Editor  |   January 2009
General Pediatrics in Its Death Throes?
Author Affiliations
  • Ronald V. Marino, DO, MPH
    Pediatrics Winthrop University Hospital Mineola, NY Professor of Clinical Pediatrics New York College of Osteopathic Medicine of New York Institute of Technology Old Westbury
    Associate Chairman
Article Information
Letters to the Editor   |   January 2009
General Pediatrics in Its Death Throes?
The Journal of the American Osteopathic Association, January 2009, Vol. 109, 4-62. doi:
The Journal of the American Osteopathic Association, January 2009, Vol. 109, 4-62. doi:

For the times they are a-changin'. Bob Dylan (1964)

To the Editor:  
A staggering number of sociopolitical, demographic, and economic forces are currently converging on the profession of medicine, substantially impacting the healthcare of children in the United States. 
An increasing number of physicians are rightly seeking to achieve a more healthy balance between their personal and professional lives than did previous generations. More and more medical school graduates find themselves in debt. Heavy administrative burdens are being borne by all licensed practicing physicians. 
Moreover, a complex, fragmented, and difficult situation has been created for the noble medical profession by the combination of state and federal unfunded mandates, continuing medical education requirements, maintenance of board certification requirements, and an insurance industry that engages in a cat-and-mouse game with physicians by requiring large administrative overhead to yield low reimbursements. 
As a result, physicians find themselves working harder than ever to maintain their economic status. 
In addition to these forces, which affect all physicians, those in general pediatrics face numerous challenges specific to our specialty, that continue to erode the desirability of our profession as a viable and rewarding career choice for young medical school graduates. 
The remainder of this letter describes some of my ongoing observations of the many challenges that lie before us. 
The types of preventive care provided for children are changing. The traditional “checkup”—a relationship-based source of joy for both patient and physician—is increasingly being provided by midlevel practitioners (eg, physician assistants, nurse practitioners) who may gladly perform this service at lower costs than physicians. 
In addition, numerous other professions (eg, naturopathic physicians, chiropractors, nurses) are donning the cloak of “doctor” by promoting themselves as providers of primary care services. 
The provision of immunizations has long been an essential part of patient services for the pediatrician. However, this service is increasingly being provided outside of the pediatric office. Government health department clinics, schools, and even pharmacies have begun to administer immunizations. Although this development may be of some public health benefit, it may also lead to decreases in the number of children being seen in the general pediatric medical home model. 
The number of children with special healthcare needs that are the result of complex multisystem problems is increasing. These patients require coordination of care among a variety of medical specialists. Will the role of generalist pediatricians evolve into one that mainly involves completion of administrative forms, such as referrals to such specialists, prescriptions, and orders for medical testing? Will generalists be able to continue functioning as vital, thinking members of the healthcare team—or will the growing prominence of subspecialty care render generalists unnecessary, except for providing administrative support? 
Hospitalists are also growing in prominence. The time involved in visiting hospitalized patients and the challenges of maintaining hospital skills have spawned hospitalist medicine as a popular new career choice for young medical school graduates. As the hospitalist approach to children's healthcare becomes the norm, most generalist pediatricians of the future are likely to provide limited or no inpatient care. 
Provision of care for illness visits has also become a challenging issue. With both parents commonly employed outside the home, families require access to office visits 7 days per week, 18 hours per day. Time constraints imposed by the demand side create an additional challenge for those on the supply side of this healthcare model; pediatricians who wish to balance work commitments with personal life and still make enough money to pay the bills find increasing challenges in the new healthcare marketplace. 
Many families find retail clinics (such as those in shopping malls) to be more convenient than the traditional doctor's office because such clinics provide the parent ready access to healthcare services. Waiting time can be used for shopping time or for some other multi tasking activity. The market-based, consumer-oriented model of retail clinics may continue to erode the traditional general pediatrics medical home model. 
Given these many challenges, one may wonder why any young medical school graduate would choose general pediatrics as a profession. 
And yet, the role of providing nurturant support and hope for the future continues to call to the hearts of idealistic young people who wish to make a difference in this world. Fulfilling this role, which is expressed in the event of a new birth and the creation of a new family, will always be intrinsically noble and satisfying work. 
As general pediatrics changes, we are increasingly challenged to adapt and preserve our profession, giving young people a reason to be satisfied with general pediatrics as a career choice. 
Without effectively addressing the challenges described in this letter, general pediatrics will likely become a quaint memory of “the good old days.” 
 Editor's Note: Dr Marino serves as a member of the Editorial Advisory Board for JAOA—The Journal of the American Osteopathic Association.