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VOLUME 50 NOVEMBER 1972 NUMBER 5
COMMENTARIES
DO
WE
REALLY
NEED
MORE
PEDIATRICIANS?
F
OR some years we have been convincedthat the United States was suffering
from a great lack of pediatricians. Every
overworked pediatrician shares this view. A
recent review1 argues that double the
cur-rent number of pediatricians are needed for
the country. But there are some straws in
the wind that make me believe we should
reconsider this current “conventional
wis-dom.” In planning for health manpower, as
in other fields, we have usually been guilty
of preparing to fight the last war. We
would be ill advised to overproduce
pedia-tricians, for to do so would risk the same
disenchantment among pediatricians that
has occurred with the current
overproduc-tion of aerospace engineers and some Ph.D.
scientists. It takes ten years from entry to
medical school and five to seven more
ears at graduation to complete education
and military service to be ready for
prac-tice. We need to look at his needs a decade hence, not just today.
There are several forces affecting the
need for pediatricians in the future, some
leading to an increase in need and sonic to
a decrease. Exactly what the balance will
be is hard to predict at this point, but it
does seem to me we should examine the
question carefully and prepare for future
shock, rather than be caught unprepared.
TOTAL QUANTITATIVE NEED FOR PEDIATRICIANS IN THE U.S.
The major factor increasing the need for
pediatricians in the past 30 years has been
the rapid decline in the number of family
physicians who, in years past, provided the
majority of primary care for children. In the
Academy of Pediatrics survey in 1949,2 it
was estimated that half of all health
ser-vices for children in the United States was
provided by general practitioners and only
one-fourth by pediatricians. In our own
stir-veys in upstate New York in the past four
to five years, this figure has been reversed,
and now 50% of all services for children
are provided by pediatricians and only
one-fourth by general practitioners. In 1940
there were 345 general practitioners per
100,000 people. Today this has fallen to less than 100, while at the same time pediatri-cians have only slightly more than doubled
from about 7 per 100,000 to 18 per 100,000
total population. Certainly if this trend con-tinues, the need is for more pediatricians.
In addition, there are many children who
have not received care to date. With better
payment mechanisms financial barriers will
be lowered and greater demands made for
pediatric services.
Yet from other viewpoints, the shortage
of pediatricians may not be as great as it
appears. There is a mild upsurge in interest in family practice, coupled with an increase
in recruitment to pediatrics. There are
be-tween 60 and 70 million children in the
United States today, depending upon
where one cuts the age, 15, 16, or 17 years
of age, etc. If each pediatrician cares for
2,000 to 2,500 of them, this would require
approximately 30,000 pediatricians to care
682 MORE PEDIATRICIANS?
for all children in the United States. We
now have somewhere about 18,000.
How-ever, if family doctors take care of
one-fourth today, this reduces the need for
pe-diatricians to about 23,000, leaving a gap of
only about 5,000 to meet the need. In
effi-cient primary care systems such as the
Kai-ser-Portland Plan, one pediatrician per
3,000 children seems to suffice, and if this
were the mode of care throughout the
country, this increase in productivity, or of
number of children cared for per
pediatri-cian, would alone yield an adequate
num-ber of pediatricians per children.
UNEVEN DISTRIBUTION
One of the major problems in providing
health care for all children in the United
States, as for providing other health
ser-vices, is the uneven distribution between
states. The proportion varies widely, with
New York State having one pediatrician per
2,000, while Nevada has only one per 7,500.
Within states, pediatricians are
concen-trated in cities, especially white suburbs,
with low concentrations in Black and
Span-ish speaking ghettos and rural areas.
How-ever, producing more pediatricians alone
has not to date increased the distribution into these areas of need.
DECREASING NUMBERS OF CHILDREN
Probably the most important factor in
de-terniining the number of pediatricians
needed in the future will be the number of
children, and here the birth rate drop has
been so striking in the past few years that
one must seriously consider whether our
current production of pediatricians will not
be adequate. In Monroe County in upstate
New York, the birth rate per 1,000
popula-tion in 1966 was 19.2, and had fallen to 18.6
by 1970, presumably largely as a result of
greater use of family planning. However, in
one \ear, 1971, the birth rate fell by nearly
20 to 15.3 per thousand, apparently
al-most entirely as the result of the
introduc-(ion of legalized abortion. Nationally, the
1971 birth rate was 17.3, the lowest to date.
A continuation of this low or lower birth
rate for five to ten years and its extension to
other areas of the United States, would
alone lead to enough pediatricians per chil-dren within five to ten years.
INCREASEDUSE OF ALLIED HEALTH MANPOWER
After Dr. Henry Silver’s introduction of
the pediatric nurse practitioner in the
mid-60’s, many groups throughout the country
have enthusiastically accepted this
innova-tion. In Rochester, New York, without a
large scale program, we have produced 35
pediatric nurse practitioners in the last
three years, who we estimate are the equiv-alent of some 12 to 15 full-time
pediatri-cians in their work productivity. In a
county with some 65 practicing
pediatri-cians, this represents an increase of over
20% in equivalent pediatric manpower in
three years.
INCREASED EFFECTIVENESS OF PREVENTIVE MEASURES
With the introduction and widespread
use of vaccines, the incidence of acute
in-fectious disease has continued to decline.
Poliomyelitis, rubeola, rubella, and mumps
are only the latest in the whole series of
effective vaccinations. With still others,
such as effective Hemophilus influenzae,
meningococcus, and possibly respiratory
syncytial virus vaccines on the horizon
there will be a further reduction of serious
infectious disease incidence among
chil-dren, again reducing the need for pediatri-cians who practice in the classic way.
THE EFFECTIVENESS OF NEW METHODS OF DELIVERY OF HEALTH CARE
Much of the hospital care of children has
in the past few years been due to the lack
of early treatment for common infectious
diseases such as vomiting and diarrhea and
pneumonia among the indigent population.
With the introduction of neighborhood
health centers, and children and youth
proj-ects, there has been a reduction in the use
of emergency rooms, and of hospitalizations
re-COMNIENTARIES 68:3
(hieing the need for hospital-based
pediatri-(IUI1S and expensive pediatric services.
Bal-aticed against this has been the increased
use of I)ediatricians in the health centers, in
areas of communities where previously
there were none.
EFFECTIVENESS OF HEALTH SERVICES
Finally, with society recognizing that the
provision of health services alone does not
increase health as much as we have
thought, and with third party payers
in-creasingly critical of what benefits they are
l)uying for their health dollar, there may
well be a decreased willingness to pay for
national health services. Such services as
the recommended 10 or 12 well child visits
in the first year of life for all children may
come under increasing attack as
unneces-sary, because they yield little increase in
health for the investment. Such a move will
also decrease the need for pediatricians.
NEW ROLES
Counter-balancing all of these factors
ducing the demand for pediatricians, the
major opposing factor ‘ill be those needs
of children never yet adequately met-the
consequences of developmental, behavioral, and social problems. Today, pediatricians
are being asked to serve in entirely new
roles: as consultants not onI’ to schools but also to the head start programs, drug crisis centers, and mental health proj’cts. \Vliik’ l
cannot predict the mans- future changes
that will similarly increase tlit’
respotisihuli-ties of tomorrow’s pediatricians, I wouki
confidently speculate that we do not need
more pediatricians than we are currently
producing,
if
they contiiiue to do what they have been doing in the past.if,
however, their distribution is changed by encourage-ment to settle in areas with low pediatrician to children ratios, andif
they take oii sonic of the new roles society is asking of them,we may not only need more but we will
certainly need new kinds of pediatricians. ROBERT
J.
HAGGRTY, Ml). Department of Pediatrics University of Rochester Rochester, New YorkREFERENCES
1. Schonfeld, FL. K., Heston, j. F., and Falk, I. S.:
Numbers of physicians required for primary medical care. New Eng. J. Med., 286:571,
1972.
2. Child Health Services and Pediatric Education: Report of the American Academy of Pediat-rics, The Commonwealth Fund, New York, 1949 survey.
3. Mason, H. R.: Manpower needs by specialty.
JAMA, 219:1621, 1972.
PLASMA
INFUSION
THERAPY
FOR
HURLER’S
SYNDROME
E
VER since the first report from Houstonof the “plasma infusion” approach to
modification of the Hurler’s syndrome
pic-ture’ there has been a wide popular feeling
that the beginnings of a “treatment” were at
hand for this group of inborn error diseases. Intriguing data on alteration of the pattern
of urinary mucopolysaccharide excretion,
and, to some extent, of the children’s
clini-cal manifestations, opened a real hope that
a substantial mechanism existed for
render-ing more normal the skewed metabolism of
these patients. In addition, the authors
commented that “human plasma infusions
seemed to fit the recommendations”
given in a previous Pr.inAllucs
Comnien-tary2 for theoretically useful therapeutic tri-als of new materials in patients with inborn error syndromes.
If indeed one assumes that most of these
hereditary conditions can be accepted as
the expression of a deficient specific
lysoso-mal hydrolase activity, then the most
pri-mal therapy would be in the area of
“re-placement” by some broad means. And
since virtually all such enzymes are
detect-able in normal plasma, this medium could