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VOLUME 50 NOVEMBER 1972 NUMBER 5

COMMENTARIES

DO

WE

REALLY

NEED

MORE

PEDIATRICIANS?

F

OR some years we have been convinced

that 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

(2)

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

(3)

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, and

if

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 York

REFERENCES

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 Houston

of 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

(4)

1972;50;681

Pediatrics

Robert J. Haggerty

DO WE REALLY NEED MORE PEDIATRICIANS?

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1972;50;681

Pediatrics

Robert J. Haggerty

DO WE REALLY NEED MORE PEDIATRICIANS?

http://pediatrics.aappublications.org/content/50/5/681

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

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