Indian Pediatrics 2000;37: 173-178
|Pediatric Tertiary Care and Subspecialities in the New Millennium|
From the Apollo Center for Advanced Pediatrics, Apollo Indraprastha Hospital, New Delhi 110 044, India.
Reprint requests: Dr. R.N. Srivastava, Consultant Pediatric Nephrologist, Co-ordinator Apollo Centre for Advanced Pediatrics, Apollo Indraprastha Hospital, New Delhi 110 044, India.
During the last 3-4 decades a phenomenal progress has taken place in the medical field. Most extraordinary advances in understanding of the mechnisms of disease, formulation of new pharamaceuticals, diagnostic technology, availability of sophisticated medical equipment and application of computers have revolu-tionised patient care. Along with these developments medical superspecialities have come about with a very high level of clinical expertise, which is necessary for applying knowledge and tools for the treatment of patients. For adult patients the specialities took roots about 40 years back and thereafter kept pace with burgeoning medical knowledge. State of the art therapeutic facilites (e.g., open transplantation, major cardiac surgery, neuro-surgery, ICU care) are now available to adults in developed countries as well as at a number of centers in many developing countries. However, while children also receive such services in the former, in a majority of developing countries they have been largely denied the benefits of advanced medical management.
Pediatric Tertiary Care
Pediatric care can be primary, secondary and tertiary. Primary care can be delivered by a MBBS doctor and secondary care (whether ambulatory or hospital based) by a trained pediatrician. Tertiary care for children includes management of complex and often recurrent or chronic disorders of various organ systems (medical and surgical), care of the sick and small neonate and comprehensive care of the critically ill child. Such care must be undertaken by pediatric subspecialists.
Delivery of Pediatric Tertiary Care
Children with complex and complicated disorders are best managed by pediatricians having special training and experience in the related speciality. Treatment by general pediatricians is insufficient and that by adult specialist inappropriate. Very often manage-ment of serious diseases of various organ systems requires involvement of a team of specialists and other supportive experts (e.g., nutritionist, physiotherapist). However, the primary responsibility rests with the pediatric subspecialist. Other specialists participating in tertiary pediatric care, particularly in the fields of radiodiagnosis and nuclear medicine, diagnostic laboratory services (pathology, microbiology, biochemistry, immunology) should also have up to date knowledge of pediatric diseases and regularly interact with pediatric specialists.
Tertiary pediatric care is ideally undertaken at a hospital exclusively meant for children. Besides medical specialists such a center should have appropriately trained nursing and other staff. The equipment should be specially meant for pediatric care. The attitude of the entire staff and the services and the ambience must be child-and family friendly. Unfortunately, no such hospital exists in the country and is unlikely to come in view of the necessary extremely high financial inputs. A few "Institutes of Child Health" and Children's Hospitals in different parts essentially provide secondary level care catering to a large volume of patients. Financial constraints and a lack of well trained specialists have precluded the development of tertiary care at these centers.
Pediatric Tertiary Care in India
Pediatric subspecialities have been very poorly developed in India with the result that children with complex conditions of various organ systems and critically ill patients continue to receive inadequate and suboptimal care. Regrettably, pediatricians themselves are to blame for the neglect of such a vital component of the care of sick children. Several years ago Pediatrics was accepted as a separate discipline and the importance of special expertise in the management of sick children, particularly of the newborn and infant, and the importance of growth and development were recognized. Initially there was resistance from physicians, which was gradually overcome and pediatrics became well established. However, Pediatrics, unlike Internal Medicine, has remained a general discipline. Over the years various subspecialities of medicine evolved to a high degree, which has been reflected in availability of quality tertiary care to adult patients. Pediatric subspecialities have not been developed because pediatricians have continued to regard Pediatrics as a broad discipline with emphasis on preventive pediatrics and general care. There is little appreciation that special training and in-depth knowledge are necessary to manage difficult systemic disorders of children and the very sick child. Untenable arguments (`child as a whole', `holistic care',) have been put forward to oppose tertiary and specialist care and to camouflage the lack of effort necessary to develop pediatric specialities.
Speciality Chapters of IAP
In 1987 the IAP took a very important decision to constitute speciality chapters(1) with an aim to develop expertise in pediatric specialities and encourage education and training. Over the years some of the chapters (e.g., gastroenterology, hematology-oncology) have grown rapidly, while some others (e.g., cardiology, endocrinology) remain very small. The chapters have done a commendable job holding a large number of CMEs and conferences and imparting training to medical and other staff, focusing on early recognition of disorders, proper management and timely referral. Unfortunately, the number of ade-quately trained pediatric subspecialists in different fields and that of Pediatric Speciality units remains very small (the latter, of course, cannot develop without the former). Neo-natology is the notable exception. The National Neonatology Forum was formed in 1980 as a separate body and played a crucial role in the establishment and promotion of newborn care and training of medical and nursing staff. There are a large number of highly competent neonatologists (many trained at leading centres abroad) and many excellent newborn units in the country. One of the reasons for recognition of neonatology as a special discipline was the fact that most pediatricians did not feel competent to treat the sick neonate unless they had received appropriate training in newborn care. The same logic should apply when treating older children with difficult problems needing specialist care!
Establishment of Pediatric Specialities
The most immediate action that can be taken is to start Pediatric Speciality Divisions at the Departments of Pediatrics of the medical colleges having 5 or more faculty staff. Many of them have varying degrees of facilities for newborn care and expertise in neonatology and all should strive to establish secondary level care. Some of the leading centers particularly those conducting the DM Neonatology program should develop level three care.
Provision of ICU management for older children should also be a priority since such care leads to survival of a good proportion of critically ill children. A separate, well equipped and adequately staffed Pediatric ICU has to be the ultimate goal but to start with, a few inpatient beds, in an area which can be closely monitored, can be designated for intensive care. It should have a greater provision of medical and nursing staff, and life saving drugs and equipment should be made available. Well trained Pediatric Intensivists are a rarity in the country but such training (for medical and nursing staff) can be provided at a number of centers. Joint efforts should be made to provide ICU care with one consultant having the overall responsibility.
Among other specialities gastroenterology and hepatology, hematology-oncology, and nephrology have a higher tertiary care workload and may have priority for development. The number of inpatients in various disciplines at a given hospital is an important factor in the provision of financial and personnel inputs. However, it would be difficult to demand major support for Pediatric specialities on that basis since the number of patients requiring tertiary care is likely to be small. In some specialities, children with diagnostic problems are evaluated as outpatients, but again they form a very small fraction of the total number of pediatric outpatients. The argument that pediatricians must put forward is that the purpose of establishing pediatric specialities is to provide state-of-the-art care to children wtih complex disorders and critically ill children (besides their role in the advancement of teaching and research) and that such care, widely available to adult patients, must not be denied to children.
There is very little information about the number of children needing tertiary care as well the incidence of complex recurrent or chronic conditions that require expert evaluation. At the All India Institute of Medical Sciences, children with acute renal failure constitute about 1% of inpatients and those with malignancies about 5%. Analysis of mortality data in hospitals indicates that a significant proportion of children die within 24 hours of reporting to hospital. It is likely that many of such patients (and other critically ill patients) can be saved with ICU care. Data from general practice are also lacking. It is estimated that a general pediatrician might see a patient with nephro- tic syndrome, diabetes mellitus, rheumatoid arthritis, severe hypertension and acute leukemia in 1 to 3 years. However, the incidence of patients with liver diseases, complicated urinary tract infections, diagnostic hematological problems, abnormalities of growth and development and neurological and genetic disorders is high. All of these require specialist evaluation. The uncommon occur-rence of some of the conditions is counteracted by the large child population of the country. A careful maintenance of records and a proper referral system will be required to obtain accurate information on the incidence of problems such as cited above and the inpatient work load.
Starting Speciality Divisions
A given speciality division should be started by a faculty member who has obtained some training in that speciality. The minimum period of such intensive, hands-on training (available within the country) should be three months but longer periods are preferred. A speciality outpatient clinic should be established and the faculty member allowed to take care of the inpatients in that speciality. The senior faculty should offer all support in this endeavour. In turn the subspecialist must show a deep commitment to his chosen field and strive to achieve the objectives. He should establish diagnostic and treatment modalities with help form other departments and teach and train resident and nursing staff. Experience has shown that if sustained and serious efforts are made resources are forthcoming.
A few of the large corporate hospitals in the private sector have attempted to establish pediatric specialities with some success. Such centers would seem to be ideally placed for that purpose, since costly equipment and other facilities need not be provided exclusively for children and their use for adult patients would justify the heavy investment. However, financial considerations dictate patient care at such hospitals, where pediatric patients are often treated by adult specialists. More unfortunately, pediatricians do not refer their patients to pediatric specialists. General physicians are mostly unaware of pediatric subspeciality facilities. A team approach must be developed in which the specialist manages the organ system disorder and the general pediatrician takes care of other problems, both sharing the total responsibility.
Training in Pediatric Specialities
A training programme in neonatology leading to a degree of DM has been established at four centers. In no other subspeciality such a facility exists. Besides a lack of enthusiasm and effort, there seems to be very little demand for pediatric specialists to justify such training! (Both the Medical Council of India and the National Board of Examiners have not shown any interest in pediatric specialities). Pediatric specialists and general pediatricians are at par when being considered for academic positions.
This unfortunate situation will exist until speciality divisions are established requiring to be manned by those with a qualification of DM or its equivalent. In the interim short and long-term training, sufficient to start a speciality division, should be made available at a number of designated centers. Financial support for such training should be provided. IAP speciality chapters have made some efforts but the Academy itself must give high priority to the need for advanced training and try to obtain funds from every possible source to establish training fellowships. The IAP has instituted a few fellowships but the financial support offered is pitifully small and these are underutilized. In contrast, those with more reasonable support (e.g., one offered by the Australian College of Pediatrics) attract a large number of applicants. The training centers are located in large metro cities where accommodation is prohibitively expensive. These issues must be addressed by the IAP, its speciality chapters and the training Institutions. The IAP should persuade Pharmaceutical and Industrial houses to support pediatric speciality training. Hitherto their very generous assistance has mostly been used for holding conferences and CME programmes.
A more extensive training with emphasis on laboratory research and therapeutic application of "high tech" equipment is ideally obtained in one of the advanced countries. The recently started IAP's collaboration with the American Academy of Pediatrics should be utilized for that purpose. The IAP speciality chapters should establish academic links with their counterparts in other countries, which must not be limited to CMEs and conferences. Their assistance must be sought for quality training, and strengthening research.
Cost of Speciality and Tertiary Care
Contrary to widespread misgivings, much of tertiary care is not prohibitively expensive. Judicious use of investigative procedures, avoiding unnecessary costly methods and treatment modalities (measures that apply to practice of medicine in general), can keep the costs down. Every Department of Pediatrics need not set up expensive laboratory facilitis and attempt complex investigative procedures that may be used only occasionally. Such tests are being made available at several private laboratories and have been found to be reliable. However, urgent laboratory tests needed for the management of critically ill children must be available. Equipment should be obtained in a well-planned and phased manner and must not be kept idle. Charitable trusts can be established and financial support obtained to support the cost of treatment for patients with chronic disorders.
The cost factor of tertiary care becomes crucial when prolonged ICU care is needed particularly with ventilatory support. Examples of such situations include neonates with sepsis and respiratory insufficiency, critically ill infants and older children with shock and multiorgan failure and complications of major surgery. It is obvious that only a few, highly equipped centres will be able to manage such cases. Ethical and moral issues become very important in decision making in such situations and would need to be addressed by the treating center.
Cooperation and Networking
Pediatric speciality division would need to cooperate with their counterparts in Internal medicine and seek their assistance especially for investigative facilities. Academic interaction is also important and good interpersonal relation-ships are mutually beneficial. Networking among Pediatric specialists in the region and sharing of knowledge and experience should be established. The pediatric departments should also keep in touch with general pediatricians as well as physicians (who still treat pediatric patients) and keep them informed of the tertiary care facilities available at their centers. Early referral is crucial in the management of seriously ill children. Infants and children with uncommon and diagnostic problems also need prompt referral to the pediatric subspecialist. The latter in his turn must regard the general pediatrician as an equal partner in the provision of optimal care to the child patient.
Pediatric Subspecialities, Teaching and Research
Establishment of pediatric subspecialities at the departments of Pediatrics will greatly augment the quality of teaching and training of the MD Pediatrics programme. With rapidly expanding knowledge in various fields of Pediatrics, it is not possible for the general pediatrician to acquire the depth and insight into all areas. It is important that new information is presented and discussed at various teaching sessions.
The development of pediatric subspecialities would have a very favorable impact on research. The MD Pediatrics training program requires conduction of independent research work and presenting it in the form of a thesis that must be approved by external experts. The effort and inputs that go into this activity are not commensurate with the outcome. The work is rarely of any significance and is seldom published in a reputed journal. The pediatric subspecialist will be in a much better position to select a topic for research and guide the student and even within the constraints of resources and time the output is more likely to be of relevance. The speciality divisions should have ongoing, long-term research programs and the student could be asked to take up one aspect of a given study. He may not have to set up laboratory methods just for his own project and his time and effort would be better channeled and MD thesis will not be considered just a punishment.
A lack of development of pediatric specialities in the country has resulted in virtual denial of tertiary care to children with complex organ system disorders and critically ill children. We need to make concerted efforts to develop specialities and establish pediatric speciality units at medical colleges and major hospitals.
Appropriate training facilities should be made available, for which the IAP should assume a major responsibility. Development of pediatric specialities would also have a very favourable impact on pediatric teaching and research.
1. Srivastava RN. Pediatric subspecialities. Indian Pediatr 1987; 24: 6 99- 701.