The importance of generalism in academic pediatrics


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Excerpt

With increasingly subspecialized disease-specific care, continual financial pressures on academic medical centers, and the success of preventive care taken for granted, the critical role of general pediatrics can often be overlooked in academic centers [1].The introduction of 17 pediatric subspecialty boards during the past few decades illustrates the increased specialization in pediatrics, as well as the growing ‘gatekeeper’ or referral role of general pediatricians [2]. In the past 2 decades, negotiated fees and decreased reimbursement rates have affected the operating margins of medical centers, particularly for non-procedure-based specialties, such as general pediatrics [3]. Finally, many adults today have never witnessed the diseases that general pediatricians continue to help control through primary care immunizations. Such complacency in preventive care undervalues the impact of primary care pediatrics. In this setting, the academic general pediatrician has been described as an ‘endangered species’ [4].Ironically, although described as ‘general’, the field of general pediatrics adds specific expertise, skills, and perspective that are vital to any academic medical center. A selection of these key contributions is highlighted below, in relation to the mission of a larger pediatric department.Expertise in disease prevention and screeningGeneral pediatricians work at the ‘front line’ and add specific expertise to primary and secondary prevention of disease. Primary prevention is averting the occurrence of a disease through specific interventions such as immunizations, or general patient education or counseling to prevent injury [5]. Secondary prevention includes attempts to slow or halt the progression of a disease through screening. Unlike faculty in other subspecialties, generalists not only treat acute disease but also routinely engage in primary (e.g., anticipatory guidance at well child visits) and secondary prevention (e.g., screening for anemia, lead poisoning, developmental delay) [6]. Even the decision to refer a patient to a subspecialist is basically a screening process. Without this key expertise in prevention and screening, an academic pediatric department becomes ‘reactive’ to disease, rather than proactive in the detection, prevention, and eradication of disease.An ‘outward’ perspectiveGeneralists add a specific perspective in viewing children in a broader context. While research in pediatric subspecialties focuses ‘within’ the patient (e.g., by organ system), research in general pediatrics looks ‘outward’. For example, research focusing on the family (e.g., the best methods to assist families in managing chronic disease), the community (e.g., how perceptions of community safety affect how often children engage in outdoor exercise), the healthcare system (e.g., how early discharge affects quality of care), cultural norms and beliefs (e.g., how differing perceptions of disease affect healthcare-seeking behavior), and healthcare policy (e.g., how the structure of a federal immunization program affects receipt of immunizations) are all natural extensions of clinical interactions in general pediatrics. Without this key perspective, a pediatric department cannot fully contribute to the public dialogue regarding pediatric healthcare in the context of the community, system, or policy.Continuity of careGeneralists model and provide continuity of care, which allows the provision of a ‘medical home’ for patients with even the most complicated conditions through coordination of services and consolidation of medical information [7]. Generalists help families interpret and synthesize complicated information that they receive from different sources into a management care plan. Generalists also ensure that the focus for patients with complicated conditions includes attention to interactions with family members, peers, and other caregivers (i.e., school personnel); activities for school and recreation; and overall child development and growth.Continuity of care is a key component of resident training and managed care arrangements [8,9].

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