ARE COMPLEX CASES IMPORTANT FOR JOB SATISFACTION?
The selection of the topic for Ulis issue of Pediatrìe Annals was based on the assumption that solving clinical puzzles, especially tricky or complex cases, is something we like, something that makes pediatrics satisfying and fun. After thinking about it, we wondered whether this is actually true. We are definitely trained to manage complex cases, but this care is stressful. Would we prefer having as few complex cases in our offices as possible?
SERIOUS PEDIATRIC MEDICAL CASES ARE DECLINING IN IMPORTANCE
How is care of difficult cases changing for the general pediatrician? One thing is clear: the common serious infectious diseases that were the core of pediatric practice are disappearing fast. The same can be said for many of the other traditional causes of childhood morbidity and mortality. The past century was marked by impressive reductions in morbidity and mortality through the introduction of vaccines, antibiotics, and improved medical care, combined with advances in technology and an increased standard of living. Infant mortality in the United States has dropped from 100 to 7 per thousand during the past 80 years. Communicable diseases, including polio, measles, and most cases of bacterial meningitis, are becoming rare.1 This is what we have worked for and it is wonderful. Nevertheless, this trend will continue and makes one ponder how it will change practice.
Most sick children seen by generalists today are basically healthy but have benign or selflimiting illnesses. This changing pattern of illness, combined with a shifting political environment, has spurred the growth of new health care professionals for children. Nurse practitioners and physician assistants earn less per hour of work than do their physician counterparts but can manage many routine problems such as otitis media, pharyngitis and upper respiratory tract infections, diarrhea, and rashes. Tney also can usually afford to spend more time with families doing anticipatory guidance, and their role in taking first call at night and telephone management for pediatricians is growing. Pediatric education and mental health specialists are addressing more problems in their fields as well.
THE IMPACT OF OTHER PHYSICIAN SPECIALISTS
At the other end of the spectrum, a growing number of children have chronic or complex diseases. Many are survivors of conditions that had been lethal in the not-too-distant past, such as prematurity, cancer, human immunodeficiency virus, or congenital heart disease. These patients and other sicker, more emergent cases are increasingly under the care of dedicated emergency center physicians, pediatric hospitalists, and subspecialists. These trends must be shifting care for many of the sicker patients away from the general pediatrician and leading to some reduction in our inpatient and procedure skills.
SOCIAL PROBLEMS ARE EXPANDING
In contrast, the challenges that the next generation of pediatricians will face will increasingly involve social, educational, and behavioral issues. Most of the problems faced by children today are social in origin. The major cause of death from age 1 year through adolescence in the United States is injury due to accidents, homicide, and suicide. The leading cause of death in this group is motor vehicle accidents. This kills adolescent boys at a rate of 48 per 100,000 population annually. Homicide is also disturbingly high, as the number two killer among adolescents. The homicide rate has actually increased dramatically across almost all races for males 15 to 24 years old, contributing to an increase in the overall homicide rate in the United States. These statistics reflect increasingly prevalent social problems of many types, including pressures on the family and the violence in our society as a whole. Suicide, the third major cause of death among adolescents, is also on the rise in that age group, even as suicide rates for the United States overall are falling.2 These problems can be viewed in two ways: as a commentary on our society's lack of progress in dealing with social problems, or as an opportunity to try to decrease child mortality, especially among adolescents. Importantly, these killers should all be preventable.
THE BOTTOM LINE
So general pediatric practice is changing. If all of the trends described above persist, prevention will occupy more and more of our time and medical management will take less and less. This means fewer challenging complex medical cases will be in our offices. Of course, all of this would change if we replaced complex medical cases with complex social cases in our practices. We are to some extent, and we have plenty of these to draw on. But we were much better trained for the management of medical problems and many of us feel disinclined and inadequate to take on many of the social, educational, and behavioral problems that are replacing "traditional" pediatric cases. We refer many of these to other professionals. This sounds depressing, at least to the authors anyway.
ARE GENERAL PEDIATRICIANS HAPPY WITH THE WAY THINGS ARE GOING?
There is evidence that we are fairly happy now. Shugerman et al. just published data about career satisfaction collected from a national sample of 1,823 general and subspecialty pediatricians and their two counterpart groups in internal medicine.3 The sample was collected and adjusted to permit generalizability for physicians in the fields surveyed. Approximately half of the sample were pediatricians, half were internists. Women were twice as prevalent among pediatricians (44% vs. 24% of the pediatric and medical generalists and 42% vs. 22% of the corresponding subspecialists were women).
General pediatricians had the highest scores of satisfaction for job, career, and specialty choice. Of the four groups, general pediatricians worked the fewest hours (50 hours per week vs. 59 for pediatric subspecialists, 55 for general internists, and 59 for medical subspecialists). They also had the lowest annual income ($126,000 vs. $156,000, $144,000, and respectively); spent the highest proportion of time seeing patients in the office (58% vs. 22%, 55%, and 41%, respectively); and spent the lowest proportion of time seeing patients in the hospital (16% vs. 44%, 20%, and 27%, respectively). The general pediatricians also had the lowest proportion of patients with complex medical histories (15% vs. 46%, 48%, and 69%, respectively) and complex psychosocial problems (17% vs. 25%, 32%, and 37%, respectively). We were also the least likely to express symptoms of job stress (18% vs. 26%, 25%, and 23%, respectively) or burnout (13% vs. 23%, 27%, and 24%, respectively).
CAREER SATISFACTION OF SUBSPECIALTY PEDIATRICIANS
Compare general and subspecialty pediatricians (the first and second numbers in each parentheses). The latter worked the hours (tied with general internists), and spent the least time in the office and the most time in the hospital. Compared with general pediatricians, our subspecialists said they permore complex medical saw more psychosocial and were much less with their careers. Also, the proportion of general versus pediatricians who said they would recommend their specialty to a medical student was 70% compared with 46%, and said they who would choose their specialty again (64% vs. 46%) plus choose medicine if they were starting over (13% vs. 23%) indicated that the subspecialty pediatricians were much less satisfied with their careers.
So here we see an inverse relationship between job satisfaction and the amount of complex and inpatient patients. General pediatricians spent much less time with these more challenging medical problems and were fairly satisfied with their careers. Pediatric subspecialists were the reverse. This suggests we would rather have fewer than more of these patients. For both pediatric groups (with the exception of annual income), lifestyle seems more directly related to job satisfaction. It looks like general pediatrics is doing just fine, whereas subspecialty pediatrics is in trouble. Consistent with this is that the proportion of pediatric residents who went on to take subspecialty fellowships decreased from 33% in 1990 to 23% in 2000.3
How can general pediatricians, who seem to be experiencing a drop in medical, especially complex medical, cases plus growing competition from other professionals for less complex medical cases, well-child care, and counseling services - and with no end to these trends in sight - be so happy, whereas subspecialists, with more challenging patients and almost certainly drifting toward a more favorable supply and demand ratio, be so dissatisfied? One possibility is that our perception that these pressures on generalists are adverse is too pessimistic and they reflect change rather than predict a bleak future. Another is that, in the short term, the generalists are happy because they are getting improvements in lifestyle, but in the longer term, subspecialty pediatric practice will have more opportunity and challenge. We are afraid the latter is the more likely scenario. Stated in another way, the general pediatricians of the future may need to redefine their roles in the care of children, lest they become victims of their own success. Next month's editorial will look at ways the general pediatrician who wants to keep more challenge in his or her practice might do so.
1. Centers for Disease Control and Prevention. U.S. Statistics for Mortality, 1999. Atlanta, GA: Centers for Disease Control and Prevention; 1999.
2. U.S. National Library of Medicine. Death among children and adolescents. In: U.S. National Library of Medicine. MEDLINE plus Medical Encyclopedia. Bethesda, MD: U.S. National Library of Medicine; May 2001.
3. Shugerman R, Linzer M, Nelson K, et al. Pediatric generalists and subspecialists: determinants of career satisfaction. Pediatrics. 2001;108:750.