Adolescent medicine: A new paediatric subspecialty in Canada

Over the past 30 years in Canada, adolescent medicine has achieved a distinct role within the field of paediatrics. An increasing number of Canadian paediatricians have chosen to subspecialize in adolescent medicine, despite the fact that it had not previously been a certified sub-specialty in the country. Until quite recently, paediatricians who were interested in pursuing subspecialty training in this field either trained in the United States where adolescent medicine had been accredited since 1994, or completed subspecialty training in one of a small number of nonaccredited programs in Canada (The Hospital for Sick Children [Toronto, Ontario], Montreal Children's Hospital and Sainte-Justine UHC [Montreal, Quebec]). A combination of changes in clinical practice, scientific advances, paediatric training needs and expectations, a growing adolescent population and societal changes have contributed to defining the need for this new field within paediatrics (1). Over the past three years, a group of Canadian paediatricians with subspecialty training in adolescent medicine have pursued paediatric subspecialty certification for adolescent medicine through the Royal College of Physicians and Surgeons of Canada (RCPSC). This endeavour has met with success, and adolescent medicine has recently been recognized by the RCPSC as a subspecialty of paediatrics. Adolescence is a unique developmental period when young people experience pivotal biological, psychological, social and cognitive changes as they transition from childhood to adulthood. Adolescent medicine subspecialists focus on the comprehensive assessment and treatment of complex adolescent health issues within the context of these major biopsychosocial events that define this developmental life stage. It is widely accepted that practicing medicine with adolescents is very different from caring for infants, younger children and adults. The scientific literature has reinforced this belief. There is a growth of peer-reviewed scholarly research that is being published in specialized adolescent medical journals and in medical journals of broader interest. For instance, advances have been made in understanding that adolescence is a remarkable and unique time for profound brain growth and development (2). There has also been a new appreciation of the relationship between puberty and the dramatic changes in neuroendocrine function (3,4), helping to better characterize this transition from childhood to adulthood. Great strides have been made in the diagnosis and management of diseases and disorders typically seen during adolescence, for example, eating disorders, substance use and abuse, and the management of chronic medical illnesses during adolescence (5). Additionally, new information regarding mental disorders in adolescence, particularly involving the use of psychotropic medications in their treatment, has contributed to further understanding about how this age group differs from both younger and older populations (6). New developments in gynecological diagnostic technologies, including the treatment of sexually transmitted infections (7–10) and new contraceptive methods (11), have also played a role in defining aspects unique to treating adolescents. Finally, adolescent medicine has played a pivotal role as a leader in promoting interdisciplinary approaches to clinical care and health research. These achievements have had a dramatic impact on furthering the subspecialty of adolescent medicine. In addition to a rise in the numbers of Canadian youth in general, enhanced medical care and technology has resulted in many children with chronic conditions surviving to adolescent years and beyond. It is estimated that up to 98% of children diagnosed with a chronic health condition now reach 20 years of age. Some of these chronic illnesses include HIV, asthma, diabetes, systemic lupus erythematosus, cystic fibrosis, spina bifida, cancer and cardiovascular disease. Over the past 25 years, the survival rate for children with cystic fibrosis has increased by 700%; for spina bifida, the increase has been 200%; and for congenital heart disease, the increase has been 300% (12). With this shift in survival into adolescence, there is a growing need for trained adolescent medicine specialists with expertise in caring for the complexities of youth with chronic health conditions. The demand for services for adolescents will continue to grow with both the population expansion and ongoing advances in paediatric care and technology. In addition to this pressing need to provide in-depth and comprehensive training in adolescent medicine for individuals who intend to do subspecialty training in this area, there is the need for expertise and resources to train core paediatric residents as well. Adolescent medicine is now a requirement of core paediatric residency training by the RCPSC, and there are still paediatric programs in Canada that lack the expertise and resources in this field to adequately instruct trainees. Despite this clearly recognized need for additional adolescent medicine subspecialists in Canada, there is already a shortage of qualified people to fill currently available positions. Over the next five years, this situation will worsen because a number of positions currently filled will also become available as individuals in the latter stages of their careers retire. Additionally, the number of newly created positions should grow as the subspecialty gains recognition in Canada. This demand for additional adolescent medicine resources will result in the need for more subspecialty training programs that are able to educate physicians in a comprehensive and standardized way. The recognition of adolescent medicine by the RCPSC as a paediatric subspecialty will accomplish the following: The highest quality of care focused on improving the health outcomes and well-being of Canadian adolescents and their families. Adolescent medicine specialists will enhance the coordination of developmentally appropriate care provided to adolescents, offer consultation and assistance with respect to the appreciation and integration of adolescent-specific issues in their treatment plans, and play an advocacy role for the involvement of the young person in treatment decisions. The net result of these changes will be improved treatment outcomes for Canadian youth. Continued focus on the development of new scientific advances in the field of adolescent medicine. Recent advancements have included an increased understanding of the neurobiology of adolescence (3,4), vaccine development (ie, human papillomavirus) (13,14) and transition of care from the paediatric to the adult health care system (15). All illustrate a profound influence on the health of adolescents. New research advances and clinical initiatives are essential for better health practices and outcomes. Adolescent medicine-trained subspecialists will play an important role in the development, transfer and dissemination of this knowledge to adolescents, their families, communities and other health care professionals caring for young people. Further support for the inclusion of adolescent medicine as a critical component of paediatric residency programs. The RCPSC has supported the need for such emphasis. Currently, paediatric residents have inconsistent training in this area, even though many new paediatricians will eventually provide general health care to this age group. In fact, in 1995, the Canadian Paediatric Society conducted a review (unpublished data) of the adolescent medicine content of paediatric residency training programs in Canadian medical schools that revealed serious inadequacies. Additionally, a recent Canadian study (16) reported on the practicing paediatricians' perceptions of their paediatric residency training as preparation for their current clinical practice. Forty-six per cent believed that they were not adequately prepared in adolescent medicine, and identified this area as a specific training need (16). Attention must be paid to ensuring that there is training and support for paediatric residents and fellows, as well as physicians and allied health professionals caring for adolescents. Additionally, a major educational role of the adolescent medicine specialist will be to work directly with youth, their families and the community at large around relevant topics in adolescent health. Enhancement of the adolescent medicine component of paediatric training programs, inclusion of continuing educational efforts addressing adolescent health topics and the provision of educational sessions to the lay public will all serve to improve the general health and well-being of adolescents. An accredited adolescent medicine training program is more likely to attract the highest quality trainee, and retain paediatricians for subspecialty training. Canadian paediatricians interested in pursuing a career in adolescent medicine will train and practice in a country where adolescent medicine is an accredited subspecialty because such programs have established rigorous standards for subspecialty training and ongoing monitoring of the training programs. They are recognized for the additional level of training they receive and compensation is commensurate with their level of training. Such programs provide an academic infrastructure that supports research, teaching, clinical care and advocacy in adolescent medicine, as well as provide opportunities for interested paediatricians to pursue an academic career in adolescent medicine. Clinical care for adolescents with complex biopsychosocial health problems can be time- and resource-intensive, involving multidisciplinary meetings and coordination with other health care professionals. Accreditation will likely result in a greater number of training positions in adolescent medicine, attend to the short supply of subspecialists, and address the funding inequities and compensation issues related to comprehensive and specialized clinical services. Improved access to adolescent-trained subspecialists could potentially result in cost savings to the health care system and better quality of care for the adolescent patient by decreasing unnecessary utilization of emergency rooms, multiple clinic visits to various health care providers and possibly even a reduction in unwarranted investigations. We are delighted to report that adolescent medicine is now the 63rd recognized discipline of the RCPSC and a subspecialty of paediatrics. Undoubtedly, adolescents, their families, the community and health care providers will all reap the benefits of the recognition of this new paediatric subspecialty. The authors (Debra K Katzman, Eudice Goldberg and Jean-Yves Frappier) were on the Committee that prepared the Royal College of Physicians and Surgeons of Canada's application for recognition of adolescent medicine as a paediatric subpseciality, along with Karen Leslie (The Hospital for Sick Children, Toronto, Ontario); Franziska Baltzer, Giosi Di Meglio and Suzanne McDonald (Montreal Children's Hospital, Montreal, Quebec); Sheri Findlay (McMaster University, Hamilton, Ontario); and Jorge Pinzon and Rosemary M Malleson (BC Children's Hospital, Vancouver, British Columbia).

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