Paediatric health care – It's time to move forward

The Canadian Paediatric Society's recent report entitled, Planning a Healthy Future for Canada's Children and Youth (1), is a document that all paediatricians, present and future, must read. As future paediatricians, residents will feel the effects of the looming crisis in child health care, and need to be educated about what is currently involved in the practice of paediatrics and the anticipated changes in the field. One of the most pronounced findings in the survey is the level of ‘burnout’ experienced by many physicians. The greater spectrum of responsibilities of paediatricians is, in large part, to blame for this burnout. In this competitive era of academic medicine, there is a greater pressure on paediatricians to have a research practice, teaching practice and administrative practice, in addition to practising clinical paediatrics and maintaining skills through professional development. The role of a paediatrician is expanding and the strain is showing. Most residents, although not yet in practice, feel the pressure to perform in many areas other than clinical paediatrics. Many training programs place significant emphasis on research and publication, as well as teaching medical students who are often starting their clerkships with rudimentary paediatric knowledge. The clinical demands on paediatric residents are also greater than those in many other specialties because there are fewer funded positions for residency training in paediatrics, given that the size of the patient population that they treat. In addition to feeling the strain, residents bear witness to the negative effect of the current climate of paediatrics on their teachers and mentors. Most paediatricians have, at some point, known of an attending paediatrician who took time off because of work-related stress or left their current position for a practice that offered more flexibility, more appropriate remuneration and less stress. In these situations, too often there are great responsibilities and not enough people to do the work. In some hospitals, subspecialists are holding up a department on their own, and are suffering negative health consequences. It is difficult for a paediatrician to maintain a high standard in all areas of his/her practice without something suffering. Given that the care of a child should always come first, it is not unheard of for resident teaching to be cancelled because the only staff that is available for teaching in a specific discipline is called away for a patient care issue. In a time when we need to be training the (fewer) residents to help deal with the manpower crisis, this problem is worrisome. More paediatricians are needed, so that they may each be able to deliver health care to children, and properly train future paediatricians to be safe and efficient. In the report by the Canadian Paediatric Society (1), it was noted that research suggests that younger physicians, particularly women, work fewer hours than their older counterparts. Also, nearly half of the younger paediatricians are women. Research has shown that female paediatricians work fewer hours than male paediatricians (2), although the average part-time paediatrician works 37 h/week (1). Young physicians may place a great deal of value on family life, and recognize the importance of spending time with loved ones. They may be more likely to advocate for part-time working hours, or maternity or paternity leave. Many paediatric residents have chosen paediatrics as a career, and are giving higher priority to family and personal life than in the past. Some residents are also interested in basic science or clinical research, and want a career that offers them the flexibility to pursue both clinical paediatrics and research as well as a somewhat normal family life. In 2000, only 60 paediatric residents graduated from Canadian programs and 40 paediatricians retired. A significant proportion of newly trained paediatricians do not practise paediatrics in Canada (brain drain to other countries, administration roles). For those residents who do stay in Canada, the possibility of having the type of career that they hope for is small because they will have even greater responsibilities to make up for those who retire or choose not to practise clinical paediatrics. This clinical scenario inevitably contributes to the problem of burnout. Although these are issues facing all paediatricians and paediatric residents, the greater problem is that faced by children in smaller communities, who do not have health care access equal to that of children in urban areas. Over 80% of paediatricians in Canada work in cities with populations in excess of 100,000, and 40% of current paediatricians are expected to retire within the next eight years. The results of the 1999–2000 Paediatrician Resource Planning Survey (2) indicate that there is a significant decline in younger paediatricians, likely the result of fewer medical schools and paediatric resident training positions than in the past. All of this adds up to a more dismal future for a child who need paediatric care in a rural community. Because there is a greater need for community-based consultant paediatricians, residency programs should place greater emphasis on the value of community-based training. Most of the time in paediatric training is spent in a tertiary care centre, in part because of the need for subspecialty training. Residents have difficulty obtaining more community-based, general paediatrics training because there is a relatively small number of residents and they have commitments to on-call duties at tertiary care centres. Part of the solution to the looming shortage of community paediatricians in rural areas is to encourage paediatric residents to seek experiences in such places so that they may develop the skills essential to a community paediatrician. This would also serve as an opportunity to develop a greater interest in serving a smaller community, where paediatricians would have a tremendous positive impact on the health of children in those communities. Children in rural or remote areas have greater difficulty accessing quality health care than children in urban areas, in part, this is due to the greater travel time and distance to specialized paediatric services. The gap in quality of health care that exists between children living in these different areas needs to be closed. For this closure to happen, it is essential that attitudes toward the health care needs of Canadian children change and that policymakers recognize these needs. The current working environment of paediatricians facing burnout needs to be ameliorated with adequate peer support, fair remuneration and job flexibility so that the lives of paediatricians are enhanced and, consequently, their productivity is optimized. Of course, it is essential that more paediatric training positions become available, and that the pursuit of a career in community paediatrics is encouraged and valued. We need to continue to advocate for an increase in the number of paediatricians serving Canada's children and for enhanced communication between community paediatricians and academic centre-based subspecialists. Perhaps, if this gap is closed, all Canadian children will get a fair chance at health care.

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