Pediatric Referral Patterns

The article by Forrest et al,¹ and the commentary by Ferris,² do not mention the main reason for the disparity in subspecialty consultations. The reason is a shift in the training philosophy of the pediatric resident. Years ago, pediatric house officers were taught: "You will be a specialist in the care of children." Today's pediatric resident, however, receives a different, double message: "You will be a specialist in the care of children but you will not be good enough to care for complex problems in infectious disease, neurology, cardiology, gastroenterology, developmental medicine, and so on. Complicated (interesting) patients must be referred for diagnosis and care to the pertinent subspecialist."

This mantra does little for the self-image of the general pediatric resident. Ask today's house officer for a treatment plan for a child with any complicated problem, and the response is: "We need a (subspecialty) consult." This philosophy carries over into the practice years, leading the pediatrician to assume the function of a triage physician for children. This is the real reason for the many subspecialty consults in the United States.

What is the reason for the change in philosophy? Years ago, there were few pediatric subspecialists, and because of their patient load, they trained pediatric residents to handle the everyday, "bread and butter" problems in their subspecialty. This did wonders for the future pediatrician's self-assuredness. Now, the plethora of pediatric subspecialists cannot survive financially without referrals, so there is less incentive for subspecialist teachers to train house officers in the skills necessary to handle the common problems in their specialty.

This is also the reason for the change in what pediatricians actually do. Pediatricians once attended cesarean sections and complicated deliveries. They hospitalized and treated their own patients, saw after-hours emergencies, and took care of all of their patients' medical needs from birth through adolescence. The pediatrician was involved. The pediatrician was needed. Many of today's pediatricians prefer not to attend cesarean section births and do not want to nor do they feel competent to handle the hospitalized patient. Consequently, the pediatrician has given up the care of the cases that make pediatrics so fascinating and satisfying. It is just "simpler" to refer the patient.

There is no question, many complicated pediatric patients do need subspecialty referral and care. However, certainly, pediatricians in the United States and the United Kingdom, should be able to take care of most of the more complicated patients without a subspecialty referral.