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Perspectives |
1 From the Department of Pediatric Imaging, Children’s Hospital of Michigan, 3901 Beaubien Blvd, Detroit, MI 48201. Received January 21, 2000; revision requested February 2; revision received February 17; accepted February 22. Address correspondence to the author (e-mail: tslovis@med.wayne.edu).
Index terms: Children • Infants • Perspectives • Radiography, in infants and children • Radiology and radiologists, socioeconomic issues
Pediatric imaging is fun. It is exciting and stimulating, and I would not trade subspecialties with anyone. However, it is changing. To understand the changes in pediatric imaging in the new century, it is necessary to review the current trends in health care. There is a new paradigm: We have moved from the era in which hospitals were the center of pediatric care, the specialist was in demand, more imaging was better, and high technology was best. Now pediatrics is a practice without walls; we need to have patients who come from a primary-care base, and with these patients, less is better because of financial constraints. The most efficient, correct care is the best. The specialist, however, is still in demand. We must remember that access and quality at a competitive price remain the priority of health care management. Quality will eventually win out.
Pediatric imagers must align themselves with other pediatric health care providers to provide optimal care for children and continue to advocate quality pediatric care. There are three pertinent issues that warrant discussion and will help us anticipate the future: (a) the current pediatric health care environment, (b) the pediatric imaging work force, and (c) the acceptance and proper use of new technology.
Pediatric Health Care Environment
We need to know where we are in order to understand where we might be going. The current pediatric health care environment reveals the following:
1. We are on the verge of either the elimination or the modification of the most common pediatric respiratory and gastrointestinal diseases caused by respiratory syncytial virus and rotavirus, respectively (1–4). The roles of these viruses in respiratory diseases (including asthma) and gastrointestinal diseases account for a substantial portion of pediatric hospital admissions and certainly many of non–children’s hospital pediatric admissions. Most of these admissions are considered to be of low acuity. It is important to realize that, according to MediQual Systems, a health care consulting firm, 86% of pediatric medical admissions are classified as low acuity. This means that we are not able to show demonstrable differences in outcome between cases of a child being hospitalized in a tertiary center versus a child being hospitalized in a community hospital. Clearly, these cases do not require the most expensive care. It is these cases that will substantially decrease with the elimination or modification of the two most common diseases. It is on these cases that hospitals make their margin of profit.
2. Preterm births, which occur in 11% of all pregnancies, are responsible for the majority of neonatal deaths and nearly one-half of all cases of congenital neurologic disability, including cerebral palsy (5). There have been major advances in prenatal therapy with the use of maternal corticosteroid agents to promote fetal lung maturity (6). These advances have diminished the prevalences of respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. They will also decrease the number of admissions to children’s and university hospitals.
3. Cases of pediatric acquired immunodeficiency syndrome have substantially decreased with the use of antiretroviral drugs by pregnant women with human immunodeficiency virus and their infants (7). This advance, too, will decrease admissions.
4. We are using our knowledge of molecular biology to decipher the human genome and potentially have the ability to prevent severe inherited congenital diseases. This has already been achieved in individual cases of Krabbe disease and Hurler disease (8). We have begun to modify the care of or cure patients with diseases diagnosed in utero by combining imaging with surgical and/or laparoscopic techniques. A typical example is the treatment of fetuses with myelomeningocele (9).
5. There are still 11 million children in the United States without health insurance despite the various federal and state programs to eliminate this problem. This group accounts for 25% of Americans without health insurance (10).
We have to ask ourselves what diseases will children get and where will they be treated. There will always be diseases owing to the failure complications of vaccines (ie, rotavirus vaccine and the increased prevalence of intussusception) (manufacturer product withdrawal notice, Wyeth-Lederle Vaccines & Pediatrics, Madison, NJ), the mutation of infective agents, and the presence of tumors because of environmental, iatrogenic, or genetic reasons. Genetic modification, if not done correctly, may eliminate survival mechanisms and make our population vulnerable to some currently nonpathogenic infectious agents. It appears that there will be fewer children affected, but the diseases that they contract may be more severe.
The disease acuity level will no longer be mild but high, with demonstrable improvement in outcome being possible if the child is hospitalized under the care and skill of a pediatric subspecialist. In all probability, these subspecialists will be congregated in university and children’s hospitals. Although these services will generally downsize, the hospitals will turn into giant intensive care units. The need for selected subspecialists will increase rather than decrease, and the degree of burnout will be great. The financial survival of these institutions will be challenged, because most hospitals make money from the rapid turnover of less acutely ill patients rather than by treating the most severely ill patients.
Most pediatric patients will be seen in outpatient environments under whatever is the current health care vogue (eg, health maintenance organizations, offices of nurse practitioners, private clinics, etc) and will not need imaging. If necessary, images will be obtained at remote locations and delivered by means of a picture archiving and communication system (PACS) to the pediatric imager at the hospital. If more hands-on studies, such as fluoroscopy, ultrasonography (US), or computed tomography (CT), are necessary, there will be satellite locations where the pediatric imager is present at selected times to perform these examinations.
There will be more women’s and children’s hospitals created to enhance prenatal diagnoses and the treatments that are beginning to flourish. There will be perinatal centers with increasing teams consisting of the obstetrician, perinatologist, pediatric surgeon, pediatric imager, and pediatrician.
The major centers caring for children—retrenched smaller university and children’s hospitals—will be given the tasks of dealing with the "medicalization" of social diseases, such as child abuse, adolescent alcoholism, drug abuse, and suicide. Pediatric care will return to its roots and truly be proactive in preventing diseases that manifest in adulthood but originate in childhood, such as obesity, coronary arterial disease, and hypertension.
All of this can happen only if the health care of children is made a priority. It is estimated that 2.1 trillion dollars will be spent on national health care by 2007 (10). How much of this funding will be devoted to the care of children? It has been recommended during the current presidential campaign that all children younger than 18 years be covered by health insurance. If this happens, we will be able to address the major health issues of this century.
Adequate funding for pediatric graduate medical education programs is crucial. Many "experts" have said that we have too many specialists and subspecialists (11). I take the contrary view that in the health care environment of the new millennium, we will need more selected subspecialists to address the more severe health problems that we will face. Subspecialists, including pediatric imagers, will be able to be more efficient and faster and do a better job. If pediatric graduate medical education programs are funded, we will have a good chance of adding subspecialists—whose training leads to added certification—to improve the overall health care of children. It is this group that is crucial to performing research and to creating teams (see the following text) that will continue the process of eliminating pediatric diseases.
Work Force Issues: Absolute Number of Pediatric Imagers and Subspecialty Training
Currently, over 50% of the members of The Society for Pediatric Radiology are in community or university center settings practicing pediatric radiology in 25%–50% of cases. We are training 25%–35% fewer Certificate of Added Qualification–eligible pediatric radiologists than there are jobs; these jobs are equally divided among community, university, and children’s hospitals (12).
Pediatric radiologists are needed because they add value to the care of children. We are comfortable taking care of children, know the diseases, and do not blindly perform what is ordered. We are truly consultants and partners in children’s care. We create a protective environment for the child. We are advocates for children. This has more than one meaning, because we must not only carry out our traditional roles—for example, in addressing child abuse—but also push for funding of meaningful research in imaging as well as in the prevention of adult diseases that have their origin in childhood. We are the ones who will stimulate and perform with our colleagues the research that will improve the care of children.
With increased acuity of disease, there will be a substantial job shift. Those pediatric radiologists who are performing pediatric radiology in 25%–50% of cases may find that small pediatric inpatient units are closing and that they have only emergency room studies to read. They will be forced to treat many more adult patients and may well become less conversant with advances in our subspecialty. It is uncertain whether pediatric radiologists will seek new employment in larger pediatric centers or, because of geographic, family, and financial reasons, stay where they are and perform adult radiology. Clearly, those in practice the longest will be the least likely to change jobs.
There will continue to be a strong demand for pediatric radiologists, however, as the needs of children’s hospitals and universities switch to not only high-acuity inpatient work but also more outpatient subspecialty work. The typical children’s hospital had a 28% increase in outpatient volume in 1998 (13). Children’s hospitals are building free-standing subspecialty outpatient centers with adjacent hotel facilities to accommodate the needs of their patients.
We currently lack subspecialty training sites for pediatric imagers in neuroradiology and interventional radiology. Other subspecialties also are understaffed and in demand. Subspecialists will be needed in high-acuity hospitalization situations, but equally important, they will provide services—either by means of remote transmission or in person—in the free-standing subspecialty centers. There will have to be support systems (eg, laboratory, nursing, specialists, etc) to run each of these highly sophisticated operations. General pediatric radiologists also will work in these two settings—that is, high-acuity hospitals and subspecialty centers—but they will also be found in centers with a substantial nursery and a large pediatric population.
Small hospital units that provide limited pediatric subspecialty care will close. The core, highly sophisticated pediatric university and children’s hospitals more than ever will be regionalized resources, but this will take time. It will happen, however, because of the inability of small and even some moderate-size centers to secure highly trained subspecialists. Owing to the relatively self-contained location of these pediatric centers, it is highly unlikely that we will be able to "brush up" the adult interventionalist or neuroradiologist because of their lack of interest and time and, most importantly, the lack of the proper support team to treat acutely ill pediatric patients in the adult treatment setting.
Pediatric imaging will not flourish as a "plain film" specialty, and we will not be able to exist academically if we do not dedicate ourselves to the training and enhancement of the subspecialty aspects of imaging. Without subspecialty skilled people, we will either become or remain a financial burden to our hospital and department. It is important to note that if one considers intervention, neuroradiology, and nuclear medicine as important aspects of pediatric imaging, there are probably only 15–18 truly full-service pediatric imaging departments in North America. This means that there are 15–18 hospitals in which imagers trained in pediatric procedures perform these services. Intensive full-service children’s and/or university hospital pediatric imaging centers of excellence, with multiple subspecialists, clearly will be a necessity in each of the regional centers.
To survive, we must reload the pipeline of pediatric imagers and create subspecialty training sites either nationally or regionally. We must avoid diluting the sophistication of our discipline. It seems obvious to me (but clearly not to everyone) that we must reinforce the subspecialists. A major way to immediately increase our work force is to offer financial incentives to our fellows to stay 1 extra year as junior staff members subspecializing, providing some service, and getting out on their own (almost) with a safety net.
To adequately train these new subspecialists, we need to organize national or regional training centers, as The Society for Pediatric Radiology and the American Society of Pediatric Neuroradiology are doing in establishing training qualifications for pediatric neuroradiologists. To become a training center, one must qualify on the basis of volume and expert personnel. Every pediatric radiology fellowship cannot provide training in pediatric neuroradiology or interventional radiology.
After these subspecialists are trained, we must find a way to reimburse them differently from generalists. Although turf issues are less of a problem in pediatric health care, our turf will be taken from us if we do not provide services in these subspecialty areas.
Research and Education
We must change our modus operandi for doing research (14). We must be focused! We must recognize the need for dedicated individuals with PhD and MD degrees whose primary responsibilities are to do research, obtain grants, and make scientific advances. We need to realize that all pediatric imagers are not the same and are not going to do research and that only a few funded centers will have the wherewithal to do basic research.
We must evaluate our roles as educators and consider the clinician-educator track (15). We need to teach the primary care physician what to order. Our subspecialty colleagues need to learn more about new modalities that help solve their patients’ problems. Using the vast electronic network, we in the pediatric imaging community can share educational programs for all levels of education (eg, medical students, residents, and staff) (16). As radiologists, we have the most intensive one-on-one sessions with our trainees—that is, the pediatric subspecialist makes rounds several hours a day while the pediatric radiologist spends the whole day reading every film with the resident. We must find some way to give this personal attention and yet free ourselves for other duties. We must use the pediatric radiologist as a multiplier.
To reload the pipeline and get more people into pediatric imaging, I think we have to look at what our major deficits are. These are the changes that are affecting pediatric radiology and the entire field of radiology. In general, we have cycles in the number of applications for radiology programs, and the fewer the people who go into the radiology field, the fewer the people who will go into pediatric radiology. In addition, we have fewer people who have been trained in a pediatric area and then go into pediatric radiology. This is because now training in radiology takes 5 years, and an additional 1 or 2 years of fellowship make it excessive years of training. Lack of adequate funding of graduate medical education and erroneous predictions of the job strategies in pediatric radiology have further deterred entrance into the field (17).
Yet there are glib answers to our workforce problems, and these are substantial lifestyle issues. According to information in a book called Faster: The Acceleration of Just About Everything, by James Gleick (18), some things become immediately clear: "Speed is connectivity ... makes [us] more efficient. ... Sadly ... [we] feel busier, maybe even overloaded." Gleick goes on to say that the obsession of the 21th century will be real-time transmission of data and points out that we are sleeping 20% less than is beneficial to our health. We have an information surplus but do not have time to assimilate the information. We do not have time to turn information into knowledge. Remember, you cannot hurry a thoughtful opinion!
Pediatric radiologists have always been hands-on, involved imaging specialists. In this new paradigm, this means overload. We have to be there for every child’s magnetic resonance (MR) study because of sedation, and we want to check the examination so that he or she does not have to be called back. The "24-7" on-call schedule further erodes our private lives.
The findings in a new book by John Naisbitt called High Tech/High Touch: Technology and Our Search for Meaning (19) are particularly pertinent in the discussion of lifestyles. Naisbitt says that "Americans are intoxicated by technology. ... At its best, technology supports and improves human life and ... at its worse, it alienates, isolates, distorts, and destroys. We are obsessed with productivity and efficiency." The fax machine and e-mail have collapsed "response time" (19).
It is hard to describe lifestyles without discussing technology. Computers have made some things better, but they have not always lightened our load and made things easier (20). We must correct this! We must find a way to modify our behavior while still giving quality care. The answers to this problem will determine whether we succeed in attaining more successful lifestyles and in attracting people to our subspecialty.
Use of New Technology
During my professional career of 25 years, I have learned to perform US, CT, and MR imaging because these were not readily available or known modalities at the time of my training. It is probable that our new trainees are faced with substantial training in new modalities, but it is certain that they will have recertification examinations. They must not only keep up, but also learn entirely new skills. Our trainees, although certainly more computer literate than my generation, need to be pushed so that they are very comfortable with the new technology. The largest growth in technology over the foreseeable future will be in information services and dissemination of information. Determining the correct way to use these systems will be a major factor in the success of our subspecialty.
Although some of our colleagues who are already familiar with the PACS claim that there is no discernible difference in the number of consultations and hallway chats with their clinical colleagues, Reiner et al (21) reported a reduction of 82% in the person-to-person consultation rate in general radiology and of 44% in the performance of cross-sectional studies. If we are to survive, we cannot let this happen in the subspecialty of pediatric imaging. In fact, we must teach our trainees to be the most superb consultants. We may need to insert ourselves into the clinical milieu and have radiography rounds through the PACS in the ward or at the bedside (22). This is crucial in neonatal and pediatric intensive care units.
We must truly partner with other pediatric health care givers. This partnering includes bundling prices to expedite contracts from third-party payers. We must be most efficient and expedite care by using the new technology for scheduling and making sure that a consultant is available to personally handle the difficult or acute cases through all the imaging that is necessary. We must remove our blinders and immediately accept the 24-7 service mentality.
More than ever, the pediatric radiologist needs to be part of, and to be perceived as being part of, a health care team that gives value to the care of children. We can do this only by (a) being present and (b) being better at what we do—that is, having a higher level of expertise. Richard Friedenberg, MD, appropriately wrote that "If we do not encourage subspecialization in radiology, we will be encouraging all specialists to read their own images" (23). Although there are fewer turf battles in pediatric radiology than in adult radiology, there is some encroachment, particularly in the use of US. However, if we do not continually strive to have the higher level of expertise, we will compromise our subspecialty and diminish the health care of children. To expound on this further, as Lee Rogers, MD, stated in an editorial in the American Journal of Radiology (24), "Filmless radiology must not be allowed to become any impediment to teaching or research."
We need to be vigilant in performing the safest examinations in our patients. Derek Roebuck, MD, Walter Berdon, MD, and Eric Hall, DPhil, wrote a series of commentaries on the effects of radiation, Risk and Benefit in Pediatric Radiology, which appeared in Pediatric Radiology in the last several months (25–27). To correctly estimate the risks, we may need many years of follow-up and meticulous outcome research. However, to decrease the radiation dose per examination and not follow our adult counterparts and their parameters are our responsibilities. These issues have become more crucial in this new century because we have greater choices of examinations, some of which with ionizing radiation and some without.
We must apply science and technology to the imaging care of children. This means that we must become more physiologic just as we have been precise in describing anatomic detail. Those who practice nuclear medicine already do this, and those who now are integrating positron emission tomography and MR imaging are teaching us about physiology. Functional MR and MR spectroscopy and noninvasive vascular imaging are examples of this approach (28). It is this kind of physiologic-anatomic evaluation that provides the best information in the imaging subspecialties. We must continue to expand our knowledge through imaging research and apply it to the clinical services and the education of our trainees.
In conclusion, pediatric imaging is fun and adds value to the care of children. It will continue to flourish, but it will change in response to our health care environment. We must reload the pipeline of pediatric imagers, encourage subspecialization, and be creative in coordinating our professional needs with a reasonable lifestyle. To accomplish these ends, we must recognize the following:
1. Our ability to prevent or alter the course of childhood diseases will reduce the number of hospitalized pediatric patients.
2. In pediatric health care, there will be a greater prevalence of higher acuity diseases that affect fewer numbers of children.
3. This highly sophisticated care will occur in children’s and university hospitals, in large part under the supervision of subspecialists.
4. Pediatric imagers with subspecialty training will be crucial in this setting.
5. Regional training centers must be established for these subspecialists.
6. Pediatric general imagers will be needed in both this setting and in the highly sophisticated subspecialty centers that are run by these institutions.
7. The community-based practice of pediatric care will be centered in pediatrician office practices and not in hospitals. The need for pediatric imagers in this setting will diminish.
8. We must rethink our educational goals and how we accomplish them.
9. To the extent that we can alter our services for the realities of a 24-7 system and accept and/or alter new technology, we will find an acceptable new type of practice.
10. We must partner with other pediatric health care providers to expedite care, continue to be advocates for children, and be vigilant against the effects of both old and new tools. Above all, we must keep our primary focus on the children and their health. They are why we are pediatric radiologists.
ACKNOWLEDGMENTS
I thank Michele Klein Fedyshin, William Lyman, MD, and Wilbur Smith, MD, for thoughtful review of this manuscript.
FOOTNOTES
See also the commentary by Friedenberg (pp 321–322 ) in this issue.
REFERENCES
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