Defining Pediatric
Subspecialty
Pediatric subspecialties are those specialties
in which a physician provides specialized
pediatric medical care beyond the scope
of primary care. There are a variety
of routes to becoming a pediatric subspecialist.
Pediatric medical subspecialists, such
as pediatric rheumatologists and pediatric
cardiologists, first complete a 3-year
residency in pediatrics and then a 3-year
fellowship in their subspecialty field.
For other fields, such as pediatric surgery,
dermatology, and anesthesiology, a physician
completes a residency in the field during
which he/she care for adults and children
and then pursues additional training exclusively
in the care of children. The American
Board of Pediatrics certifies the pediatric
medical subspecialties while other Boards
certify pediatric surgical subspecialists
and others.
The Hierarchy
of Pediatric Subspecialty Care: A Theoretical
Model
One can envision pediatric subspecialty
care as a hierarchy that depicts not only
the increasing level of specialization
among the providers involved, but also
reflects their relative numbers and geographic
dispersion (Figure A.1). At the base
family practitioners represent the most
common general providers. 76
Family practitioners, available in over
99 percent of towns with populations as
small as 10,000 to 20,000, are also the
most geographically accessible providers
of pediatric care. Pediatricians and
physicians double boarded in internal
medicine and pediatrics may be considered
more specialized than family practitioners
in the care of children. In contrast
to family practitioners, pediatricians
spend their 3 years of residency dedicated
to the treatment of the under-18 population.
While family practitioners also have a
3-year residency their training programs
includes the care of both adults and children;
therefore, their pediatric training is
less intense. Pediatricians devote their
patient care to children; consequently,
the breadth and depth of their pediatric
experience exceeds that of family practitioners
over time. Pediatricians are also less
numerous and less geographically diffuse
than family practitioners. 76
In addition to general pediatricians,
adult (internist) subspecialists may be
an important source of chronic illness
care for children and adolescents. While
adult subspecialists are not trained intensively
to treat pediatric patients, some adult
fellowships include opportunities to train
in the treatment of pediatric patients
in conditions relevant to their specialty
area. Endocrinology training, for example,
requires training in the care of adolescents
with diabetes mellitus. Thus, adult subspecialists
are a potential source of care for chronically
ill pediatric patients that may be more
specialized than the care provided by
general pediatricians. The report discusses
at length the role of internist rheumatologists
in the care of children with rheumatic
diseases.
[D]
Pediatric subspecialists are at the top
of the hierarchy for pediatric subspecialty
care. Pediatric subspecialists have the
most intensive training in the treatment
of chronically ill children and represent
the optimum source of pediatric subspecialty
care. Pediatric subspecialists treat
relatively low-incidence diseases; standard
economic location theory predicts that
these specialists will locate in large
urban areas. 77
Furthermore, the location decisions
of pediatric subspecialists may be strongly
dependent on the location of academic
medical centers.
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