920
patients.1o In teaching hospitals acute, high labour intensive such as neonatology have first call on resources and children with developmental and behavioural problems are generally seen in ambulatory and community settings. The survey reported provides further strong evidence that, at least in Australia, there is a substantial mismatch between paediatric practice and training. I suggest that such surveys are essential when setting the agenda for what is likely to become a more lively debate in many countrieswhat should be the content of paediatric training programmes?
Mismatch between paediatric training and
most
paediatric practice
areas
SllR,-In much of the English-speaking world there have been changes in paediatric training to take into account altered practice patterns. However, assertions that there is a "new paediatric morbidity", that new models of training and practice should be introduced,2 and that more attention needs to be paid to training in the new morbidity are largely unsubstantiated by any calls for
reliable data.3 An American study suggested that paediatricians were spending more time on developmental and psychosocial problemsand one study from Australia indicated many children had conditions with a largely psychosocial aetiology.5 These two studies apart, all information about a "new morbidity" is anecdotal. On the other hand there has been widespread criticism of the content of paediatric training and paediatricians do seem to perceive gaps in their training 67even though morbidity data are lacking. I report here a questionnaire survey of Australian paediatricians to obtain data on whether the content of paediatric practice was changing and whether paediatricians perceived their training as having been adequate. The vast majority of consultant paediatricians in Australia are members of the Australian College of Paediatrics, which publishes a directory of members, who are asked to nominate a specialty interest, if any. The questionnaire was sent in 1985 to all College members who did not designate themselves as subspecialists and could thus be regarded as consultant general paediatricians. 287 questionnaires were mailed. Anonymity of respondents was preserved. The response rate was 80-9%. For eight of the conditions commonly held to comprise "the new morbidity" in paediatrics respondents were asked to indicate whether there had been an increase or decrease in numbers of these patients seen in the past five years. For all eight conditions there was a striking increase: /ne/eae
Co/7c//f/bn Condition Behavioural problems,
hyperactivity
Developmental delay
Learning and school problems Enuresis, encopresis Child at risk/abuse Need for parent/family
counselling
Headache/abdominal pain Adolescent problems All (average)
Increase (%) 50-5.5 348 57.5.5 22-6 46-7 672 34-8.8 41 7 44.5
/Vo No
c/M/e (5y.)
change 44.8.8 61.0 40-6 66.0 .0 453 31-5 63-8.8 52-6.6 50-7
Remaining % accounted for by decrease or by "can’t say" or missing data Paediatricians considered their training in the traditional
subspecialty areas such as infectious diseases, respiratory medicine, and gastroenterology to have been appropriate. For nine such subspecialties the averages were 57-4% "just right", and 16-8% and 16-4% "too much" or "too little" emphasis, respectively. However, their training in the "new morbidity" areas had been, they thought, inadequate, especially in behavioural paediatrics, adolescent medicine, parent counselling, and the care of children with chronic handicaps: Area of training
Psychiatry Behavioural paediatrics Child development Adolescent medicine Community child health Parent counselling Genetic counselling Chronic handicaps All (average)
Just right
Too little
(%)
(%)
18-8 .9 13.9 24-4 106 18 3 115 38-8 .8 13-9 18-8
66-1 74-2 .2 66.0 78-4 68.3.3 78-4 42-0 .0 77.4 68-9.9
Do training programmes arm paediatricians with the skills they need to address the sorts of problem they will have to confront? The results of this study suggest not. Suggestions for changes in training include getting paediatric experience in outpatient settings, in paediatricians’ offices,8 and in community hospitals,9 one concern being that in the large teaching hospitals where training has traditionally been done doctors are exposed not only to a small, biased segment of morbidity in childhood but also to models of diagnosis and delivery of care that are not relevant to the needs of
Department of Ambulatory Paediatrics, Royal Children’s Hospital, Parkville, Victoria 3052, Australia
FRANK OBERKLAID
1. Haggerty RJ, Roghmann KJ, Plass IB. Child health and the community. New York John Wiley, 1975. 2. Engel GL. The need for a new medical model. a challenge for biomedicine. Science 1977, 196: 129-36 3. Pines A. Burnout: a current problem in paediatrics Curr Prob Pediatr 1981; 11: 11 4. Burnett RD, Bell LS. Projecting pediatric practice patterns. Pediatrics 1978; 62 (suppl 1): 625-80. 5. Dugdale AE, Chandler D. Specialist paediatric practice today Lancet 1977; i: 1298-99. 6. Dworkin PH, Shonkoff JP, Leviton A, Levine MD. Training in developmental pediatrics: how practitioners perceive the gaps. Am JDis Child 1979; 133: 709-12 7. Feldman W, Milner R, Punthakee N. Canadian paediatricians: demographic characteristics, perception of training, and continuing medical education. Can Med Assoc J 1980, 123: 185-89 8. McKay RJ. The academic pediatrician and the practising paediatrician. Am J Dis Child 1985; 139: 39-40. the community hospitals Child 1983; 137: 902-06. 10. Rogers DE, Blenden RJ The academic medical center: institution. N Engl Med 1970; 298: 940-50. J 9.
Charney E. Secondary care. the role of
in pediatrics Am J Dis a
stressed American
Cost of oral screening SIR,-Recent reports have highlighted the need
for increased
screening to detect oral cancer, 1,2 the morbidity of which is similar to that of cervical cancer.1 Indeed, it seems likely that if we are to improve the prognosis for oral cancer, then the diagnosis has to be made at an earlier stage, especially since treatment has not much improved prognosisAlthough reasons for delay in diagnosis have been investigated,4,5 diagnosis is dependent on the attendance of the patient at the doctor’s or dentist’s surgery. In the UK free dental examination was abolished from Jan I, 1989. Thus all patients over school age and in employment are now required to pay a fee for an assessment of their dental and oral mucosal health. Oral cancer and indeed oral mucosal abnormalities are more common with advancing age.6 This makes the screening of those over 50 years all the more important. However, there is evidence that this age group is less likely to seek a regular oral
check-up.
Although the effect of the examination fee on patient attendance is
not
yet clear, the 1988 adult dental health survey7 shows
a
pronounced trend towards a decrease in regular attendance with increasing age. Although this is marked by a proportionately higher prevalence of loss of teeth with advancing age, all people over 50 are at an increased risk of mouth cancer, irrespective of dental state. This may be particularly important in Scotland, where the incidence of oral cancer is higher than that in England and Wales8 but yet the proportion of regular attenders is lower.’ Those without teeth are less likely to seek a regular inspection of their mouths, often attending only when they feel something is wrong. Unfortunately, oral cancer is often symptomless in its early stages,9 and this presents an even greater difficulty since very few people usually examine their oral cavity. Although oral cancer does not arise exclusively in unskilled manual workers, it certainly is seen more frequently within that group than in non-manual workers. Once again the very group at an increased risk of oral cancer is less likely to seek regular dental treatment..7 Will the revenue accrued from the examination fee outweigh the increased cost to the NHS of treating dental and oral mucosal lesions that present at an advanced stage owing to a delay in diagnosis, if patients are less inclined to seek regular examination? It is not acceptable that a patient can obtain a free mouth inspection from his doctor but not his dental surgeon. One hopes that we shall not have to wait for the next adult dental health survey before the
patients.1o In teaching hospitals acute, high labour intensive such as neonatology have first call on resources and children with developmental and behavioural problems are generally seen in ambulatory and community settings. The survey reported provides further strong evidence that, at least in Australia, there is a substantial mismatch between paediatric practice and training. I suggest that such surveys are essential when setting the agenda for what is likely to become a more lively debate in many countrieswhat should be the content of paediatric training programmes?
Mismatch between paediatric training and
most
paediatric practice
areas
SllR,-In much of the English-speaking world there have been changes in paediatric training to take into account altered practice patterns. However, assertions that there is a "new paediatric morbidity", that new models of training and practice should be introduced,2 and that more attention needs to be paid to training in the new morbidity are largely unsubstantiated by any calls for
reliable data.3 An American study suggested that paediatricians were spending more time on developmental and psychosocial problemsand one study from Australia indicated many children had conditions with a largely psychosocial aetiology.5 These two studies apart, all information about a "new morbidity" is anecdotal. On the other hand there has been widespread criticism of the content of paediatric training and paediatricians do seem to perceive gaps in their training 67even though morbidity data are lacking. I report here a questionnaire survey of Australian paediatricians to obtain data on whether the content of paediatric practice was changing and whether paediatricians perceived their training as having been adequate. The vast majority of consultant paediatricians in Australia are members of the Australian College of Paediatrics, which publishes a directory of members, who are asked to nominate a specialty interest, if any. The questionnaire was sent in 1985 to all College members who did not designate themselves as subspecialists and could thus be regarded as consultant general paediatricians. 287 questionnaires were mailed. Anonymity of respondents was preserved. The response rate was 80-9%. For eight of the conditions commonly held to comprise "the new morbidity" in paediatrics respondents were asked to indicate whether there had been an increase or decrease in numbers of these patients seen in the past five years. For all eight conditions there was a striking increase: /ne/eae
Co/7c//f/bn Condition Behavioural problems,
hyperactivity
Developmental delay
Learning and school problems Enuresis, encopresis Child at risk/abuse Need for parent/family
counselling
Headache/abdominal pain Adolescent problems All (average)
Increase (%) 50-5.5 348 57.5.5 22-6 46-7 672 34-8.8 41 7 44.5
/Vo No
c/M/e (5y.)
change 44.8.8 61.0 40-6 66.0 .0 453 31-5 63-8.8 52-6.6 50-7
Remaining % accounted for by decrease or by "can’t say" or missing data Paediatricians considered their training in the traditional
subspecialty areas such as infectious diseases, respiratory medicine, and gastroenterology to have been appropriate. For nine such subspecialties the averages were 57-4% "just right", and 16-8% and 16-4% "too much" or "too little" emphasis, respectively. However, their training in the "new morbidity" areas had been, they thought, inadequate, especially in behavioural paediatrics, adolescent medicine, parent counselling, and the care of children with chronic handicaps: Area of training
Psychiatry Behavioural paediatrics Child development Adolescent medicine Community child health Parent counselling Genetic counselling Chronic handicaps All (average)
Just right
Too little
(%)
(%)
18-8 .9 13.9 24-4 106 18 3 115 38-8 .8 13-9 18-8
66-1 74-2 .2 66.0 78-4 68.3.3 78-4 42-0 .0 77.4 68-9.9
Do training programmes arm paediatricians with the skills they need to address the sorts of problem they will have to confront? The results of this study suggest not. Suggestions for changes in training include getting paediatric experience in outpatient settings, in paediatricians’ offices,8 and in community hospitals,9 one concern being that in the large teaching hospitals where training has traditionally been done doctors are exposed not only to a small, biased segment of morbidity in childhood but also to models of diagnosis and delivery of care that are not relevant to the needs of
Department of Ambulatory Paediatrics, Royal Children’s Hospital, Parkville, Victoria 3052, Australia
FRANK OBERKLAID
1. Haggerty RJ, Roghmann KJ, Plass IB. Child health and the community. New York John Wiley, 1975. 2. Engel GL. The need for a new medical model. a challenge for biomedicine. Science 1977, 196: 129-36 3. Pines A. Burnout: a current problem in paediatrics Curr Prob Pediatr 1981; 11: 11 4. Burnett RD, Bell LS. Projecting pediatric practice patterns. Pediatrics 1978; 62 (suppl 1): 625-80. 5. Dugdale AE, Chandler D. Specialist paediatric practice today Lancet 1977; i: 1298-99. 6. Dworkin PH, Shonkoff JP, Leviton A, Levine MD. Training in developmental pediatrics: how practitioners perceive the gaps. Am JDis Child 1979; 133: 709-12 7. Feldman W, Milner R, Punthakee N. Canadian paediatricians: demographic characteristics, perception of training, and continuing medical education. Can Med Assoc J 1980, 123: 185-89 8. McKay RJ. The academic pediatrician and the practising paediatrician. Am J Dis Child 1985; 139: 39-40. the community hospitals Child 1983; 137: 902-06. 10. Rogers DE, Blenden RJ The academic medical center: institution. N Engl Med 1970; 298: 940-50. J 9.
Charney E. Secondary care. the role of
in pediatrics Am J Dis a
stressed American
Cost of oral screening SIR,-Recent reports have highlighted the need
for increased
screening to detect oral cancer, 1,2 the morbidity of which is similar to that of cervical cancer.1 Indeed, it seems likely that if we are to improve the prognosis for oral cancer, then the diagnosis has to be made at an earlier stage, especially since treatment has not much improved prognosisAlthough reasons for delay in diagnosis have been investigated,4,5 diagnosis is dependent on the attendance of the patient at the doctor’s or dentist’s surgery. In the UK free dental examination was abolished from Jan I, 1989. Thus all patients over school age and in employment are now required to pay a fee for an assessment of their dental and oral mucosal health. Oral cancer and indeed oral mucosal abnormalities are more common with advancing age.6 This makes the screening of those over 50 years all the more important. However, there is evidence that this age group is less likely to seek a regular oral
check-up.
Although the effect of the examination fee on patient attendance is
not
yet clear, the 1988 adult dental health survey7 shows
a
pronounced trend towards a decrease in regular attendance with increasing age. Although this is marked by a proportionately higher prevalence of loss of teeth with advancing age, all people over 50 are at an increased risk of mouth cancer, irrespective of dental state. This may be particularly important in Scotland, where the incidence of oral cancer is higher than that in England and Wales8 but yet the proportion of regular attenders is lower.’ Those without teeth are less likely to seek a regular inspection of their mouths, often attending only when they feel something is wrong. Unfortunately, oral cancer is often symptomless in its early stages,9 and this presents an even greater difficulty since very few people usually examine their oral cavity. Although oral cancer does not arise exclusively in unskilled manual workers, it certainly is seen more frequently within that group than in non-manual workers. Once again the very group at an increased risk of oral cancer is less likely to seek regular dental treatment..7 Will the revenue accrued from the examination fee outweigh the increased cost to the NHS of treating dental and oral mucosal lesions that present at an advanced stage owing to a delay in diagnosis, if patients are less inclined to seek regular examination? It is not acceptable that a patient can obtain a free mouth inspection from his doctor but not his dental surgeon. One hopes that we shall not have to wait for the next adult dental health survey before the
