Neurology -- Correspondence for Laureta and Moshé, 62 (6) 864-869

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Correspondence published:

Reply to Mcabee: Solomon Moshe, MD, Emma Laureta, MD (28 June 2004)

State of training in child neurology 1997–2002: Gary N. Mcabee, DO, JD (28 June 2004)

Reply to Mcabee 28 June 2004

Solomon Moshe, MD,
Department of Neurology, Albert Einstein College of Medicine
K316, 1410 Pelham Parkway South, Bronx, NY 10461,
Emma Laureta, MD
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Re: Reply to Mcabee

moshe{at}aecom.yu.edu Solomon Moshe, MD, et al.

We wish to thank Dr. Mcabee for the interesting comments. Overall, the number of practicing pediatric neurologists appears to be diminishing as documented by the long waiting lists for patients to be seen and the ample availability of open academic positions and the 12% reduction in the number of child neurology training programs. [1]
In our report, we documented that the number of women entering child neurology programs is increasing and emphasized that this change will require restructuring the Child Neurology academic departments and practice groups to allow for more flexibility. Dr. Mcabee’s point about the possible role of fiscally-sound sub-specialty telemedicine may have to play is worth exploring.
We also agree with Dr. McAbee that it is highly unlikely that pediatric neurologists will stop managing disorders related to nervous system dysfunction and that more generalists will address pediatric neurology problems. As neurology is one of the many electives offered during a pediatric residency, not many residents choose it as an elective and their training may be inadequate. For the same reason, it is highly unlikely that a surplus of generalists will increase the pool of applicants for Child Neurology positions with its complicated training requirements including the adult year. Only with the introduction of incentives and research opportunities, training programs will become more attractive to students/physicians inclined to study brain development and dysfunction.
Our data are the first step in discussing the issues relating to the training of future pediatric neurologists with specific benchmarks in place to ascertain that the subspecialty will survive the “midlife crisis” [2] and enter the golden years.
References
1) Laureta E, Moshe SL. State of training in child neurology 1997- 2002. Neurology 2004;62:864-869.
2) Rothman S. Pediatric neurology's midlife crisis. Neurology 2004;62:845-846.

State of training in child neurology 1997–2002 28 June 2004

Gary N. Mcabee, DO, JD,
UMDNJ
42 E. Laurel Road, Suite 2100, Stratford, NJ 08084
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Re: State of training in child neurology 1997–2002

mcabeegn{at}umdnj.edu Gary N. Mcabee, DO, JD

There are several other factors that may impact some of the issues revealed in the Child Neurology Workforce Study[1]and the concerns expressed in Rothman's editorial[2] on the current and future pediatric neurology workforce. The 1990s increase in number of generalists desired by managed care organizations may have resulted in a shortage of specialists that is only temporary. If the suggestion of a surplus of general pediatricians is true, it will likely increase the number of future fellowship applicants. According to the Child Neurology and General Pediatric [3] Workforce studies, the most important issue will the be the impact of an increase in number of female child neurologists (pediatric residency pool currently at over 60% female) on future needs, since female physicians prefer to work fewer hours and see fewer patients. [3] An additional factor is the current medical student's desire of working fewer hours to control lifestyle [4], and how a career in child neurology will be perceived as being compatible with this lifestyle. Furthermore, any analysis of a needed increase for physician- shortage areas must include a discussion of the fiscally-sound role that specialty telemedicine will have in resolving such shortages. [5] The impact of all of these factors are currently speculative at best.
Rothman's perspective that a projected shortage of child neurologists may be exaggerated might be accurate, but the point that child neurologists are managing disorders that can be capably managed by generalists is influenced by societal conditions not controlled by the medical community. Increased referrals of such patients has most likely been impacted by both managed care and the malpractice crisis. With the elimination of capitation "bonus" points for fewer numbers of referrals(which had resulted in increased capitation payments), the generalist no longer had a financial incentive for taking the necessary time to manage these uncomplicated patients. Regarding other disorders (e.g. developmental delay), I question whether a generalist would be willing not only to spend the necessary time but also to assume the added liability risk to evaluate these children. Thus, in a managed-care dominated market during a malpractice crisis, it is "fiscally and risk- management" savvy to simply refer such children to a specialist.
Any efforts to contract or expand the child neurology workforce should be done cautiously as I suspect the next five years of health care, with any anticipated shortage or surplus of specialists, will be as unpredictable as the last five.
References
1) Laureta E, Moshe SL. State of training in child neurology 1997-2002. Neurology 2004;62:864-869.
2) Rothman S. Pediatric neurology's midlife crisis. Neurology 2004;62:845-846.
3) Gruskin A, Williams RG, McCabe ERB et al. Final report of the FOPE II: Specialists of the Future Workgroup. Pediatrics 2000;106(suppl):1224-1244.
4) Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173-1178.
5) Karp WB, Grisby KR, McSwiggan-Hardin M et al. Use of telemedicine for children with special health care needs. Pediatrics 2000;105:843-847.