Correspondence Address:
Dr. Vyom Aggarwal
E21, Vijay Nagar, New Delhi - 110 009
India

Full Text

I consider myself fortunate to see tremendous growth of various pediatric subspecialties which were in their infancy when I graduated. Till then, postgraduation was a complete qualification in itself, and perhaps the end of the learning curve for most. Nowadays, pediatric residents are fortunate to graduate after being trained, grilled, and examined by doyens of pediatric subspecialties. From pediatricians with a special interest in a particular subspecialty to those practicing their field of expertise exclusively & from a few select medical colleges to hospitals across India; we have traveled a long way. Now, postgraduation implies real-time knowledge and experiential learning beyond books to attain basic competency in managing most illnesses.

The downside to the widespread development of subspecialties is the change in perspective toward the general pediatrician. The clinician himself/herself may be reluctant to deal with complex ailments that require brainstorming, intensive literature search, and discussion with colleagues; opting for the easy way out of the blind referral. If one desires a more in-depth discussion, it may even be met with a gentle rebuff by the expert. I recollect an incident when I asked a pediatric cardiologist about the importance of pressure gradient in a child with a ventricular septal defect. His reply was "Sir, why do you need this knowledge? You are going to refer such cases in any case to a cardiologist."

Then, we have our knowledgeable clientele equipped with "Google wisdom." What in fact prompted me to write this piece was a recent encounter with an educated mother; "Doctor, my 7-year-old child has been having headaches, body pains, and abdominal pain for 3 months. I have consulted a gastroenterologist, neurologist, ophthalmologist, orthopedician, and psychologist, but the symptoms do not resolve." I asked her if she had been referred to these experts by her pediatrician, wondering why she had chosen to entrust me with the care of her child. Her response disturbed me deeply. "I only visit my pediatrician for routine vaccinations or ailments such as cough and cold. The severity of these complaints made me decide to see these consultants, without wasting any time. Someone suggested that I seek guidance from you about whom to go to next." Imagine my frustration. The only solace is that subspecialties such as "vaccine (ology)" and "cough (ology)" have not emerged yet. We are safe for the time being!

Without a doubt, the evolution of subspecialties has improved patient care and outcomes. The latest technology and minimal invasive interventions are being adopted. Guidelines are being framed and revised, ensuring ongoing education of our brethren. Our unique health-care system allows patients to directly avail expert services immediately or within a reasonable timeframe, at no expense or an affordable cost; compare the fees of a practicing retired professor from AIIMS with a Supreme Court senior advocate of equal experience. A concrete diagnosis gets established and appropriate treatment is initiated in no time at all.

Nonetheless, a general pediatrician is the best person for a holistic evaluation. A complete diagnosis is made rather than a piecemeal one pertaining to a particular system; the child is managed as a whole. Specialists often fail to comment on clinical findings that lie outside their system of interest. They seldom outline the treatment of anemia, failure to thrive, or the plan for an unimmunized child. A referral that emanates through a general pediatrician has usually been worked up thoroughly, has a correct diagnosis, and even has preliminary evidence-based initial therapy. At the end of the day, both professionals are important for the child. To avoid being designated as a "Jukhaam – Bukhaar ka doctor" (doctor of cough and cold), we must maintain our standards, by attending conferences, reading journals, pro-actively learning from each encounter, and not simply referring anyone who seems challenging!

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