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William T. Couldwell, MD, is editor of the AANS Bulletin He is professor and Joseph J. Yager Chair of the Department of Neurosurgery at the University of Utah School of Medicine |
The Institute of Medicine’s June 2006 report on emergency care highlighted the national problem of children’s access to such care, including their access to emergency neurosurgical care.
As a neurosurgeon who typically provides pediatric care for only unusual skull base and vascular cases, I offer my thoughts on the issue and provide some suggestions for solutions to this current problem. The main issues can be summarized as follows:
ER Coverage Crisis There is limited availability of pediatric neurosurgery coverage in many regions of the country. This limited availability is delaying care for emergent neurosurgical problems because pediatric patients must be transferred to a regional children’s hospital with dedicated pediatric neurosurgeons.
Reduced Reimbursement There is a large and apparently increasing number of uninsured and underinsured families, which translates to increasing numbers of people, including children, presenting to the ER and stressing the available resources. In addition, physician reimbursement levels for providing pediatric services are less than for the equivalent services provided to adults, creating a disincentive to care for children.
Waning Workforce Few graduates of neurosurgical residencies—fewer than 10 individuals per year entering pediatric fellowship training for the last several years—are interested in pursuing careers in pediatric neurosurgery. The number of pediatric neurosurgeons retiring approximates the current number entering the subspecialty, which portends a larger problem in the future. The pediatric neurosurgical shortage is far more extreme than that for general neurosurgery.
What Are Our Potential Solutions?
Neurosurgeons must cover pediatric neurosurgical emergencies. Neurosurgeons
must increase their participation in the coverage of pediatric neurosurgical
emergencies such as shunt malfunction and head or spine trauma. These are routine
procedures and remain part of core neurosurgical training and competency. To
enhance coverage of pediatric critical emergencies and to avoid delay of patient
care with transfer, there should be a general understanding and acknowledgement
as a specialty that pediatric emergency care does not require advanced training
beyond residency. Such acknowledgement should help neutralize the perception
that providing pediatric care will increase one’s liability.
It should be noted that currently there are no neurosurgical subspecialty certificates issued by the American Board of Neurological Surgery; recently, the directors of the ABNS reviewed this issue at length and for the present have decided not to proceed with subspecialty certificates. Instead, to reflect the true mix of the individual’s practice, recognition for subspecialty practice will be through the ABNS Maintenance of Certification process. This decision supports the reality that many subspecialty areas significantly overlap those of general neurosurgery, and further that formal recognition of a subspecialty area can produce disenfranchisement of the generalist who is providing important care in subspecialty areas.
Better financial support must be provided. While better reimbursement for pediatric neurosurgical procedures is a long-term goal, in the short term, given the relatively poor reimbursement for these procedures, increased financial support of pediatric neurosurgeons is necessary. While one source of such support has been through cross-subsidization in large neurosurgical groups, other sources exist. For example, hospital reimbursement for Medicaid in most states is quite reasonable, and the hospital often sustains a profit for this care. Many institutions now are recognizing this and are able to help surgical subspecialties through support of medical directorships or pay for on-call activity. Additionally, given the limited availability of such providers in most areas, children’s hospitals such as our own in Utah have been successful in negotiating enhanced reimbursement from third parties for pediatric tertiary care.
More neurosurgical trainees must be encouraged to pursue careers in pediatric neurosurgery. Part of the solution lies in the specialty sharing the load of covering pediatric emergencies and in finding ways to curtail financial disincentives for providing pediatric care. In addition, good mentorship is crucial to encouraging careers in pediatric neurosurgery. In our own neurosurgical department, neurosurgeons in the pediatric group function as excellent mentors for our residents, many of whom have subsequently sought pediatric fellowship training, and the department currently is far exceeding the national percentages of residents entering the pediatric neurosurgery subspecialty.
To solve neurosurgery’s current and worsening problem in the coverage of emergency pediatric neurosurgery requires a combined effort as a specialty. The first step is recognition of the problem; given the limited number of pediatric subspecialists, all neurosurgeons will have to pitch in until the availability of pediatric subspecialists increases to meet demand.