Career focus

Paediatrics

With almost as wide a range of subspecialties as medicine itself, paediatrics is paradoxically a specialty for generalists. Vin Diwakar, Mike Hocking, and Janet Anderson explain how to get started.

A career in paediatrics has something for everyone. Its scope ranges from the forefront of technology in the neonatal intensive care unit to the complex and sensitive issues of child protection in the community. Paediatricians do more than treat sick children; they are advocates for child health, ensuring that children's rights and needs are reflected in social, public, and health policy, locally, nationally, and internationally.

There are two main fields of paediatrics: general paediatrics practised in hospital and in the community and the paediatric specialties. During training, doctors will spend some time in each. However, most develop a specialist interest in addition to general paediatrics, and some will concentrate on that alone. Consultant paediatricians working in district general hospitals are likely to have commitments in hospital and community. Those based in teaching hospitals are mostly single system specialists, although they also provide a general service.

 

Pros and cons of paediatrics Attractions Variety of challenges ranging from acute illnesses to chronic diseases Hospital and community based approaches needed Range of skills needed for children from prematurity to adolescence Dealing with young patients in the context of people around them (parents, extended family, peers, school)   Opportunity to take part in large multidisciplinary teams Good opportunities for flexible training   Overseas work encouraged   Research encouraged but not mandatory   Large number of different career paths possible   Not overspecialised: all paths require some skills of a generalist Drawbacks Heavy service commitment with sleep deprivation Emotionally demanding Little scope for private practice   Heavy demand for child health services with limited resources   Political commitment to expanding the consultant base not established

General paediatrics
Most acutely ill children requiring hospital admission are treated by general paediatricians in district hospitals. General paediatricians also see most outpatient referrals for medical opinions in children in general outpatient clinics. A vast range of illnesses is seen, from the common problems of infancy such as failure to thrive or behavioural difficulties to the diagnosis and long term management of more serious acute and chronic childhood illnesses such as severe asthma, cystic fibrosis, diabetes, epilepsy, and cancer. Taking account of the impact of an illness on the child's social, psychological, and emotional development is important.

The propensity of children to become ill and recover quickly leads to a rapid turnover of patients on paediatric wards. This has given rise to the concept of "ambulatory paediatrics,"1 in which the care of sick children and their families is coordinated as much as possible out of the hospital setting with the involvement of primary, secondary, and tertiary staff.

Community child health
Prevention and surveillance of illness in children is generally performed by general practitioners or by paediatricians working in community child health in close collaboration with health visitors and school nurses. Essential parts of their work include:

		Health education
		Immunisation
		Early detection of disability
		Developmental screening
		School health
		Complex special needs and disability
		Behavioural disorders
		Child protection (identification and management of cases)
		Multidisciplinary working with education and social services.

Some community paediatricians develop expertise in disability, audiology, or child protection.

Paediatric specialties
The specialties of paediatrics are the same as those of adult medicine, with the addition of neonatal medicine and developmental paediatrics. Usually based in university teaching hospitals with specialist equipment, therapists, and clinical and research laboratories, these specialists accept referrals from district general hospitals over a wide geographical area.

Neonatal medicine is the largest specialty and is found in most hospitals. Neonatologists look after all aspects of the perinatal and postnatal care of babies from 24 weeks onwards. They work closely with obstetric colleagues in counselling the families of high risk babies and those with antenatally diagnosed abnormalities. Many of the newest paediatric advances are in neonatal intensive care, improving the survival of the smallest patients with the best possible outcomes.

General training
Paediatric training may begin in the preregistration year with a four month post combined with adult medicine and surgery, from general practice vocational training schemes, from general professional training in accident and emergency (where over 25% of attendees are children), and from general professional training in general paediatrics, community paediatrics, neonatal medicine, and specialties. A few trainees enter from adult specialties such as paediatric cardiology, haematology, or immunology, having developed an interest in its paediatric aspects.

Senior house officer posts in paediatrics often provide the first exposure to the specialty, as there are few preregistration house officer posts. The minimum training for entry into higher specialist training is two years, during which the paediatric option of the MRCP(UK) or the MRCPCH examination must be passed (current regulations).2 Posts in general, neonatal (with separate senior house officer on-call rota), community, and specialty paediatrics allow breadth of training. As entry into the specialist registrar grade is becoming increasingly competitive,3 participation in audit, presentations, publications, and development of guidelines is encouraged to enhance curricula vitae. Most trainees spend at least three years in general professional training. Experience in primary care or overseas is an advantage.

The syllabus and training record gives trainees an opportunity to record their experience.4 Educational supervisors should ensure that the educational objectives of the early years are met.

The diploma of child health is now organised and owned by the Royal College of Paediatrics and Child Health (RCPCH) and covers the broader issues of child health in community and hospital. It is suitable for all aspiring paediatricians and those pursuing a career in primary care and others who wish to work with children. Before the RCPCH was established, the Royal Colleges of Physicians examined for paediatric membership in two parts that comprised the MRCP (UK). We are currently in transition: the membership of the Royal College of Paediatrics and Child Health (MRCPCH) replaces the paediatric option of MRCP (UK) from September 1999. The format is unchanged but is under review.5

Specialist registrar posts
The average length of specialist registrar training is five years.6 The first two years are in the core specialties of general, community, and neonatal paediatrics, after which trainees can pursue special interests. A small number of trainees confine themselves to one system specialty and may require longer training. They cannot take part in general paediatric on-call duties when they reach consultant level. There is concern that the supply of trainees in some subspecialties may outstrip demand. Most trainees are currently advised to maintain some general paediatric skills.

Structured systems of appraisal, mentoring, and education are being developed. Progress through the system is by annual assessments, which are likely to involve reports from educational supervisors and portfolio reviews. Some trainees undertake a higher degree in the form of an MSc during specialist registrar training, but such courses are not compulsory. Paediatric cardiology is currently part of the remit of the Royal College of Physicians.

Academic paediatrics
Improving the health of children depends on research. Most of those who aspire to academic excellence take time out of the specialist registrar programme to complete MD or PhD degrees. Universities recognise the need for robustly supported and protected research fellows.7 There is a problem with recruitment to clinical research posts,8 but some tertiary specialties are presently oversupplied with trainees, All doctors are encouraged to take an interest in research methodology, service evaluation, and audit.

Working abroad
The learning opportunities presented by experience overseas are viewed positively by paediatricians.9 There are no hard and fast rules about where and when to go; most trainees are advised to have at least two years' postregistration experience behind them, and most prefer to have exams out of the way.

Flexible training
Paediatrics is particularly sympathetic to the needs of trainees who wish to train flexibly. Any trainee can do so for the right reasons, but women with child rearing commitments form the largest group. In paediatrics, 66% of trainees are women, 20% of women in all training grades work flexibly; 7% of consultant paediatricians currently work flexibly, and the forecast is for the proportion to rise.4 All regions have a paediatric flexible training advisor.

Consultant opportunities
There should be adequate job opportunities when trainees reach the end of their training. Moreover, information about likely opportunities in different paediatric subspecialties should be available to trainees early in their careers, so that they can model their training appropriately. The royal college is trying to estimate trends in consultant numbers by monitoring the career intentions of specialist registrars and carrying out regular censuses of all doctors in paediatrics.4 The information is not perfect. All those seeking careers in paediatrics should seek advice from tutors, supervisors, and college regional advisors regularly.

Children and their families need doctors with imagination, vision, leadership, and determination. Paediatricians are united in this common purpose. The range of career pathways possible within paediatrics is vast, and children need doctors with every sort of skill. The work is hard but rewarding. For doctors who are uncertain about their future career, a junior post in paediatrics will be invaluable to their future patients.

Vin Diwakar, specialist registrar,
Birmingham Children's Hospital,
Mike Hocking, consultant paediatrician,
Birmingham Children's Hospital,
Janet Anderson, consultant paediatrician,
New Cross Hospital,
Wolverhampton,
and officer for general professional training,
Royal College of Paediatrics and Child Health,
50 Hallam Street,
London W1N 6DE.
0171 307 5600.
email: enquiries{at}rcpch.ac.uk
URL: http://www.rcpch.ac.uk

References

1 Meates M. Ambulatory paediatrics - making a difference. Arch Dis Child 1997;76:468-76.

2 Royal College of Paediatrics and Child Health. Paediatric training handbook. London: RCPCH, (in press).

3 Royal College of Paediatrics and Child Health. The medical workforce in paediatrics and child health 1995-1997. London: RCPCH, 1998.

4 Royal College of Paediatrics and Child Health. Syllabus and training record for general professional trainees in paediatrics and child health. London: RCPCH, 1997.

5 Royal College of Paediatrics and Child Health. Examination handbook. London: RCPCH, 1999.

6 Department of Health. A guide to specialist registrar training. London: DoH, 1998.

7 Aynsley Green A. What's to be done about the malaise in science training in paediatrics and child health? Arch Dis Child 1998;78:101-4.

8 UK paediatric clinical research under threat. Arch Dis Child 1997;77:1-3.

9 Costello AMdeL, Eunson PD. Opportunities in the developing world - a guide for paediatricians in training. Curr Paediatr 1996;6:114-8.

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