From the Chair
What Happens When Our Patients Grow Up? Taking on a Tough Topic: Transitional Care
In the past, pediatric neurosurgeons were fundamentally self-taught. They designated themselves as a loose confederation of mutually supportive surgeons who focused their practice in pediatrics as they developed the techniques and methods necessary to their evolving subspecialty.
Technical advances and improved equipment have allowed pediatric neurosurgeons to successfully manage many congenital problems experienced by our patients. Children with hydrocephalus constitute one of our largest patient subpopulations. A second subpopulation includes patients who suffer various congenital malformations such as tethered cord, spasticity, and spina bifida.
Having survived childhood against many odds under the care of their pediatric neurosurgeons, these patients mature into adulthood. Unfortunately, when pediatric neurosurgeons try to transfer their now adult patients to others for age-appropriate care, they sometimes encounter neurosurgeons who are unwilling, unable, or simply lacking the knowledge base to manage these patients. This problem is not unique to pediatric neurosurgery; pediatric physicians who have sought to transition the care of patients suffering cystic fibrosis, congenital heart diseases, and juvenile endocrine abnormalities have been stymied by this same dilemma.
How do we solve the problem of transitional care for these patients? In many instances, our patients lack insurance coverage or are covered inadequately and lack financial resources. This situation is an impediment to transferring their long-term care to other neurosurgeons. Furthermore, the subset of U.S. neurosurgeons who have essentially abandoned their commitment to being "brain surgeons" is growing as they embrace the more financially lucrative practice of spinal surgery, which equates with spinal stabilization procedures.
The problem I present here has two aspects: first, commitment; and second, professionalism and medical ethics.
The first aspect concerns the pediatric neurosurgeon who seeks to transfer a patient with a chronic condition to another neurosurgeon for age-appropriate care. Some pediatric neurosurgeons postpone the "transition dilemma," at least until retirement from medical practice, by continuing to care for patients into their adulthood. However, pediatric neurosurgeons who work for children's hospitals must restrict their practice to children, and they find that their transitioned adult patients receive either no care or suboptimal care that might skimp on the quality of follow up necessary for chronic congenital disorders.
The second aspect of this problem involves the responsibility and commitment of the neurosurgical workforce to its profession and medical ethics. The question of the degree to which a neurosurgeon can restrict his or her practice has challenged our subspecialty for decades. Obviously, any neurosurgeon must provide at least emergency care for congenital problems upon presentation. The complex chronic congenital problems of our patients when they reach adulthood will require the care and follow up by a group of physicians who can manage their congenital problems as well as the "more normal" problems of the larger U.S. population as it ages.
First, all neurosurgeons must address the issue. The American Academy of Pediatrics already has begun to study how restricting practice imapacts transitional care, and one of the abstracts scheduled for presentation at the Pediatric Section's annual meeting in San Francisco will address transitional care.
I believe that all neurosurgeons must eventually acknowledge the impediments to appropriate transitional care for our patients before we can resolve the problem for the greater good.