It was very interesting to read the letters about the status of pediatric gastroenterology in Poland (1), Chile (2), and Cuba (3). These letters reported remarkable progress in establishing training programs for pediatricians and in providing medical care for children and adolescents in these countries. It gave cause for reflection on the status of Pediatric Gastroenterology, Hepatology, and Nutrition (PGHN) in Germany.
Knowing that any comparison is tentative without quantitative evaluation, we cannot ignore the fact that the resources of Germany are not inconsiderable. The WHO health report for 2000 described the German health-care system as one of the most expensive (but not one of the most effective) systems in the world. What does this mean for German children suffering from PGHN diseases? To date there have been no studies on the quality of PGHN in Germany. It takes approximately 7 to 9 months for an initial diagnosis of chronic inflammatory bowel disease and 22 months in children under 10. The number of children suffering from severe and chronic PGHN diseases, who are treated by adult physicians and pediatricians without any referral to a pediatric gastroenterologist, has not been accurately determined but is possibly not insignificant. It is not uncommon for children to be referred to children's hospitals with complications from therapy and neglected diagnoses or with traumatic examinations performed without adequate sedation and analgesia. Let us describe just two exemplary cases: First case: An 18-year-old boy diagnosed with Crohn's disease at the age of 13.5 years. He was referred to a pediatric endocrinologist because of short stature (162.8 cm) and delayed puberty (testicular volume 3 ml, no pubic or axillary hair). He was treated regularly with prednisolone (> 20 mg/day) without any azathioprine or other immunosuppressive drugs during the last years. Second case: A 9-year-old girl with a colectomy and ileal resection because of aganglionosis of the colon was referred to a pediatric unit for inborn errors of metabolism because of precoma and hyperammonemia. She had short-bowel syndrome, bacterial overgrowth, severe malnutrition, and failure to thrive (15.0 kg) as well as massive hepatosplenomegaly and hypoalbuminemia. Neither patient has ever been referred to a pediatric gastroenterologist.
In a country with a population of 82 million, Germany has 6,100 pediatricians working full-time in private practices and 3,900 pediatricians working in children's hospitals. A pediatrician needs approximately 80 patients per day to operate a private practice cost-effectively. In addition there are 33,000 general practitioners, 17,600 specialists in internal medicine, and 500 adult gastroenterologists who work solely in private practices, as well as 1,100 adult gastroenterologists in hospitals, all of whom are allowed to treat children and adolescents. None has received any formal training in PGHN.
In the past the German government has transferred the duties and organization of the health-care system to corporate institutions to enforce basic democratic innovations and self-government. Together with local physicians whose services are remunerated in accordance with health-insurance schemes (called the Kassenärztliche Vereinigungen, KVs), health-insurance companies decide how much hospitals are to be paid for outpatient care. Hospitals then must cover all of their costs for diagnostic and therapeutic services provided within a given three-month period with a fee of ¤ 35 per outpatient. The number of inpatients is still extremely high in Germany because inpatient care is better paid. It is very difficult to provide outpatient care to chronically ill patients paid according to the KVs (¤ 35) that conforms to high professional standards because it is so poorly paid. This affects PGHN particularly because chronically ill children and adolescents expect primarily outpatient services to cover medical as well as psychosocial care. It is important to note that the German Medical Association (called the Bundesärztekammer, BÄK), which is also a corporate organization that makes decisions on training programs currently in effect, has rejected a training program for PGHN in line with the European syllabus so far. The delegates' conference of the BÄK as well as of the KVs consists mainly of physicians who operate independent practices, i.e. 70% and 80%, respectively. One criticism of the German health-care system maintains that the corporate system disregards outpatient care by hospitals to ensure the survival of independent practices.
The German-speaking Society for Pediatric Gastroenterology and Nutrition (GPGE) has been calling for a training program in PGHN for many years—unfortunately without much success. The only results of the GPGE's recent efforts have been that a BÄK commission intends to propose a subspecialist-training program, which will be similar to the ESPGHAN syllabus, at the BÄK delegates' conference in 2003. There is also no guarantee that this plan will survive additional BÄK commissions and may become a controversial issue at the delegates' conference in 2003. This is because the conference is dominated by private health care professionals of adult medicine. It is very difficult for them to realize that there is a need for subspecialist-training programs in pediatrics. Even some pediatricians oppose such a subspecialist training program in PGHN or favor so-called “proof of qualifications,” especially for technical skills, which can be acquired during training in general pediatrics. It will be crucial for German pediatricians to recognize that progress in patient care, education, and science in this subspecialty will only be achieved when PGHN becomes an institutionalized subspecialty in professionally organized centers within children's hospitals. PGHN training programs beginning after completion of training in general pediatrics as well as the establishment of centers for PGHN in children's hospitals are mutually interdependent.
To improve PGHN in Germany, three main points will be required:
(a) Institutionalized quality control for medical care (Bundesgeschäftsstelle für Qualitätssicherung, BQS), which was recently introduced into German law, must be applied to PGHN in Germany.
(b) German pediatricians should follow the ESPGHAN syllabus for training in PGHN.
(c) Outpatient care at children's hospitals will have to be reimbursed commensurate with the services rendered.
Only when these points have been implemented can PGHN in Germany improve. There is still much to be done, and the question is whether we have already reached the “end of the beginning” as Churchill said: “This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”
1. Szajewska H. Pediatric Gastroenterology in Poland: a Personal Perspective. J Pediatr Gastroenterol Nutr 2002; 34:2–3.
2. Guiraldes E. Pediatric Gastroenterology in Chile—A Personal Perspective. J Pediatr Gastroenterol Nutr 2001; 33:231–32.
3. Castaneda C. Pediatric Gastroenterology in Cuba. J Pediatr Gastroenterol Nutr 2001; 33:525–26.