Limits of Pediatrics

[azmatti]

Hi All,
I have heard some contradictory things about Pediatrics.

I have heard that as a Pediatrician, one can not see or prescribe to anyone over the age of 21!? Is that true?!

Thanks!

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[deleted87716]

I have heard that as a Pediatrician, one can not see or prescribe to anyone over the age of 21!? Is that true?!

21 years of age is the cutoff specified by the AAP. It's not illegal for them to treat older patients, more an issue of scope of practice and training.

Pediatricians specialize in the care of children. Why are you surprised that there's an upper age limit?

 

[edmadison]

Where does the AAP give a "cutoff", I'm curious as to the source. Many pediatricians take care of patient's over 21. Some patients have diseases that are pediatric in nature, but that afflict patient who have lived over age 21. These include cystic fibrosis and musclular dystrophy. Also, MR patients are often cared for by pediatricians. Physicians are given authority to treat by the state licensing board. As far as I know, there is no restriction on this. Theoretically, a radiologist could perform brain surgery and it would not be illegal. Scope of practice is limitted by the individual provider, institutions at which he or she has privileges and insurance reembursement.

Ed

 

[deleted87716]

Where does the AAP give a "cutoff", I'm curious as to the source.

The AAP web site and the pediatric literature contain multiple references to the age of 21 as the upper limit of adolescence, and the vast majority of pediatricians elect not to treat patients older than 21 years of age. There are well-known exceptions, as you noted. As I stated, any age restrictions are based on scope of practice and training, not by law. The OP seems to be under the impression that pediatricians can't see patients older than 21, which is not the case. Most choose not to do so, however.

 

[azmatti]

Yes, I was under the impression that as a pediatrician, I can not legally see a patient over the age of 21 or prescribe medication to anyone over 21.

But I have been researching this more and it seems that there's no problem with seeing patients over 21.

 

[Bernardo_11]

Yes, I was under the impression that as a pediatrician, I can not legally see a patient over the age of 21 or prescribe medication to anyone over 21.

But I have been researching this more and it seems that there's no problem with seeing patients over 21.

Exactly. One of my moonlighting jobs as a pediatrician was working at an Urgent Care clinic in which I saw adults. As long as you have passed step 3 and are licensed to practice medicine at that state, you have "status" as a general practitioner and can practice to your level of comfort. Be careful though, as constant mistakes, especially toward those age groups you are not trained to take care of, could lead to your license being revoked.

Take care.
Nardo
DB Peds Fellow

 

[ntubebate]

I know of two peds trained MDs who see all age groups. One is very popular, everyone loves him.

The other one... well. Bad idea to be a pediatrician, see all age groups then decide you are going to be a pain management specialist and write more MS Contin/Percocet/Norco/Darvocet than every other MD in your county combined. He's enjoying a nice long "vacation".

ntubebate

 

[Homunculus]

Where does the AAP give a "cutoff", I'm curious as to the source. Many pediatricians take care of patient's over 21. Some patients have diseases that are pediatric in nature, but that afflict patient who have lived over age 21. These include cystic fibrosis and musclular dystrophy. Also, MR patients are often cared for by pediatricians. Physicians are given authority to treat by the state licensing board. As far as I know, there is no restriction on this. Theoretically, a radiologist could perform brain surgery and it would not be illegal. Scope of practice is limitted by the individual provider, institutions at which he or she has privileges and insurance reembursement.

Ed

ed, as usual, is right.

i am currently licensed for "medicine and surgery". it says so right on my license

we've admitted 28 yr olds to the ward before. i just took care of a 29 year old in a top ten children's hospital PICU. we have several CFers in their 20's as well.

not to mention-- a medical license is a medical license, regardless of residency/fellowship/etc. The army routinely sends pediatricians, pediatric subspecialists (even neonatologists ) to iraq/afghanistan as general medical (read: basic FP urgent care-ish stuff) officers. Not the best model, i agree (54 yo with chest pain? ekg, MONA . . then. . . ummmm . . .) but for most things it works-- mainly because of basic medical knowledge and augmentation with references (and google if ya got internet access).

--your friendly neighborhood one stop shop for all your medical needs caveman

 

[oldbearprofessor]

ed, as usual, is right.

i am currently licensed for "medicine and surgery". it says so right on my license

we've admitted 28 yr olds to the ward before. i just took care of a 29 year old in a top ten children's hospital PICU. we have several CFers in their 20's as well.

not to mention-- a medical license is a medical license, regardless of residency/fellowship/etc. The army routinely sends pediatricians, pediatric subspecialists (even neonatologists ) to iraq/afghanistan as general medical (read: basic FP urgent care-ish stuff) officers. Not the best model, i agree (54 yo with chest pain? ekg, MONA . . then. . . ummmm . . .) but for most things it works-- mainly because of basic medical knowledge and augmentation with references (and google if ya got internet access).

--your friendly neighborhood one stop shop for all your medical needs caveman

Single most terrifying event that can happen in an NICU is an adult code (family member, staff member). I've seen it twice and a few other close calls. We had to establish an adult code cart, team response plan, etc.

 

[RuralMedicine]

Single most terrifying event that can happen in an NICU is an adult code (family member, staff member). I've seen it twice and a few other close calls. We had to establish an adult code cart, team response plan, etc.

I was involved in a successful one in the NICU as a resident. After things were more stable our neonatologist joked that he was glad we had a large Med-Peds presence at our institution. In fairness to the neonatologists my adult pulmonology/ critical care attending arrived at a code involving a 6 week old who went apneic while visiting grandpa in the ICU and later admitted he was really glad "grandpa" had been admitted to a team led by Med-Peds resident (More fortunately the resident was in the patients module when this happened, the nurse had recently made the transition from ED to ICU and didn't miss a beat. It is also helpful that at that hospital all adult code carts have a "peds drug drawer" and ET tubes from size 3.5 up).

 

[nerdoman]

This is very old thread. Contrary to this can an physician trained to treat adult patients treat pediatric patients?

 

[SurfingDoctor]

This is very old thread. Contrary to this can an physician trained to treat adult patients treat pediatric patients?

If you can find an employer to hirer to do so... but why would they want to? Additionally your malpractice may not cover you if you practice outside your scope and are sued.

 

[mvenus929]

This is very old thread. Contrary to this can an physician trained to treat adult patients treat pediatric patients?

Can they? Sure. Should they? Well... I should absolutely not be responsible for caring for adult patients beyond the initial stabilization. I can't see how providers trained to take care of adults would be comfortable managing things in children, since the pathologies are so different. But, the only specialty that doesn't train to take care of children is internal medicine.

 

[mdphd2b]

At my hospital, we can see them until age 26. Obviously we try to transition before then, but some specialties such as Cardiology keep their patients well into adulthood (have seen 40-50yo patients on my pediatric cards and genetics rotations when I was training).

 

[nerdoman]

May I know if any body has experience or if their institution regarding pediatric stroke code

1.My friend who is adult neurologist is being in a situation where asked to attend pediatric stroke codes.
2. Is it common practice to give tpa for children?

 

[SurfingDoctor]

May I know if any body has experience or if their institution regarding pediatric stroke code

1.My friend who is adult neurologist is being in a situation where asked to attend pediatric stroke codes.
2. Is it common practice to give tpa for children?

There is a very short window to give tPA. I don't remember off the top of my head, but I want to say 5 hours from the onset of symptoms. Unless you are watching a child in the hospital develop symptoms in front of you, it is very hard. When it does happen, it's rare to give systemic tPA. Most pediatric stroke centers will have neurointerventionalists, who can shoot an angiogram and give catheter-directed local tPA.

Here's a study where they tried to study the question of tPA in pediatrics. The enrollment in the window of giving tPA was so low, the NIH cut funding to the study.
Thrombolysis in Pediatric Stroke (TIPS) study

 

[VA Hopeful Dr]

If you can find an employer to hirer to do so... but why would they want to? Additionally your malpractice may not cover you if you practice outside your scope and are sued.

Bingo. My internist wife's malpractice policy says no one under age 16.

 

[Stitch]

There is a very short window to give tPA. I don't remember off the top of my head, but I want to say 5 hours from the onset of symptoms. Unless you are watching a child in the hospital develop symptoms in front of you, it is very hard. When it does happen, it's rare to give systemic tPA. Most pediatric stroke centers will have neurointerventionalists, who can shoot an angiogram and give catheter-directed local tPA.

Here's a study where they tried to study the question of tPA in pediatrics. The enrollment in the window of giving tPA was so low, the NIH cut funding to the study.
Thrombolysis in Pediatric Stroke (TIPS) study

Agree. I've worked at several pretty big centers. Even in places where we had interventionalists, I remember basically just scrambilng everyone and then doing nothing. We'd get an MRI, we'd talk about tPA, but often the kids were considered too small to get a cath in or too much time had passed. The hard part was getting people to recognize stroke in younger kids so these pathways could be activated, but all in all there aren't great interventions at this time.

 

[BigRedBeta]

The hard part was getting people to recognize stroke in younger kids so these pathways could be activated

People look at me cross-eyed when I tell them kids can have strokes.
My fellowship had a very strong neurocritical care team and I can only remember once where someone got tpa - teenager who developed issues while they were in the midst of their varsity sport, so the decline was readily apparent. Otherwise, the typical story is that it happened last night, parents sent them to bed, was still the same in the morning, go to one ED, parents aren't happy so they go to the Children's ED, then we find it 24 hours after the fact...it's hard being a kid (and a parent).

 

[MEN2C]

Our pediatric hematologists see people with certain benign heme problems (factor deficiencies for example) for their whole lives. Our peds trained cardiologist follows adult congenital patients their whole lives (now there's a specific fellowship for that). Our Pulm people frequently follow their CF patients forever.

 

[Stitch]

Our pediatric hematologists see people with certain benign heme problems (factor deficiencies for example) for their whole lives. Our peds trained cardiologist follows adult congenital patients their whole lives (now there's a specific fellowship for that). Our Pulm people frequently follow their CF patients forever.

This is pretty common in those select populations, but it's becoming increasingly clear that there needs to be an adult physician home for these patients. As they grow older, they develop adult illnesses which are out of the scope of general pediatrics, especially if they need in patient admission. I can easily take care of a Fontan, but coronary artery disease and chronic diabetes aren't really things I know much about. They have social issues that children's hospitals aren't equipped to handle. Sometimes there's even a problem with nursing or APP licenses, which limits who can do the bedside care and note writing/billing.

The answer is a multidisciplinary approach, but as of right now they tend to get dumped onto inpatient pediatric floors and they don't receive the best care since many adult services are either unavailable or unwilling to be involved. Med/Peds dual trained people seem to (appropriate) be leading the way in developing these systems.

 

[nerdoman]

The important point is my friend is not pediatric trained. He is adult neurology trained and he does not want to see pediatric neurology patients including pediatric acute strokes. Can he refuse to see such consults stating he is not trained. Emergency doctor wants him to document this in chart. Does he need to document it in chart or just verbally tell them that he cannot see the pediatric consults since it doesn't fit his scope of medical practice?.

 

[PTPoeny]

That sounds like the sort of thing that should be clarified at a higher level than the individual practitioner. If the group your friend practices with is contracted to the ed to cover consults (or it is in the employment contract if employed by the hospital) refusing to see consults could cause problems.

I also thought some Peds was part of the standard neuro residency?

 

[Mad Jack]

Our pediatric hematologists see people with certain benign heme problems (factor deficiencies for example) for their whole lives. Our peds trained cardiologist follows adult congenital patients their whole lives (now there's a specific fellowship for that). Our Pulm people frequently follow their CF patients forever.

Same with pedi pulm for CFers

 

[Stitch]

That sounds like the sort of thing that should be clarified at a higher level than the individual practitioner. If the group your friend practices with is contracted to the ed to cover consults (or it is in the employment contract if employed by the hospital) refusing to see consults could cause problems.

I also thought some Peds was part of the standard neuro residency?

Agree with this. It's really a systems issue that needs to be addressed at the medical director/division chief/department chair level. Discussions and arguments in the heat of the moment at 0200 are never good for anyone, including the patient. Exact expectations need to be clear to all parties involved, written out if necessary. If this ends up being part of the job expectation and he's uncomfortable with it, then he needs to find a new job instead of being the only one in a group who refuses. Communication and clarity of expectations are key here.

 

[SurfingDoctor]

The important point is my friend is not pediatric trained. He is adult neurology trained and he does not want to see pediatric neurology patients including pediatric acute strokes. Can he refuse to see such consults stating he is not trained. Emergency doctor wants him to document this in chart. Does he need to document it in chart or just verbally tell them that he cannot see the pediatric consults since it doesn't fit his scope of medical practice?.

This is a system issue and this system sounds like a mess. But he needs to protect himself first and foremost. He should not be practicing medicine in a specific population which he is neither qualified nor experienced in treating... and he can’t be forced to (unless the system he works in forces, but he better have it in writing that the system will cover him entirely less he gets sued)

 

[nerdoman]

That sounds like the sort of thing that should be clarified at a higher level than the individual practitioner. If the group your friend practices with is contracted to the ed to cover consults (or it is in the employment contract if employed by the hospital) refusing to see consults could cause problems.

I also thought some Peds was part of the standard neuro residency?

As per my friend peds is not part of neuroresidency. There is a separate pediatric neurology residency. Actually neuro do one year of internal medicine as intern but they don't treat chest pain in the ED correct!

 

[BabyDoc86]

This is very old thread. Contrary to this can an physician trained to treat adult patients treat pediatric patients?

Ever been to an Urgent Care?

 

[MEN2C]

As per my friend peds is not part of neuroresidency. There is a separate pediatric neurology residency. Actually neuro do one year of internal medicine as intern but they don't treat chest pain in the ED correct!

Adult neurologists have to do three months of pediatric neurology as part of their training. Pediatric neurologists generally do six months to one year of adult neurology during their training (it's usually two years peds residency, six months to a year of adult neurology and then two years of peds neurology). Adult neurologists don't usually see kids, and vice versa. Although in some places, there are exceptions (some older epileptologists will see and interpret EEGs fotboth adult and kids, one person I know who does movement disorders sees kids as well as adults).

People usually stay in their lane but things in real life are oftentimes blurred .

 

[mytirf]

I'm a subspecialty pediatric cardiologist and I see patients "Fetus to Fifty" but usually will not see new patients much beyond 30yo. However, age is not really a good measure of where pediatrics stops and adult medicine begins. Each specialty has their own "Wheel-house" or things that they see everyday. Patients with congenital problems are simply more uncommon and there are many more zebras in pediatric subspecialty medicine than adult medicine. I have cared for adult patients transferred from adult institutions because they did not have the same expertise in a particular area. Absolute age, is not a good dividing point.

 

[VA Hopeful Dr]

I'm a subspecialty pediatric cardiologist and I see patients "Fetus to Fifty" but usually will not see new patients much beyond 30yo. However, age is not really a good measure of where pediatrics stops and adult medicine begins. Each specialty has their own "Wheel-house" or things that they see everyday. Patients with congenital problems are simply more uncommon and there are many more zebras in pediatric subspecialty medicine than adult medicine. I have cared for adult patients transferred from adult institutions because they did not have the same expertise in a particular area. Absolute age, is not a good dividing point.

I'm hoping with the increasing number of adult cardiologists who do the congenital disease fellowships this will start being less common

 

[MEN2C]

I bet you that it will be the pedi cards people doing the congenital fellowship at a much, much higher rate then the adult cards people.

But either way, yes, it makes sense for there to be a home for these patients where the physician is comfortable seeing both adult and kids problems (since the ACHD fellowship coming from a pedi cards program is very adult focused - taking care of a lot of bread and butter adult cardiology first year, and lots of bread and butter peds cardiology for the poor sap adult cardiologist who chose this path).