Wednesday, August 29, 2007

Preparing oneself for multiple choices - Study break musings

I have my "pediatrics board exam" coming up in mid-October.

Here is one of the practice items, an example of the type of question that appears on the exam:

“During the resuscitation of a 1.5-kg preterm infant who has apnea, you notice that inflation pressures of 15-10cm H2O for the first three breaths do not result in chest wall excursion, and the infants color remains poor. The heart rate is 90 beats/min. Of the following, the BEST next course of action is:
(A) administration of intravenous epinephrine
(B) administraion of intravenous naloxone
(C) chest compression
(D) endotrachael intubation
(E) Increase inflation pressure”

In most all of Swaziland, births occur at home, certainly premature ones. Even if they occur in the hospital, there are no newborn (much less preemie) face-masks to resuscitate. Except for a finger on the femoral pulse of the baby, there are no heart rate monitors.

IV meds, ET tubes, and mechanical ventilators there are none. Of course, there are no neonatologists.

So, why am I telling you all this on a blog that aspires to be upbeat?

Well, I have done several hundred of these pediatric boards "prep" questions over the last month, and there is not even a whimper about practicing pediatrics in resource-limited settings.

Here is the problem: almost all of the world's pediatrics is practiced in resource-limited settings.

There is certainly plenty of vile childhood illness here in Africa on which to base multiple choice questions. Most of these illnesses have inexpensive, relatively simple treatments...i.e. answers.

So, why doesn’t the American Board of Pediatrics test me on how to address the world’s most common illnesses in the plain, impoverished context in which most of the world’s illnesses are addressed?

Why not give me one question that asks me to help a child with limited resources at my disposal?

Now, I am assuming that you, the reader, are eager to point out that we are not tested about African children because US-trained pediatricians are almost all US-based pediatricians. We are, after all, talking about certification in the USA.

Good points. Now consider the following:

· In the USA, there are 28-165 pediatricians per 100,000 children, and the states with higher per capita income have more pediatricians.
· Before I came to Swaziland, a nation of about 500,000 under 18 year-olds, I was told that there was one in-country pediatrician. (I met her. She is great and works hard.)
· Baylor currently employs nine Swazi-based, US-trained pediatricians, as well as a family practitioner and two adult internists. This gives Swaziland around 2 pediatricians per 100,000 children.
· Meanwhile, 153 of every 1,000 children in Swaziland die before age five. In the US, the under-five mortality rate is 8 per 1,000.

I understand that it is a good thing that US-based pediatricians are able to spend thousands of dollars to help save the life of a child. It is not a surprise that our credentialing process reflects that.

But, does our credentialing body not agree with me that child health is global by definition, that a healthy, sick or dead child is still a child, regardless of nationhood?

The American Academy of Pediatrics’ states that it is “Dedicated to the health of all children.”


The American Board of Pediatrics, who administers my certification exam, strives to promote “high quality health care for infants, children and adolescents.”


My point is this:

Either these mission statements need to end with the words “in the USA” or the AAP and ABP must strive to encourage American pediatricians to reflect on child health promotion in resource limited settings.

At least one question.

Gotta go. Off to study.

PEDIATRICS Vol. 116 No. 1 July 2005, pp. 263-269
PEDIATRICS Vol. 100 No. 2 August 1997, pp. 172-179


At 10:07 AM, Blogger Karen said...

Unjani my name is Karen and I'm a general surgery intern in Southern California. I've spent 2 months this past year in Swaziland helping out at RFM. I totally fell in love with the country and I appreciate reading your blog. You seem to have put many of my thoughts into words. I fell in love with the country and plan on returning when I get a chance. How long have you been in SD? How long do you plan to stay? Would love to be a pen pal so to speak. if you're interested my email is Good luck and enjoy an appletizer for me.

At 9:37 PM, Blogger Jeannine said...

Hello Ryan.
I have also been at a loss to find easily accessible information (at least among my textbooks) regarding the care of children in resource poor settings. There are a 'smattering' here and there that I have come across but little in depth. I know that Dr. Marie Lubin published guidelines years ago on the diagnosis and management of TB infection in such settings. Partners in Health has done a wonderful job of providing guidelines for the management of HIV infection in such settings, but there do not seem to be enough guidelines out there for the professionals who care for most of our world's children. (And, although about 3% of our world's kids are here in the US, I would venture to say that a majority (or at least a much greater percentage than 3) of pediatric healthcare dollars spent annually in our world benefit kids in this country.)
Let's do some research on those 'guidelines' and see what we can come up with.

Kimbe fem,


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