Background
Pediatrics is a specialty of medical science that is concerned with children’s physical, mental, and social health from birth to young adulthood, as defined by the American Academy of Pediatrics (AAP) [
1]. It covers a broad spectrum of health services, ranging from preventive health care to diagnosis and treatment of both acquired and genetic illnesses. Furthermore, it ensures children’s and youths’ growth and development for prospering in their society.
Pediatrics is a heterogeneous field of medicine. This heterogeneity extends to include variable ages and developmental stages. Prior to establishing the modern-day field of pediatrics, families, friends, and midwives attended to infants’ and children’s needs. Physicians rarely contributed to this population’s health in the past. As medicine evolved in the 19th and early 20th centuries, there grew an interest in creating a separate field for caring for sick children. The first known hospital in the western world that was devoted entirely to caring for children was the Sick Children’s Hospital, and was established in Paris, France in 1802 [
2]. By the 1850s, greater attention was given to the value of specialized training and education to equip future pediatricians [
3].
Pediatrics is one of the first specialties founded in Saudi. Arabia [
4]. Over the last two decades, it has rapidly become a well-recognized specialty in the young Kingdom, with many subspecialties [
5]. Furthermore, it has continued to grow into a successful example for the whole region [
6]. In 1981, the Saudi Pediatrics Association (SPA) was instituted, aiming to improve healthcare services provided for children all over the country [
7].
This original study investigates general pediatric providers’ and pediatric trainees’ perspectives on the current status of, and how to improve, general pediatrics in Saudi Arabia. It proposes a qualitative methodology through personal interviews. This methodology aims to reach a representative sample of the general pediatric workforce, delivering child healthcare to discover different viewpoints on successes, challenges, and opportunities. This approach can provide new insights on how to address many unvisited territories of child healthcare in the young Kingdom, and it is the first to explore the quality of general pediatrics in the region, as far as we know. Therefore, this study is meant to serve as a bridge between general pediatricians and policymakers in order to overcome challenges in the field and invest more in successes of delivering a high quality child healthcare. Additionally, findings can voice the various new opportunities that might improve the practice of general pediatrics in the Kingdom.
Methods
Data analysis: We adopted a thematic analysis and hermeneutic phenomenology to analyze our data. First, transcriptions of interviews were reviewed using a thematic analysis to identify common denominators. This analysis allowed for themes to emerge to understand the common consensus among participants. Each theme emerged following a six-step analysis: familiarization, coding, reviewing, generating, defining, and writing. Later, adopting hermeneutic phenomenology allowed for illuminating all details and shinning a light on trivial aspects from interviews. Those aspects helped in understanding attitude and participants’ prospective. All analyses were done manually and no computer-based analysis was used.
Results
Nevertheless, we need to encourage more residency graduates to pursue a career in general pediatrics, as three pediatricians explained. One pediatrician suggested adding a “Billing System” to attract more graduates and encourage better productivity than the current base salary system. Another pediatrician demanded channeling the pediatric residency focus to meet the Saudi public’s needs, especially in addressing autosomal recessive syndromes, complex care, and car safety. On the other hand, all participants had a positive attitude regarding virtual health and thought it can improve access to care, especially for patients from rural areas. Lacking a physical exam might be a downside of this innovative approach as one pediatrician and two residents mentioned.
Discussion
Pediatrics pioneers and first-generation child health advocates in the young Kingdom of Saudi Arabia have accomplished a lot in a short period of time. Their accomplishments are measured by considerable improvement in child health and lower mortality rates. Now, only seven children per 1000 die before their fifth birthday compared to 160 children in 1972 [
8].
Despite suggestions from study participants to offer general pediatrics as a primary care service, it would be impractical to do so with the limited number of current practicing general pediatricians and the lack of community pediatricians. Integrating general pediatrics with family physician practices and offering pediatric training to family medicine trainees can be temporary alternatives until a higher workforce is available. Successful examples of training family medicine trainees are well established in countries like Canada [
9]. Luckily, such training is already in place in some parts of Saudi Arabia. Furthermore, having community pediatricians is crucial and cost-effective in Saudi Arabia with the overutilization of pediatric emergency rooms [
10]. A study by Porter B. et al. showed that a pediatric community practice, rather than a tertiary-based general pediatric, can lower a child’s number of emergency visits [
11].
Pediatric care may start periconceptionally and proceed from early gestation to early adulthood. The AAP previously released a statement on the age limit for pediatrics in 1988, which was reaffirmed in 2012, and established the upper age limit as 21 years [
12]. Alternatively, the CPS defines the upper age limit as 18 years of age. Despite recommendations from the Saudi Health Council to treat children until the age of 16 in pediatrics, the pediatric age limit varies among institutions and wide between 12 and 14 years old. Knowing that nearly 30% of the Saudi population is under 14 years of age obligates a better-accustomed age limit of pediatrics in order to include all adolescents, especially middle and late adolescents (15–18 years old).
Communication skills have been a hot topic of discussion in Saudi pediatric literature. They have always been criticized and deemed deficient [
13] [
14]. On the bright side, awareness of poor communication skills among trainees and pediatricians has improved, compared to the findings in an earlier report [
15]. Additionally, it is promising to see initiatives already in place to improve communication skills during residency training. However, communication skills training should start at earlier stages of medical education in medical schools and be culturally appropriate.
Recent reports documented a high prevalence of pervasive developmental disorders in Saudi Arabia [
16]. Additionally, consanguinity has been linked to developmental delay [
17]. Consanguinity is a common practice in Saudi Arabia [
18]. Dealing with behavioral and developmental issues should not be limited to pediatric development specialists and child psychiatrists. Pediatric residency should prepare future pediatricians to address these issues, and some initiatives have already been implemented.
General pediatric residency training programs in Saudi Arabia have evolved tremendously over the past decade. Pediatric residency training is intended to instill the expertise, skills, and attitudes needed for family-centered healthcare. Likewise, it needs to have a prominent role in meeting complex 21st century health needs and demonstrating an overlap between clinical pediatrics and public health issues. Most importantly, it needs to address public needs while practicing culturally appropriate care. Having giant and well-resourced organizations as references shows an eagerness to learn and follow recent updates among Saudi pediatricians and trainees. However, there is a need for a local organization to address culturally sensitive topics and unique problems affecting Saudi children and youths, like fasting Ramadan for youths with type 1 diabetes or addressing the prevalence of certain metabolic diseases because of consanguinity. Fortunately, there is a well-established SPA, and hopes are high for its future role in generating practice guidelines, advocacy, health literacy, and meeting Saudi children’s needs.
Conclusion
Saudi general pediatrics is well established and has made considerable contributions to Saudi society. It needs to recruit more residency graduates in order to meet public demands and 21st century needs. The goal is to have a primary care general pediatric service starting with an early first visit in the first few days of life for every child in Saudi Arabia. Pediatricians want to advance the current age limit to include more adolescents. They feel unready to address developmental delay and behavioral issues, and ask for more exposure to such cases. High demands, a low number of qualified physicians, poor communication skills, limited allocated clinic time, unsuccessful well-baby clinic design, and lack of enough community pediatricians are significant challenges for general pediatrics in Saudi Arabia. On the other hand, the current pediatric residency training gives a lot of hope for a brighter future. From training residents on communication skills to addressing developmental delays and managing adolescents, the next generation of general pediatricians will thrive in the field. More importantly, they will continue improving child and youth health in Saudi Arabia and beyond.
Limitations
The number of participants was limited due to the novelty of qualitative methodological studies in Saudi Arabia. Many pediatricians were not comfortable with this approach and declined to participate. Even pediatric residents expressed dissatisfaction with this method. Additionally, it was hard to arrange one-hour interviews around their busy clinical schedules. All of the participants showed considerable reluctance to record the interviews. Another significant limitation was the inability to recruit pediatricians from other cities, despite all efforts. However, this paper can set foundations for many more studies to help in improving general pediatrics in Saudi Arabia.
RIA: Acquisition of data, analysis and interpretation of data, revising the manuscript, and final approval of the version to be published.
SMA: Substantial contributions to conception and design, drafting the article, revising it, and final approval of the version to be published.
Acknowledgements
Authors would love to thank Saudi pediatric pioneers for establishing strong foundations for Saudi general pediatrics. Additionally, we would love to thank all of the participating physicians for their time, thoughts, and passions for improving child health in Saudi Arabia and around the region.
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