acta pediátrica portuguesa - Sociedade Portuguesa de Pediatria

Acta Pediatr Port 2010:41(5):S5
Conferência 3
A PEDIATRIA QUE EU VIVI
Nesta retrospectiva dos 50 anos da minha vida profissional separei os vários
acontecimentos que testemunhei, ou de que fui protagonista em três vertentes:
1. Actividade Hospitalar, compreendendo a Assistência, o Ensino e a Inves -
tigação Clínica
2. Actividade como Médico Militar, durante a guerra do ultramar (colonial)
3. Actividade de Clínica Privada
Actividade Hospitalar
O que caracterizou, fundamentalmente, a evolução na assistência pediátrica
hospitalar foi:
1. Um aumento exponencial da possibilidade de recurso a meios auxiliares
de diagnóstico
2. Uma mudança na prevalência das patologias existentes assistindo-se,
simultaneamente, à transição de um modelo de patologia aguda para um
outro de doença crónica
3. Avanços notáveis nas possibilidades terapêuticas, tanto médica como
cirúrgica
Consequências desta evolução:
1. Uma secundarização progressiva da semiologia clássica na observação
dos doentes e uma menor necessidade de raciocínio clínico em termos de
diagnóstico diferencial
2. Substituição progressiva de um dos maiores encantos da pediatria – que era o
de tornar saudável uma criança dias antes moribunda - pela satisfação mais
continuada, mas não menos gratificante, de a ajudar a viver com a sua doença
por mais tempo e com uma boa ou, pelo menos, aceitável qualidade de vida
Ensino (Pré- e Pósgraduado)
1. Aulas práticas: «Tudo na mesma (mal) como a lesma»
2. Aulas teóricas, conferências e outras formas de apresentação oral: Do
Quadro Preto ao Power Point
3. Colóquios: As sessões esquecidas
Investigação Clínica
1. As dificuldades: Antes ainda mais do que agora
2. O despertar para a importância da Ética na investigação clínica pediátrica
Actividade de Médico Militar
1. A perspectiva preventiva do pediatra: Vacinação anti-variólica
2. O médico e os seus sentidos: Ver, Ouvir e Palpar
Actividade de Clínica Privada
1. A responsabilidade do pediatra na clínica privada e no exercício da medicina
hospitalar
2. O tempo dedicado a cada consulta
3. As visitas domiciliárias
4. O Sr. Dr. «salvou» o meu filho
5. Situações de alguma comicidade
6. Até quando o seguimento pelo pediatra?
Como tudo o que evoluciona à superfície da Terra, também, na nossa profissão,
nascemos (licenciatura), nos desenvolvemos (carreira médica e/ou académica),
atingimos o apogeu da nossa competência técnica e da nossa sabedoria, iniciando-se,
depois, uma fase de declínio, em geral, lenta, mas sem retorno.
Aqui ficam alguns conselhos:
1. Não deixem que a medicina seja tudo na vossa vida
2. Arranjem alguns hobbies, se ainda não os têm
3. Criem condições favoráveis à ocorrência de acontecimentos gratificantes
4. Lutem por alcançar vitórias, mesmo que trabalhosas e difíceis
Tudo isto os ajudará na tal fase, «menos boa» da nossa vida profissional, a
fazerem coisas de que gostam e a terem boas recordações o que, de certo
modo, é voltar a viver.
BOA SORTE
Mesa Redonda_1
Primary Paediatric Care in Europe
Diego van Esso (Barcelona)
Robust evidence shows that patient care delivered with a primary care orientation
is associated with more effective, equitable, and efficient health ser -
vices. (Starfield B. N Engl J Med 2008)
Primary Care is defined as a set of functions: first contact care; person (not
disease) focused care over time; comprehensiveness in attending to the needs
of populations, subpopulations, and patients; and coordination of care when
services have to be received elsewhere or from others (Starfield B. N Engl J
Med 2008). Paediatric primary care (PPC) is primary care for “children” it
does not imply by itself who is delivering this care. It seems reasonable that
the professional who will take care of this activity is well trained both in paediatrics
and in primary care. But this is not the case in many European countries
in which PPC is in hands of GPs/FDs well trained in primary care but
little of not trained at all in paediatrics.
For the purpose of this presentation the term “children” includes from newborn
babies until the end of the paediatric age span which for many countries
is set at 18 years.
Who takes care of this population? Paediatrics is the medical speciality which
takes care of the health of children. Although this is more or less clear in the
hospital setting it is not so clear at the primary care level as has already been
pointed out.
Countries with excellent paediatric care at the hospital level have few or no paediatricians
available at the primary care level. In those countries the first contact
with the health care system is done by General Practitioners (GPs), Family
Doctors (Fds) and preventive care is done also by them or in some cases is done
by nurses or other professionals which specific training in preventive care.
On the other hand there are many countries which provide PPC by paediatricians.
In some countries paediatricians are in charge of most of the paediatric
primary care. In others, PPC is mixed: both paediatricians and GPs or Fds
take care of them.
The demography of PPC in Europe has identified 3 main models. One is the
model where the paediatrician is the main health care provider another is the
model where primary care is in hands of GPs/FDs and the third model is a
mixed model in which both paediatricians and GPs are responsible for health
care at the primary care level.
Europe is a large continent and comprises many countries with a long his tory
and tradition. Health care does not escape this “tradition” and when health
care systems of the different European countries are studied it is clear the they
differ in many aspects. One of the is paediatric primary care.
As paediatricians, proud of our speciality and convinced that nobody cares,
in medical terms, better for a child than we do, it is difficult to understand and
accept that in many countries children at the primary care level are cared for
by GPs or FDs.
All European countries have public primary care health services with more or
less free access. In general the system defines in its structure who will take care
of paediatric primary health care and there is little election left to the patient.
In countries where the population is free to choose a health care provider for their
children there is a clear increase of the role of paediatricians more evidently in
the urban areas (probably due to the lack of paediatricians in the rural areas).
The aim of this presentation is to analyse the current status or paediatric primary
care in Europe.
Demography of Paediatric Primary Care in Europe
In a landmark paper published in Pediatrics (M. Katz et al. 2002) the demo -
graphy of Paediatric Primary Care in Europe in relation to delivery of care
and training was explained for the first time.
Data were collected trough a questionnaire mailed to the presidents of each
of the 33 national paediatric societies that belonged to Union of National
European Pediatric Societies and Associations (UNEPSA) and to 8 non member
societies.
The main results were that in 1999 a total of 167444 paediatricians served a
population of 158 million children younger than 15 years of age which lived
in the 34 reporting countries. The median number of children per paediatrician
was 2094 with large variations (range 410 to 15150) between countries.
12 countries had a paediatric system for PPC; 6 countries had a general practitioner
system and a combined system was reported for 16 countries.
Paediatricians did not work at the primary level at all in 3 countries.
This study found that Infant mortality rate was lower in countries with a higher
income per capita. In addition, a paediatric system of primary care had a
protective effect when looking at IMR as the outcome.
Regarding the involvement of paediatricians in aspects of community medicine,
the study concludes that paediatricians from 14 out of 34 countries work
in some aspects of community medicine.
The conclusions of this paper were that at the end of the 20th century PPC in
Europe showed a considerable variation both in delivery and training. It identified
3 different health care delivery systems for PPC.
Regarding formal training in PPC or community paediatrics it varied from
established curricula to no training at all.
S5