I'm taking a seminar class this semester called The Art and Science of Medicine. It's really aimed at premed students (which, obviously, I'm not) to let them get a closer look at the day to day life of a doctor. We meet once a week; every week has a topic (this week was "Pediatric Medicine"; the week before spring break was, IIRC, "Research and Medicine"; next week is "Dermatology"), and a student or two will present a journal article on the topic. The main focus, though, is on the guest speaker - a different person every week, they tend to be local doctors specializing in the topic of the week. They also generally have some other "feature" they talk about - the women answer the questions a lot of female premed students have about balancing a time-consuming career (heck, the education too) like medicine with the demands of raising a family 'before the clock runs out', one of our speakers talked about working overseas as a way of gaining experience you won't have here in the US (diphtheria, for example, is not common in the US; you pretty much only see it overseas now).

So, like I said, the topic yesterday was pediatrics. One of the students wanted to know at what age it was appropriate for a patient to start seeing a GP or internist rather than a pediatric physician. I think the question was aimed more at the general population (i.e., "when should a parent set their kid up with a GP"), but our speaker took it in an interesting direction. He brought up the fact that a lot of health conditions used to be pediatric specialties - cystic fibrosis, for example (according to wikipedia, the life expectancy was 4 years in the 60s, and is now 35ish, with some patients living to 40 or 50). Now, the mortality rate is much lower, and people with these conditions survive to adulthood, but because that's a relatively recent development, you run into two problems. The first of these problems is that non-pediatricians are not well trained in dealing with these disorders - after all, when they went to med school, the only way you'd see a patient with cystic fibrosis was if you were a pediatrician. That's a problem of distribution of knowledge - who has the necessary knowledge. The other problem is one of existence of knowledge - there just isn't a history of adults with cystic fibrosis. For example, how does cystic fibrosis behave in a post-pubertal patient? How does cystic fibrosis affect, say, reproductive health, or age-related problems like hearing loss, arthritis, and so on? What happens to the lungs in the long term - over several decades - as a result of cystic fibrosis? (Note: y'know why Hippocrates never wrote about osteoporosis? Because people didn't live long enough for it to be a problem; it just didn't have time to develop far enough for symptoms to become apparent to the patient.) The issue of reproductive health in particular reminds me that we're also dealing with the non-medical impact of some of these health issues - as I was doing some research for this post, I came across several sites dealing with the specific issues of fertility for CF patients, both from a medical perspective, and from a "how do you raise kids as a parent with CF?" perspective.

This isn't just related to cystic fibrosis; it just tends to be the canonical example because it's a relatively high profile example of a disorder where childhood mortality used to be the norm, and now, all of a sudden ... it isn't (not to the same degree, anyway). I believe spinal fusions had a similar effect in Morquio Syndrome; now that spinal fusions (and other treatments, yes, but that's the obvious one), there's no reason a patient with Morquio can't live to be 70-80-90 years old.

There's also an issue that the speaker didn't raise, of how you deal with leaving a doctor you've known for 10-20 years when you have *any* unique and chronic health issue. How do you deal with that? All of a sudden, the doctor who knows your history, who knows how your body behaves, is kicking you out and telling you to find someone else - someone who doesn't know your body, and just as importantly, doesn't know you. A lot of children's hospitals will grandfather (no pun intended) you in until you're about 25, but then you're on your own. And it's not just about transferring medical records. It's about the more holistic end of medicine - the doctor's experience and intuition, and the relationship you've developed over a decade or two.