Academic General Pediatrics: The State of the Art Tina L. Cheng, MD, MPH

Clinical Care EducationResearchAdvocacy

ACADEMICGENERALPEDIATRICS

Academic General Pediatrics 1960: Association for Ambulatory Pediatric Services 1968: name change to Ambulatory Pediatric Association 1978: Robert Wood Johnson General Pediatrics Academic Development Program trained over 100 general pediatrics faculty

“The field of academic general pediatrics now is established. It is the responsibility of graduates to produce creative research and expand fellowship programs, as well as to do good clinical care, if a vigorous field of academic general pediatrics is to be achieved.” Haggerty RJ & Sutherland SA. “The Academic General Pediatrician: Is the Species Still Endangered?” Pediatrics 1999:104;

The State of Academic General Pediatrics Divisions: A National Survey Ambulatory Pediatric Association Division Director Special Interest Group

Study Aim To assess the current state of academic general pediatrics divisions in US medical schools including their current missions, activities, successes and challenges

Methods Confidential survey of US academic general pediatrics division directors Survey distributed by mail and with three mailings of each over a 6 month period Near the end of the survey period all programs were called to verify program director name and address

Results: General Pediatrics Divisions 199 US general pediatrics divisions identified Survey response rate 59% (118/199) respondents more likely from programs in the mid-Atlantic and respondents more likely from programs in the mid-Atlantic and New England (p=.043) New England (p=.043) When asked “How many other general pediatrics divisions is your medical school affiliated with?” an additional 75 divisions were mentioned

Results: What’s in a Name? Word in Division Name % “General Pediatrics” 79 “Ambulatory”11 “Academic”9 “Community”5 “Primary Care” 5

Results: Growth of Divisions No. Divisions

Results: Primary Responsibilities Responsibilities,% Yes Administrative Teaching Resident continuity clinic(s) Out-patient faculty practice Emergency service Urgent care center Normal newborn nursery In-patient units Hospitalist program Behavioral/Developmental service Adolescent medicine service

Results: Primary Responsibilities Responsibilities,% Yes Administrative Teaching Residency program Medical student clinical clerkship Child abuse program Environmental health program Chronic disease clinic(s) Other

Results: Division Faculty NOW Mean (SD) 5 years ago Mean (SD) “How many MD faculty are in your division?” 15.6 (11.7) Median (8.2) Median 9 “How many non-MD faculty are in your division?” 2.1 (2.6) Median (1.8) Median 1

Results: Division Faculty % Full-time Rank N (%) “How many MD faculty are in your division?” N= % full-time 207 (12%) Professor 323 (18%) Assoc Prof 916 (52%) Asst Prof 244 (14%) Instructor 77 (4%) Other 77 (4%) Other 98 (6%) Tenured 98 (6%) Tenured “How many non-MD faculty are in your division?” N=210 75% full-time 25% PhD 46% PNP 16 (8%) Professor 13 (7%) Assoc Prof 28 (15%) Asst Prof 21 (11%) Instructor 115 (60%) Other 6 (3%) Tenured

Results: General Pediatrics Division Director Turnover Over a month period, 21% of programs had a change in leadership with a new general pediatrics division director

Results: Division Missions MISSION “How important to your division are the following missions?” %Not impt %V impt “What is your perception of the dept/institutional financial support for this?” %Too low %Just right %Too much Clinical Care Education Research Advocacy Administration

Results: Division Revenue

Results: Outpatient Clinics Annual outpatient visits: Mean 29,821 (26,487), Median 23,825 Mean 29,821 (26,487), Median 23,825 Range 0 – 200,000 Range 0 – 200,000 Number of pediatric residents with continuity clinic at the institution ’ s clinic Mean 36.7 (23.1), Median 32 Mean 36.7 (23.1), Median 32 Total residents: 43.3 (24.0), Median 39 Total residents: 43.3 (24.0), Median 39

Results: Fellowships Does your Division have a fellowship program focusing on clinical care, education, or research? 31% have a fellowship (36) 31% have a fellowship (36) Of those, 76% offer a degree Of those, 76% offer a degree 15% one yr, 50% two yr, 35% three yr 15% one yr, 50% two yr, 35% three yr 65% funded by federal/foundation $ 65% funded by federal/foundation $ 32% funded by hospital/department 32% funded by hospital/department 13% plan to start a new fellowship within 2 yrs 13% plan to start a new fellowship within 2 yrs

Results: Grants and Contracts Total new and renewal grants and contracts (research, education and service) contributing to the division budget in : Number of Grants and Contracts: Mean 7.6 (11.0), Median 4, Mode 0, Range 0-60 Mean 7.6 (11.0), Median 4, Mode 0, Range 0-60 Total Directs

Results: Grants and Contracts Total Directs: # Programs

Results: Reported Top Successes in the Past 5 Years

Results: Reported Top Problems/Challenges in Past 5 Years

Limitations Generalizability No information on other pediatric divisions

Conclusions Academic general pediatric divisions are no longer endangered in the US The number of divisions have grown steadily Division faculty have grown in number over the past five years Divisions have a large role in clinical care, education and research

Haggerty & Sutherland’s 1999 Recommendations Support more 3 year academic fellowships by foundations or federal grants Make more research funds available Support from departments for academic generalists for scholarly work and not burdened by heavier service, teaching and administrative loads than those in other divisions

Conclusions Funding the missions of clinical care, education, and research are major challenges for divisions clinical care: Medicaid concerns education: Many programs funded by Title VII research: Federal funding concerns

Implications With growth in general pediatrics divisions, faculty development, fellowship training, and pipeline efforts must be priorities Division director leadership had rapid turnover suggesting need for leadership development A forum to share strategies across programs is important

Future of Academic General Pediatrics Future of Primary Care

1980

“Primary Care In Crisis: Current Pressures and Threats to Primary Care as We Know It.” The Future of Primary Care, Jossey Bass, 2004 “The End Of Primary Care,” NY Times Magazine, April 18, 2004 “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care : A Report from the American College of Physicians,” January 2006

FOPE II Determinants of Future Roles for Pediatricians Roles for Pediatricians Child and Family Health Needs Health Care System Scientific Advances

Present & Future Opportunities for Primary Care continuity provider head of household in the medical home or team player advocate addressing health disparities chronic care coordinator new morbidity manager/community collaborator public health coordinator genomic interpreter web interpreter/telemedicine doctor hospitalist healthcare quality and systems researchers Cheng TL Pediatrics 2004; 113:

Future of Academic General Pediatrics Future of Primary Care

Primary Care Now and In the Future CURRENTFUTURE WHO Primarily Doctors & Nurse Practitioners Interdisciplinary Teams WHAT Individual Patient OrientedIndividual Patient & Public Health Oriented Organ BasedIntegration of Genes to Organs to Persons to Communities WHEN Child Health Maintenance & Acute Care Child Health Maintenance, Acute Care, Visits with Other Team Members, Group Visits, Other Sites. WHERE Office FocusedCommunity Based & Community Integrated HOW Continuity through Visits & Phone Continuity through Visits, Phone & Other Information Technology Cheng TL Pediatrics 2004; 113: