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PEDIATRICS Vol. 106 No. 5 Supplement November 2000, pp. 1199-1223
,
, ¶,,
From the * Children's Hospital, San Diego and Department of
Pediatrics, University of California, San Diego, San Diego, California;
§ Department of Pediatrics, Harvard University School of Medicine,
Boston, Massachusetts; Department of Pediatrics, University of
Chicago Pritzker School of Medicine and ¶ University of Chicago,
Children's Hospital, Chicago, Illinois; # Howard University College of
Medicine, Washington, DC; ** Maine General Hospital, Augusta, Maine; and
Maine Medical Assessment Foundation, Manchester, Maine.
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ABSTRACT |
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Top
Abstract
Conclusion
References
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The Future of Pediatric Education II (FOPE II) Project was a 3-year, grant-funded initiative, which continued the work begun by the 1978 Task Force on the Future of Pediatric Education. Its primary goal was to proactively provide direction for pediatric education for the 21st century. To achieve this goal, 5 topic-specific workgroups were formed: 1) the Pediatric Generalists of the Future Workgroup, 2) the Pediatric Specialists of the Future Workgroup, 3) the Pediatric Workforce Workgroup, 4) the Financing of Pediatric Education Workgroup, and 5) the Education of the Pediatrician Workgroup. The FOPE II Final Report was recently published as a supplement to Pediatrics (The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. Pediatrics. 2000;105(suppl):161-212). It is also available on the project web site at: www.aap.org/profed/fope1.htm This report reflects the deliberations and recommendations of the Pediatric Generalists of the Future Workgroup of the Task Force on FOPE II. The report looks at 5 factors that have led to changes in child health needs and pediatric practice over the last 2 decades. The report then presents a vision for the role and scope of the pediatrician of the future and the core attributes, skills, and competencies pediatricians caring for infants, children, adolescents, and young adults will need in the 21st century. Pediatrics 2000;106(suppl):1199-1223; pediatrics, medical education, children, adolescents, health care delivery.
Since the early 1900s, pediatrics has evolved as the
medical specialty focused on the provision of exemplary health care to infants, children, adolescents, and young adults.1 To
establish excellence, pediatricians train for 3 years under expert
supervision to care for children within the context of the family and
larger community. Pediatric board certification, continuing medical
education, and board renewal of certification are also in place to
assure quality lifelong learning.
The 1978 Task Force on the Future of Pediatric Education report
accurately anticipated the need to increase time spent in residency
training in the ambulatory setting, to incorporate more training in
behavioral, developmental, and adolescent issues, and to improve
physicians' skills in working with other health professionals. New
forces have emerged in pediatrics since 1978, however, that could not
have been foreseen by the authors of the 1978 report. The outcomes of
these ongoing changes are not predictable and the role of the
generalist pediatrician in the 21st century is unclear. Some pundits
have actually questioned whether there will be a role for the
generalist pediatrician in the future. What is clear is that the
generalist pediatrician's role will not remain static.
The FOPE II Task Force was convened in 1996 to address changes that
have occurred over the past 2 decades, to speculate on factors that may
alter the role of the pediatrician over the next 20 years, and to
provide direction for pediatric education. This report is a product of
the Pediatric Generalists of the Future Workgroup of the Task Force.
The Generalist Workgroup was charged with defining the role and scope
of practice of the generalist pediatrician This report looks at 5 factors that have led to changes in child health
needs and pediatric practice over the last 2 decades. These factors
include: 1) new patterns in morbidity and mortality stemming from a
combination of changing disease patterns, technological advances, and
sociodemographic trends for children and families in the United States;
2) advances in molecular biology and genetics; 3) the changing
sociodemographic and educational makeup of the available pool of health
care providers for children; 4) computer technologic advances leading
to new capabilities for data management and communications systems; and
5) paradigm shifts in the financing and delivery of child health
services. The report then presents a vision for the role and scope of
the pediatrician of the future and the core attributes, skills, and
competencies that pediatricians caring for children will need in the
21st century.
New Patterns in Morbidity and Mortality
The role of the generalist pediatrician is intimately connected
with the health care needs of children. These needs are evolving as
disease patterns change, diagnostic and management innovations are
introduced, and the sociodemographic makeup of children and families in
the United States alters. Historically, child health during the first
half of this century was characterized by high rates of infant
mortality and infectious diseases. The development of vaccines and
antibiotics in the 1940s and 1950s significantly reduced infectious
causes of pediatric morbidity and mortality. In addition, strides were
made in neonatal and obstetrical care, further decreasing mortality
rates for children <1 year of age.
As infectious diseases decreased both in prevalence as well as in
severity, many of the chronic problems children faced were more easily
recognized. The 1960s and 1970s were a time of growth in the science of
pediatric physiology and pathophysiology and led to an increasingly
sophisticated subspecialty care system for children with chronic
medical conditions. This era witnessed the introduction of pediatric
ventilatory assistance, multidisciplinary oncology care, and pediatric
surgical and transplantation services, to mention but a few. Pediatric
primary care also evolved during this period; Haggerty and
colleagues2 at the University of Rochester introduced the
term "the new morbidity" in the 1970s to describe the increasing
number of health-related problems children experience secondary to
emotional, social, economic, and demographic factors. Adolescent
medicine developed as a unique field dedicated to adolescent preventive
health and illness needs. The school setting became increasingly seen
as a site where children's medical, social, and educational needs
overlapped, leading to the development of school-based health centers
and the passage of Public Law 94-143. Lastly, children living in
poverty were identified as uniquely vulnerable to multiple factors
leading to decreased access to health care services and poor health
status.
Since the publication of the 1978 report, scientific progress in
reducing childhood health risks from medical conditions has continued.
The introduction of Haemophilus influenzae vaccines has
reduced the incidence of this high morbidity acute infection; the
varicella vaccine promises to do the same for this low morbidity but
ubiquitous disease. New vaccines, like the rotavirus and respiratory syncytial virus vaccines, have the potential to dramatically reduce hospitalizations. Alterations in recommendations for sleep positioning have reduced rates of sudden infant death. Growing recognition of the
importance and cost-effectiveness of prevention is illustrated by the
acceptance of the Bright Futures guidelines and the American Academy of
Pediatrics' (AAP) periodicity schedule by third-party payers. Despite
these successes and advances, there has been an increase in many
socioeconomic risk factors that have an adverse effect on child health.
Injuries, homicides, and suicides remain the leading causes of
mortality in children over 1 year of age (Table
1) and a major challenge to those persons
concerned about the health and well being of children and youth.
TABLE 1
OVERVIEW
including case mix,
severity of illness, and the delivery of preventive, acute, and chronic
care services. Also under consideration was the impact of managed care,
both in private health plans and under Medicaid, on practice trends.
CHANGES IN PEDIATRIC CARE IN THE LAST
TWO DECADES
Five Leading Causes of Death for Persons 0 to 24 Years of Age in the
United States, 1997
Advances in Molecular Biology and Genetics
Over the last 2 decades, the sciences of molecular biology and genetics have made a number of breakthroughs that have the potential to alter child morbidities and mortalities and, by extension, the practice of pediatrics. The success in these arenas led to the establishment of the Human Genome Project in 1990. The goal of the project is to determine the entire sequence of the human genome by the year 2005, and it seems to be far ahead of schedule, finishing, perhaps, as early as 2001.3 The project holds potential applications that will improve the prevention, diagnosis, management, and treatment of pediatric conditions. It also will raise ethical issues.
The Changing Makeup of Child Health Professionals
Another advance over the last several decades that has allowed pediatricians to better manage the changing health care needs of children has been the growth in allied health practitioners. Pediatricians have pioneered the use of a variety of providers and extenders in their practice. Alliances of allied health practitioners and pediatricians have allowed for some opportunities for the integration of children's health care and related services over the last 20 years. Nurses have played a vital role by tracking care for children with chronic illnesses, providing acute care services for children, guaranteeing office follow-up and coordination, and developing case-management services. The reasons for working with a variety of allied professionals are many, including the realities of: 1) dealing with large number of patients who require frequent visits; 2) performing multiple procedures on a daily basis (immunizations, vision screening, hearing screenings, laboratory analyses, developmental screenings, and blood pressure monitoring); 3) triaging large numbers of telephone queries; and 4) interacting with a variety of private and public agencies providing services to children.
Pediatricians in primary care practice have also long been dependent on a variety of other professionals and health workers to allow them to provide care and services to their patients. Pediatricians have worked in concert with nutritionists, social workers, psychologists, occupational therapists, physical therapists, and speech therapists to provide specific, necessary health-related services to children. Other physicians have played a role in meeting the health care needs of children, including family physicians, emergency department physicians, psychiatrists, and pediatric subspecialists. These relationships are likely to continue for the foreseeable future.
New Capabilities for Data Management and Communication
Several other advances over the last 2 decades have improved the ability of pediatricians to better manage the health-related needs of children. Changes in computer and media sciences have revolutionized many areas in Western culture, including medicine. In the world of 1978, computers, as they are used today, did not exist. The 1980s witnessed the arrival of faster processors, the explosion of computer memory, and the development of user-friendly interfaces. Today, a medical office without a computer is an exception. Demographic data, immunization records, and lists of recent diagnoses are sources of information that are accessible in current office management systems. In addition, many physicians routinely use electronic media and the Internet for communicating and collecting data and information. Electronic media and web pages are already in use by offices for giving health information to families and eventually may be commonly used for other functions, such as scheduling. Computer advances are helping to improve and monitor quality of care, increase efficiency, and enhance communication among the various levels of the health care delivery system.
Changes in the Financing and Delivery of Child Health Services
Political and financial forces have also driven change in
pediatric practice at a remarkable pace. Employers and legislators, the
primary purchasers of health care in the second half of this century,
have demanded restructuring in the financing and organization of health
care to control escalating health care costs. The recent widespread
adoption of managed care as a panacea for skyrocketing health care
costs has occurred in both the private and public sectors. Much like
private insurance purchasers, state Medicaid programs are looking
toward managed care to cut costs, expand preventive services, and
decrease emergency department and hospital use. As state and federal
coverage for children increases, the continued role of managed care
will likely increase. The widespread implementation of managed care has
led to some salutary improvements in the health care systemincluding
some progress in the elimination of waste and redundancy, a greater
focus on health promotion and disease prevention, decreased
hospitalization without obvious decline in quality of care, and initial
decline in employers' health care costs.4 Negative
effects of managed care have included limited access to certain
necessary services, such as specialists, and shorter visits with
primary care providers.
Health insurance coverage provided through public sector services is
particularly important in pediatrics for several reasons. First,
approximately one fifth of all US children live at or below the federal
poverty level and use publicly funded health care services when these
services are available.5 The federal-state Medicaid
coalition (or Title XIX of the Social Security Act) has provided
substantial funding of health services to low-income children since
1965. The last half of the 1980s witnessed steady expansion of Medicaid
services, to the point that 25% of children under 21 years of age were
enrolled in the Medicaid program at some time during
1995.6 Second, employer-based coverage for children has
steadily decreased over the last decade, while the number of uninsured
children has risen.7,8 This decrease in health care
coverage for children has been attributed to employers dropping health
insurance coverage for dependents or increasing employees' costs for
coverage, as well as workers moving into businesses that traditionally
have not offered health insurance.9 Lastly, the State
Child Health Insurance Program (SCHIP), Title XXI, passed in 1997, extends health benefits to children in poor families not eligible for
Medicaid. As SCHIP is implemented nationwide, it is hoped that over 8 million children approximately three quarters of all uninsured
childrenwill be found eligible for either SCHIP or expanded programs
in Medicaid.10
Although analysts cannot accurately predict how health insurance will
evolve in the 21st century, most conclude that the implementation of
managed care strategies in both private and public sectors will
continue over the next few decades. Managed care may need to change,
however, to survive.4,11,12 Consumer demand will push some
of these changesthere has recently been a public backlash of
anti-managed care legislation specifying lengths of stay after
delivery, ensuring emergency care, limiting gag rules, and promoting
patient rights. This public outcry can be expected to grow, along with
the demand for consumer protection, accountability, and quality
assurance.13 In addition, consumers want to choose their
own health care provider, have unlimited drug formularies, and have
ready access to specialists and emergency department
services.14 Federal and state officials are also coming to
terms with their role as purchasers of care and as regulators of
quality monitoring and assurance.15
Summary
The last 2 decades have been a time of turbulent change for child health needs, biomedical technology, computer and media technology, pediatric health care provider characteristics, and the financing and organization of health care services. The task of the Generalist Workgroup of the FOPE II Project was to attempt to define the role of the pediatrician in the 21st century within this historical context. In the next section, we address each of these 5 factors, speculating on their impact on the role and scope of practice of the generalist pediatrician in the 21st century.
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PROJECTIONS FOR THE 21ST CENTURY |
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The Generalist Pediatrician: The Impact of New Patterns in Morbidity and Mortality
Any speculation on the future role and scope of the generalist
pediatrician must first and foremost address child health needs. In
this section, we have arbitrarily broken the scope of pediatrics into
discrete categorieswell-infant, -child, and -adolescent care, acute
care, chronic care, adolescent health, and projected new morbidities.
Currently, 15% of visits to pediatricians are for screening exams, preventive care services, and anticipatory guidance.16 Prevention is a core value for pediatricians. Pediatricians spend much of their time in this activity, which has evolved over the years from the so-called physical to the health maintenance visit. In addition to being a vehicle for focusing on immunizations, these visits allow pediatrician to: 1) promote healthy lifestyle choices (safety and nutrition), 2) monitor for physical and behavioral pathology, 3) provide age-appropriate and individualized anticipatory guidance to avert risk-taking behavior patterns, and 4) understand a child within the context of the family and community. With improvements in living standards has come the relative decline in infectious morbidities and micronutrient deficiencies that were a previous focus of pediatric prevention; other preventable issues should now become our major challenge. As knowledge of the importance of early brain development continues to grow, preventive care needs to include measures to restore and enhance developmental potential. Much of pediatric preventive care today also focuses on guiding or modifying parental and child behavior to improve outcomes. Preventive measures that focus on infant sleep positions and the hazards of secondary smoke inhalation are examples. In addition, prevention of morbidities common in adulthood requires lifestyle interventions in childhood.
Families in the United States today also face a number of challenges not as common in the early 1970s, and the agenda addressed in well visits will need to take these into account. First, the increasing geographic mobility of our society leads to a consequent lack of social connections. On average, 1 of every 5 families in the United States moves each year, limiting both extended family as well as community support for family units.17 Second, mothers are increasingly working outside the home, with the numbers doubling since 1970. Now, 60% of all mothers of children <6 years of age are in the labor force, and this number will undoubtedly rise under welfare reform.18 Parents are trying to balance multiple roles, often in isolation from neighbors, community institutions, and extended family. Well-child care will need to address the emotional needs of children and parents, as well as their time limitations for accessing clinical visits. Pediatricians caring for children will also need thorough training in child health and development issues related to time spent in day care for young children and after-school program attendance for youth and early adolescents.
Well-child care will also need to take into account the changing sociodemographic characteristics of children in the United States. In 1978, the year of the first Task Force report, there was an estimated 3.4 million children (17.5%) younger than 6 years of age living in poverty; in 1996, ~13.9 million (20%) of all children were living in poverty. Children younger than 18 years of age continue to represent a large proportion of the poor population (40%), although they make up only one fourth of the total population. Children in single parent households are at particular risk. In 1996, 59% of children younger than 6 years of age resided in single parent, female-headed households with incomes below the federal poverty level, while only 12% of children younger than 6 years of age lived in married-couple families with incomes below the federal poverty level. Children of color are disproportionately represented in poor, single parent homes; nearly 40% of black children and 40% of Latino children live with single mothers whose incomes fall below the poverty level, compared with 10% of white, non-Latino children.19 Economic status and race/ethnicity affect health status in critical ways. Issues, such as infectious diseases, adequate housing, nutritious food, and environmental pollutants, are more likely to threaten the health of poor children. Poor children are also less likely to visit a physician and, thereby, have reduced opportunities to receive preventive or continuous care.20,21 Children who live in rural and inner-city areas with concentrated poverty pose even greater challenges to the delivery of well-child and other health care services.
Family structure in the United States has also changed substantially since the early 1970s. Many children currently spend their childhood in step, blended, sequential, homeless, or foster families. Marital instability and higher rates of out-of-wedlock births have led to an increase in the number of children living in single parent households. In 1978, 11 710 000 children (18.5%) younger than 18 years of age lived with only 1 parent, compared with 19 799 000 (27.9%) children in 1997.22 Divorce affects over 1 million children each year, and an equal number of infants are born to unwed mothers.23 In addition, nearly 500 000 US children are in foster care at any single point in time.24
Cultural and ethnic diversity have also increased over the past 20 years and are projected to increase even more by the year 2000, when
the Census Bureau projects that 33% of the population younger than 19 years of age will be from racial and ethnic minorities.25
Further projections estimate that by 2020, 48% of US children younger
than 18 years of age will be black, Latino, Asian American, or Native
American. Latinos will surpass blacks as the largest minority group,
and Asians will more than double their representation (Table
2). Increased rates of immigration are
only partially responsible for these expected trends. These changing
demographics may have implications for service use as well as for the
acceptance of interventions by caregivers. In addition, other special
populationsincluding homeless children, children in migrant families,
and children in foster carewill reflect even more cultural and ethnic
diversity and require sensitive attention from the providers who care
for them.
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Well-child care will thus continue to be an important part of the pediatrician's responsibilities. In fact, parents seem to want more information and support on many issues.26 The growth of allied health professions and technological innovations may, however, radically alter its form. Pediatricians may free up their personal time by supervising others who perform the direct patient contact and by making use of media and the Internet for patient education. These advances would serve the purpose of keeping preventive care available, affordable, accessible, and culturally appropriate to the needs of families. The pediatrician will need to continue to be the director and coordinator of such care.
Pediatric Acute Care
Much of pediatric acute care today involves the diagnosis and management of infectious diseases. Development and release of new vaccines in the next decade will greatly impact pediatric morbidity and mortality secondary to acute infectious illnesses. New vaccines or monoclonal antibodies anticipated or recently introduced include the conjugated pneumococcal vaccine, respiratory syncytial virus monoclonal antibody, rotavirus vaccine, and group B streptococcal-conjugated vaccine. The introduction of these vaccines could potentially decrease otitis media episodes, acute infectious disease-related office visits, and hospitalization rates for infants and children.
Pediatric acute care also involves treating minor trauma and managing children who present with acute deterioration in their health status. Of paramount importance is the ability of the provider to determine the severity of the child's presentation, stabilize his or her condition, and intervene or refer to critical care in a timely manner. These skills help to assure quality pediatric care. Pediatric training in the past has excelled in providing residents with these vital skills and must continue to do so in the future.
Although pediatricians in past decades spent much of their time dealing with acute illnesses, the care of children with chronic conditions is now beginning to dominate many practices. Current estimates of the number of children with chronic illnesses and other disabilities vary somewhat, depending primarily on the breadth of definition one uses. Approximately 2 million children meet stringent definitions based on the level of severity of the condition.27 A broader definition of disability, based on findings from the National Health Interview Survey on Disability (1994-1995), identifies between 15% to 18% of children as having ongoing chronic health conditions (developmental, physical, or mental) that affect functioning or require compensatory services to maintain functional level.28 Among children with chronic conditions, approximately half have developmental disabilities, mental health impairments, or psychological conditions, ranging from common diagnoses like attention deficit hyperactivity disorder to severe psychiatric disorders. A wide range of chronic physical conditions make up the other half, with moderate and severe asthma accounting for nearly one third of such conditions.29
The number of children and adolescents with moderate to severe chronic medical conditions requiring ongoing care has increased over the last several decades. Although some of this reflects the growing incidence of certain conditions, including asthma and acquired immunodeficiency syndrome, much of the increase reflects improvements in life-prolonging medical and surgical care. Because of technological advances, there are increasing numbers of survivors of previously fatal conditions, such as prematurity, organ failure, and childhood cancer.30 Currently, estimates are that over 95% of children with severe chronic conditions survive to young adulthood (J. M. Perrin, personal communication, February 1998). Some of these children are permanently dependent on complex medical interventions, and many experience serious developmental or emotional morbidity.30,31 Pediatrics must address the long-term complications of their diseases and treatment, as well as the unique developmental and behavioral needs of these children. Long-term survivors of prematurity and childhood malignancies are altering the profile of pediatric health care, and decisions will need to be made about who will provide care as they transition into adulthood.
In addition, although behavioral and developmental issues are hidden in the context of most patient encounters in pediatrics, a growing percentage of children are developing more severe developmental-behavioral pathology, placing them in need of more intensive therapy. One study estimated the rate of significant behavioral pathology in children between 9 and 17 years of age at 9% to 13%.32 If subthreshold disorders are included, the number might range as high as 40%.33 Rarely does a 3-year training program afford enough experience with the spectrum of developmental-behavioral disorders to make the new graduate expert.
At the same time, infectious disease experts warn that a number of chronic infectious diseases potentially present problems for children in the future. Tuberculosis and acquired immunodeficiency syndrome rates have increased over the last 2 decades, and drug resistance is common in some parts of the country. Altered antimicrobial susceptibility patterns and increasing failure/relapse rates are being identified for streptococcal, staphylococcal, and other infections. Although some infectious diseases may be better controlled or even eradicated in the future, other pathogens may emerge and require more complex treatment regimens and up-to-date information on community resistance trends for effective therapy.
The generalist pediatrician can thus expect that 1 of 10 children will have a moderate to severe long-term health condition. Of this group, nearly one half will have mental retardation, developmental disabilities, or significant mental health problems. The other half will consist of children with a variety of chronic medical diseases, including asthma, diabetes, sickle cell anemia, and cystic fibrosis. Currently, 5 chronic conditions occur in children with relatively high frequency: asthma, recurrent otitis media, adolescent depression, attention deficit hyperactivity disorder, and developmental disabilities (primarily mental retardation and cerebral palsy). Other conditions occur so infrequently that an individual pediatrician may have little experience with that disease (J. M. Perrin, personal communication, May 1998).
These figures have important implications for pediatric training. With respect to developmental- psychological pathologies, practitioner surveys have identified a lack of confidence in ability to identify and treat these problems as a major barrier to care.34-36 The evolution of new tools, including symptom checklists and the Diagnostic and Statistical Manual for Primary Care, along with post-graduate education in this area, can allow pediatricians to become knowledgeable members of a team of providers managing these cases. Families of children with chronic medical needs have reported variable access to care and confidence in their specialty providers and have also commented on inadequate attention to parental concerns by primary care providers.37 Clearly, improved partnerships among families, pediatricians, and pediatric subspecialists (medical and surgical) must be developed. Pediatricians will need sufficient training in the unique requirements of children with special needs. Evaluation and management of children with chronic conditions take time and flexibility away from a physician's productivity requirements; reimbursement and time constraints remain a major impediment to managing these important health-related needs of children. Other barriers also exist including delay in activation of health care benefits with changes in coverage and restrictions for needed services, including durable medical equipment and mental health care.38,39
Three types of data are commonly used to identify the projected health needs of adolescents. First, the prevalence of high-risk behaviors is the most frequently quoted set of statistics for the adolescent population. Second, important quantitative measures of adolescent health service use, such as hospital discharge data and ambulatory care/physician data, are more difficult to access but reflect key indicators. Third, the trends in adolescent health behaviors that serve as adult precursors for adverse health outcomes, such as obesity, cigarette smoking, and alcohol and drug abuse, are also important in directing preventive health efforts.
With respect to the prevalence of high-risk behaviors, the trends in outcomes related to early sexual activity, substance use, violent behavior, and deaths secondary to unintentional injuries are more readily accessible than data that reflect trends in mental health behaviors, with the exception of suicide. Teen births negatively impact both the mother and child by limiting the mother's educational and employment opportunities, increasing the likelihood they will need governmental support, and ultimately affecting the overall development of the child. Although the adolescent birth rates steadily declined between 1960 and 1985 (89.1 to 51.0 per 1000), the trend reversed briefly from 1985 to 1991 (62.1 per 1000) and then moderately declined after 1991 to 52.9 per 1000 by 1997.40 Measures of substance use vary by specific substance and the age group of the adolescent. During the 1990s, there was an overall increase in the percentages of 8th, 10th, and 12th grade students who smoked daily, drank heavily, or used illicit drugs.19 Males and females are equally likely to be frequent smokers according to 1993 data. Marijuana use almost tripled among 8th graders (from 3.2% to 9.1%) and more than doubled among 10th graders (from 8.7% to 17.2%) between 1991 and 1995.41 For teens 15 to 19 years of age, homicide accounted for 10% of all deaths and unintentional injury accounted for 46% of all deaths40; gun-related injuries and unintentional injuries including automobile-related injuries continue to be major causes of morbidity as well. Data addressing the suicide rate for adolescents demonstrate that the suicide rate for adolescents from 15 to 19 years of age doubled from 5.9 to 10.8 per 100 000 between 1970 and 1990. Since 1990, the overall suicide rate has stabilized at 11 per 100 000.40
Both type of conditions and quantitative impact must be examined with respect to measures of health care utilization. Data published in 1998 indicate that injury and poisoning, mental disorders, and pregnancy and childbirth represent 43% of the top 5 hospital discharges for young adolescents, 85% for older adolescents, and 87% among young adults. Ambulatory care visits involved relatively straight forward conditions for nearly 25% of the visits, and included colds and sore throats, ear infections, skin and vision problems, hay fever, and allergies. Younger adolescents had more visits for general exams and asthma, whereas older adolescents had more visits for skin problems, urinary tract disorders, and contraceptive management.42 From 1986 to 1996, the rates of hospitalization for 15 to 24 year olds dropped by nearly 30%; hospital care of adolescents for conditions other than trauma will probably continue to decrease. Ambulatory visits for conditions related to at risk behaviors will increase as access to care improves.
Obesity and tobacco use are examples of the conditions during adolescence associated with increased health risk in adulthood that could be positively influenced by intervention strategies in recent preventive guidelines.43 Obesity (or weight excess) can be exhibited in childhood and tracked into adolescence. Data from national surveys indicate that adolescent obesity is increasing with as many as 26% of white females and 25% of black females determined to be obese by skin fold thickness. Obesity is not only a major risk for cardiovascular diseases in adulthood but is independently correlated with hypertension, hypercholesterolemia, diabetes mellitus, gallbladder disease, arthritis, and gout.44 Cigarette use is increasing for most age and gender groups after some evidence of reduction in 1992 and has been linked to chronic diseases in adulthood, such as cardiovascular disease, various cancers, and chronic obstructive lung disease.19,45
Although the term new morbidity was not quoted in the 1978 report, the biopsychosocial and developmental aspects of pediatrics were addressed. The need for pediatricians to have the skills to deal with injury prevention, child abuse, suicide attempts, birth of a disabled infant, and other common behavioral disorders was specified. The critical importance of good interviewing techniques, systematic observation, and communication with parents and children was stated, but the reports stopped short of specific recommendations in the area of counseling and recognition of specific mental disorders. Evidence since 1978 indicates that pediatricians will be called on to do more in these areas. The trends in several of the biopsychosocial issues of concern have shown an increase; for example, the rate per thousand children experiencing child abuse under 18 years of age has increased from 11/1000 in 1990 to 15/1000 in 1995,46 (E. Wood, personal communication, 1998). A number of surveys suggest that pediatricians still express low comfort and confidence in certain skills necessary to address biopsychosocial and developmental care.34-36 There is still much to do in the education of pediatricians and parents relative to the new morbidities.
It is also true that the new in the new morbidity will continue to change. In the 1990s, the medical-social epidemics of cocaine/crack use, homelessness, poverty, urban violence, and human immunodeficiency virus disease are among the newest challenges to pediatric care.17,47 The previous concerns for developmental and behavioral problems in young diabetic, asthmatic, and nephrotic children have been expanded to encompass chronically ill children and young adults with chronic conditions. The impact of a shortage of quality day care for all US children continues to be a problem and will increase as more mothers enter the workforce under welfare reform. Although it is impossible to anticipate which morbidities will be added in the next millennium, the early years of the next century will be spent responding to the challenges of these changes.
Summary: The Impact of New Patterns in Morbidity and Mortality Children will continue to need well-child health care, including screening histories and physicals, immunizations, and anticipatory guidance. Effective strategies and attention to behavioral and developmental issues will be essential to address many of the causes of morbidity and mortality in children and adolescents. These interventions will need to occur during well, acute, and chronic care visits and in a child's family and culture. There will be fewer visits for common current acute care conditions like otitis media, diarrheal diseases, and other infections for which vaccines will be available. There will still be febrile episodes and other acute illness conditions, which will require evaluation. Chronic care visits will become more prominent, reflecting the increasing numbers of children with ongoing physical, developmental, and emotional problems. Changing sociodemographics of US society will alter the agenda of the preventive visits, as well as compel adjustments in the hours and settings in which care to children and families is provided. Projections are that by the year 2020, over half of the nation's children will consist of traditionally underrepresented minorities. Attention must be given to the recruitment and support of minority pediatricians.
The Generalist Pediatrician: The Impact of Molecular Advances in Biology Genetics
Technological advances are rapidly changing the scope of molecular genetics in the diagnosis and treatment of childhood illnesses and it is unclear at this time what the impact of these advances will be on the health care needs of children in the next 2 decades.48 The impact of the new biology currently is far-reaching, including the use of polymerase chain reactions in the diagnosis of infectious diseases, advanced chromosome techniques for many syndromal diagnoses, and genetic probe tests for some metabolic defects.49 This section describes recent advances in molecular biology and genetics addressing recent scientific and technological advances and the impact of genomics on the role of the generalist pediatrician.
Important scientific and technological advances will be forthcoming from the Human Genome Project. The US Human Genome Project began in 1990, as a coordinated effort of the US Department of Energy and the National Institutes of Health, to identify all the estimated 80 000 genes in human DNA and to determine the sequences of the 3 billion chemical bases that make up human DNA. In addition, this information will be stored in databases from which it can be retrieved for interpretative analysis. A unique aspect of the project has been that funds have been earmarked to address the ethical, legal, and social issues, which will inevitably rise from this new information.
The goals of the project are to produce a comprehensive genetic map based on pedigree analysis, then a physical map of the distances between genes, followed by a map of the location of genes in the human genome, and finally a determination of the complete DNA sequence. To date, over 50 000 genes have been mapped to particular chromosomes and tens of thousands of human gene fragments have been identified and assigned to positions on chromosome maps.50 The physical mapping goal is to establish a marker or sequence tag every 1 000 000 bases across each chromosome or approximately 30 000 markers per chromosome. Because of the development of automated sequencing machines and DNA chip technology, the process of gene mapping occurs much more rapidly.
When completed, the detailed DNA information will help us fully understand the structure, organization, and function of DNA in chromosomes. Genes involved in many diseases will be found and analyzed as either direct or indirect contributors to pathophysiology. Medical practice will have access to rapid and accurate diagnostic capabilities for both extant disease processes and susceptibilities. This will allow much greater emphasis on prevention because we will be able to identify individuals predisposed to a particular disease and, therefore, have the opportunity to intervene, whether by gene therapy techniques, avoidance of environmental comorbid factors, the development of new therapeutic agents, or other mechanisms.
Rapid advances in technology and understanding over the next 2 decades will continue to dramatically alter our understanding of the pathogenesis, diagnosis, and treatment of many different kinds of childhood cancer.51 In addition, improved diagnosis of infectious diseases will increase the speed and precision with which we are able to identify specific infections. Many other conditions in pediatrics are amenable to diagnostic molecular genetic technologies, eg, sickle cell anemia, thalassemia, Duchenne muscular dystrophy, cystic fibrosis, as well as many others, as the human genome project continues to identify new candidate genes.
Generalist pediatricians will need to understand the uses and limitations of these tools and be able to clearly discuss them with children and their families. Many health care providers have limited genetics training and are incompletely prepared to deal with the complexity of the emerging information. Medical training in genetics has lagged far behind scientific advances. Both medical schools and training programs must develop courses and faculty to cope with the rush of new information. The rapidity of advances will compel physicians to continually update their knowledge and strain the limits of printed information to be current. Thus, access to computerized databases as reference tools will be essential.
As techniques for genetic testing of children for adult-onset diseases develop, pediatricians will also need to be advocates for children. The psychological, economic, and physical risks that might result from genetic testing must be balanced against the benefits of earlier detection.52 Our understanding of molecular genetics technically is much further along than our understanding of its ethical implications, especially in the areas of autonomy, privacy, and justice.53 Ethical implications of these principles must be examined in the areas of genetic testing, carrier identification, prenatal diagnosis, gene therapy, and insurability.
Summary: The Impact of Molecular Advances in Biology and Genetics Advances in molecular biology and genetics are occurring at a rapid rate and promise to substantially affect the diagnosis, treatment, and understanding of a number of pediatric conditions. Pediatric training in human genomics currently is inadequate, both in terms of updating physician knowledge as well as understanding ethical implications. This must be remedied in the future. The ultimate impact of this technology and related issues on medicine in general and on the practice of pediatrics in particular will be of great importance.
The Generalist Pediatrician: The Changing Makeup of Child Health Professionals
Another factor potentially affecting the role and scope of the generalist pediatrician in the 21st century is the changing demographic and educational makeup of the available pool of health care providers caring for children. In the following section, we discuss a variety of provider groups, speculating on their partnerships in the future with generalist pediatricians. Interactions with other health care providers offer opportunities to improve both access to and quality of care for children; they may also lead to competition for patients, negatively affecting care. These challenges are discussed below. The potential impact of the increasing number of women entering pediatrics was also considered.
Future opportunities for nurses and medical office workers in the context of the pediatric practice are multiple. These traditional extenders will be used to expand opportunities to improve practice efficiencies. They will, for example, ensure compliance with treatment, collect data on quality of care and patient outcomes, and survey patients around satisfaction measures, as well as assure compliance with government regulations and assist patients with accessing care and services in an increasingly regulated environment.
Practitioners partnering in the care for children with generalist pediatricians include child psychologists; masters of social work; nutritionists; and physical, occupational, and speech therapists. Although large multispecialty groups have long included mental health services as part of their practice structure, integration of mental health services in most pediatric practices has been slow. Because issues concerning developmental, behavioral, and mental health are so critical to primary care practice, the success of this particular future alliance will have important implications for the future of the generalist pediatrician. Likewise, the use of nutritionists in pediatric practice for issues around dietary counseling, weight control, food fadism, and nutrition for special populations in pediatrics is a natural extension of primary care. The direct integration of occupational, physical, and speech therapy specialists into pediatric practices is also desirable. Clearly, the types of health-related problems these providers address are common and anticipated to increase in the future.
Changing reimbursement patterns must allow for creative use of an extended network of providers to better meet the needs of children. Large groups will have to develop subcontracts with these allied providers if they can not be supported within the practice setting. Research will need to be performed to demonstrate the effectiveness of these partnerships and to address the necessary ratio of providers to available patients. Alternatively, if reimbursement for pediatric services is priced too low to cover costs or there is no mechanism for receiving reimbursement for specialized services, financial barriers could be erected, affecting access to needed services.
Pediatric nurse practitioners (PNPs) have a major responsibility for providing direct patient care with a strong focus on primary care. Approximately 77.5% of PNPs work in urban areas with populations over 50 00054 and function in a variety of settings including hospitals, clinics, health maintenance organizations, private practices, and school and community clinics. Most children seen by PNPs are younger than 12 years of age and come from families with low educational attainment and of limited financial resources.55 PNPs have also been providers in alternative delivery systems including school-based health clinics, day care centers, foster care, and juvenile detention.56
Collaborators with pediatricians for the past 3 decades, the opportunities for cooperation between pediatricians and nurse practitioners should increase in the future. Although nurse practitioners have engaged in many of the facets of care performed by pediatric generalists, many opportunities to carve out specialized competencies in practice exist. PNPs are already acknowledged as particularly skilled in health promotion activities.56 Expanding opportunities could target educational programs for families, patients, and staff; coordinate case management for patient populations like children with asthma and lead poisoning; provide gynecologic and contraceptive services; and perform longitudinal follow-up for children with chronic illness.
Because of training biases, preferences, and reimbursements issues, physician assistants have tended to be incorporated primarily in the hospital setting in the past but increasingly are making their way into the office setting. Since the nature of their training directs that they must practice in a regulated environment under direct physician supervision, they offer the pediatrician an attractive alternative means to expand the scope and range of services provided. In this perspective, it is also clear that physician assistants, depending on their background, might be particularly useful in expanding the diverse nature of practice from a social, cultural, ethnic, and medical perspective. However, there is discussion in the physician assistant field to reclassify physician assistants with >6 years of practice experience as physician associates. This possibility would tend to suggest a movement toward independent practice, similar to some nurse practitioners, with the same potential for interdisciplinary strife.
The overlap between the roles of primary care pediatrician and family physician certainly creates the potential for competition in areas with physician oversupply. Pediatricians have increased training time both in the pediatric outpatient and pediatric inpatient setting. Health policy research has not proven conclusively that there is a consistent measurable difference in behavior between the 2 groups.
Pediatricians in rural settings have described a variety of models for cooperation with family physicians in areas where physician undersupply promotes cooperation. First, the presence of a pediatrician in a relatively remote area improves the standard of care for common pediatric illnesses, as the pediatrician educates local family physicians about new standards of pediatric care. Second, pediatricians are often subsidized by rural hospitals to provide neonatal services and, in turn, train a cadre of interested family physicians to share the call burden. Third, rural pediatricians act as intermediaries between local family physicians and pediatric subspecialists, playing a consultant role to save the families the expense and difficulty of traveling a long distance for what might be a simple problem.
None of these benefits are applicable to a suburban location with large numbers of primary care physicians, specialists, emergency departments, and sophisticated hospitals. The American Academy of Family Physicians calls for 1 generalist per 2849 persons.57 This does not take into account the presence of the increasing numbers of internists and pediatricians choosing primary care; we can then expect an oversupply. Pediatricians in a crowded environment will need to compete both with each other and with other types of providers based on measurable competence, cost-effectiveness, and patient satisfaction. National organizations will need to work together to improve distribution of physicians, while controlling oversupply, establishing practice guidelines to define quality of care, and fostering improvements in the child health components of training programs.
As mentioned previously, the mental health care needs of children and adolescents are substantial. Responding to this projected and currently unmet need will require adequate training in the diagnosis and management of mental health needs and will necessitate a workforce capable of responding to those needs. There is growing concern, however, that managed care may negatively impact access to mental health services for children. First, mental health visits may be limited to relatively few visits, which may not be appropriate given an individual child's level of functioning.58 Second, the numbers of child and adolescent psychiatrists are limited and their role is increasingly relegated to prescribing and monitoring the use of psychotropic medication for seriously ill children (D. R. DeMaso, personal communication, 1997). Lastly, appropriate specialty care may not be available within a given managed care network. Clearly, the mental health needs of children and adolescents necessitate more service than is currently being provided. Generalist pediatricians must work in concert with psychiatrists, pediatrician-psychiatrists, behavioral and developmental pediatricians, and other mental health providers to advocate for access to these services.
Over the past decade, nearly 20% of pediatric residents have chosen the Med-Peds combined residency pathway. The impact of 400 graduates annually entering the workforce of child health care is not fully understood. Nonetheless, it is highly likely that Med-Peds graduates will be important in the care of children.
The scope of practice and skills of Med-Peds graduates, as well as local needs, will determine the precise role of these physicians in the care of children. The duration and rigor of training and other factors including graduate medical education funding may limit entry into Med-Peds residencies, possibly leaving this group to play a lesser role relative to other primary care disciplines that care for children. In addition, the maturation of individual Med-Peds practices may influence practitioners to focus on age-related different components of their knowledge base and skills as their careers mature. How the effect of that transition and the quality of practitioners that the discipline will attract will ultimately affect the quality of care children receive is uncertain.
Currently 15% of students choosing pediatrics as a career select a Med-Peds residency.59 Hence, Med-Peds will remain a significant proportion of those physicians intensively trained to care for children. An indirect impact of Med-Peds will be to help maintain interdisciplinary integration within medical centers. The discipline offers the opportunity to create new collaborative bridges with other fields outside the customary domain of pediatrics. Thus far, Med-Peds has created a legacy that pediatric departments can use to increase their familiarity with access to other areas of excellence within their own institutions. The discipline can also develop models and mechanisms to improve the probability that the morbidities pediatricians strive to prevent will not be underemphasized as children transition to adult care. Collaborative models will need to be fostered, as competition and compartmentalization threaten the cohesive integrity of medicine.
The operative factors will be the expanded skill set of Med-Peds practitioners, an evidence-based approach to generalist care across the age spectrum, a unique perspective, and the prevailing emphasis on primary care. As recognition of the discipline as a viable alternative for students continues to increase, Med-Peds cannot help but enhance the esteem of total generalist care. The expanded skill set of Med-Peds practitioners will permit new combinations of areas of clinical emphasis for generalists in multiple practice sites. There are multiple other examples in which a dual-discipline perspective may influence management orientation. The overall minority position of Med-Peds in the entire domain of generalists may somewhat minimize the impact, although their uniqueness may provide them some enhanced visibility and influence.
Med-Peds has the potential to become important for practitioners of certain subspecialties whose existence is currently challenged, such as pediatric rheumatology. In other specialties and subspecialty niches, the Med-Peds graduate may represent an ideal practitioner, eg, in areas such as adolescent medicine and transitional diseases, such as cystic fibrosis, survivors of congenital heart disease, and sickle cell disease. They are likely to participate to the degree that they need to be considered in planning workforce needs, in areas such as infectious disease, gastroenterology, nephrology, and pulmonology. A subspecialty area that is not likely to be affected is neonatology. Limitations of Med-Peds program graduates entering subspecialty training include the length of time required, the challenge of developing dual-discipline integration at a fellowship level, the expense of initial and continued dual-discipline certification, and the need to declare a primary departmental home in most academic medical centers.
In conclusion, selection of the Med-Peds pathway by pediatric residents continues. The obvious advantages of this pathway are the potential of a dual board-certified generalist physician with an understanding of adult transitional care and the capability to follow patients for long periods of time. Disadvantages are the length of training and the relative uncertainty of public acceptance of this discipline.
Similar to the situation with PNPs and family physicians, the possibility of physician oversupply has encouraged discussion between primary care pediatricians and pediatric subspecialists about the roles of generalists and subspecialists and the linkages between the 2. Research in internal medicine on the outcomes and quality of care provided by generalists and subspecialists is limited and conflicting.60-62 Several studies have shown that generalists treating certain conditions have equivalent outcomes to subspecialists but consume fewer resources. Other studies have shown better process and outcome measures when conditions have been managed by subspecialists. Research is needed in pediatrics addressing appropriate care parameters for generalists and subspecialists. Research must also be undertaken to ascertain whether pediatric subspecialists provide better quality care to children, compared with adult subspecialists who lack sufficient training in child physiology and developmental stages and knowledge of appropriate community resources.63
There is growing consensus in the pediatric community that primary care pediatrics in the future will continue to provide routine illness care and anticipatory guidance, but an increasing amount of time will be spent managing chronic illness. Episodes of care that begin with visits to a primary care clinician as opposed to other sources of care are associated with reductions in expenditures.64 Pediatricians can provide ongoing care for many children with chronic conditions, in collaboration with subspecialists, as demonstrated by the long experience of many childhood cancer programs.65 In most locations, generalist pediatricians will continue to provide both newborn care and some inpatient services. Future trends might include the expanded role of academic consultative generalists, to assist primary care providers in linking patients to the appropriate branch of the tertiary system when the clinical situation is not clear.
There are several barriers to the implementation of the collaborative, tiered model. First, several studies have suggested that parents are not confident with generalists' level of skill in managing complex illnesses.66,67 Second, there is no clear consensus as to what types and severity of problems or what aspect of any given chronic problem should be managed by primary care pediatricians and what should be the domain of the specialist. Third, time and productivity pressures under managed care seem to be generating increased practitioner referrals to subspecialists of children with normal variations in physiology, at least in the field of cardiology.68 Fourth, if a subspecialist is not affiliated with one's health plan, the out-of-pocket cost for a necessary consultation may be prohibitive for many families.
The changing makeup of child health professionals also includes
the rapid influx of women into pediatrics. Data collected by the
American Board of Pediatrics identify that 64% of 1998-1999 first-year pediatric categorical residents are female.69
This is the highest percentage of women residents in any specialty. Although women have chosen pediatrics as a profession for many years,
women pediatricians in general are a young group. Data collected by the
AAP Department of Research identify that although 49% of active AAP
members are women, 61% of female pediatricians are <40 years old,
compared with 37% of male pediatricians.70 Thus, the
pediatrician of the future is most likely to be female. Similar to
women in other professions, juggling child care, household needs, and
care of elderly parents still tends to be the responsibility of women
pediatricians. The pediatrician of the future may be sharing a position
or having office hours or time commitments that reflect other
priorities and interests. Thus, she is more likely to have a better
appreciation of parenting problems and family dynamics. She has,
however, the potential of being undervalued, underpaid, and
exploitedparticularly if she chooses to work part-time.
Recent surveys have pointed out that younger male and female physicians are both reporting moderate levels of role conflict.71 As societal expectations change, male physicians are being asked to shoulder increasing familial and household responsibilities.72 Both younger male and female physicians also report making career changes because of their marriage or children, although female physicians were more likely to have made changes for their children.71 Pediatrics, thus, must not only consider the needs of the number of women entering the field but those of the young dual career couples with 1 or both partners practicing medicine and attempting to balance multiple roles. As Fletcher and Fletcher72 so succinctly state, society can "expect physicians to be unusually responsible, educated, and hard-working. But the old way of demanding single-minded dedication to the profession needs to be recast because it depended on a full-time backup for the rest of life's activities."
Medicine as a profession needs to grapple with the issues surrounding the balance between work and family as other professions are beginning to do. But pediatrics, because of its changing demographics, urgently needs to face these issues and pave the way for change. The increase in large group practices may make some of these changes easier. Pediatric practices also need to consider the importance of coordinated schedules, fair leave policies for childbirth and child-rearing, quality day care at or near the workplace that helps parents address the issue of sick or vacationing children, and nontraditional work hours. Flexible approaches for the recruitment of pediatricians, academic promotion and/or advancement, and achieving partnership in practice must also to be considered. Fees for membership to medical organizations may need to be adjusted to take into account part-time positions or couples who do not need 2 copies of every mailing. True job-shares need to be developed with flexible benefit packages. The needs of dual-career families may be particularly important in rural underserved areas; anecdotal reports by young women physicians in rural areas stress the importance of recruiting that takes into account their partner's occupational needs as well. Many of these changes may also improve patient care. Increased evening and weekend hours, use of electronic media and telecommunications, and a heightened sensitivity to family issues may offer more opportunities for women pediatricians as well as better access to care for working families.
Summary: The Impact of the Changing Makeup of Child Health Professionals Allied professionals will be important for addressing the future health care needs of children, but integration may be difficult given changing reimbursement strategies. The specter of provider oversupply must be considered and ongoing dialogues with the National Association of Pediatric Nurse Associates and Practitioners, the American Academy of Physician Assistants, and the American Academy of Family Physicians must continue. Primary care providers must fight their battles cooperatively, over issues such as adequate time with patients, access to appropriate subspecialty care, and provider authority for decisions about patient care. Pediatricians must, however, continually stress the added value that they bring to an encounter with a child and his or her family. This includes their detailed knowledge of child health and physiology within the context of developmental stages, their expertise in managing both ambulatory and critical care conditions, and their focus on the child within the context of the family. In addition, generalist pediatricians can be expected to manage children with chronic conditions, especially those with lower acuity. Adequate training during residency in subspecialty outpatient care, effective continuing medical education programs, and strong linkages to pediatric subspecialists will be essential. Lastly, the impact of the changing gender of pediatricians must be addressed. The pediatrician of the future is likely to be female and to be balancing career and home life. At a time when generalist pediatricians need broader capabilities and when workforce issues among a variety of health care professionals could either lead to collaboration or competition in the care of children, issues of gender and commitment must be transformed into strengths and not allowed to undervalue the discipline of pediatrics.
The Generalist Pediatrician: The Impact of New Capabilities for Data Management and Communication
Advances in computer technology and electronic media also hold promise for allowing the pediatrician to better care for children and their families and are reviewed below.
Computers have the potential for strengthening the physician-patient encounter. For example, templates that guide providers through a directed history and examination of patients with specific categories of conditions not only improve documentation, but also promote appropriate physician action. Templates can be individually modified and customized, as experience and new knowledge change the clinical relevance of different data items. Similarly, computers have the potential to help with diagnostic decision-making. Their ability to quickly search through reams of information and consider thousands of possibilities provides an outline to the practitioner, delivering sensitivities and specificities of clinical and laboratory features of the conditions under consideration, expanding the differential diagnosis, and allowing the clinician to quickly explore myriad possibilities.73 Yet templates and guidelines can only elicit knowledge that already exists in the mind of the practitioner, helping him or her to make new connections. Pediatricians will need the skills to use templates and algorithms without being dependent on them and have the knowledge base to address how to improve the capabilities of the computerized encounter.
Computers also have a role to play in therapeutic decision-making. The medication prescription is often the final pathway of the clinical interaction and one that can make the difference between success and failure. Computerized prescription writing (linked to information from the patient record) affords the possibility of eliminating common errors involved in this process, such as prior allergic reactions, or not considering drug interactions in patients with complex problems on multiple medications. Computer systems also provide the practitioner with information on the cost of alternative medications and with a list of those medications on formulary with an individual patient's insurance plan. Incorporation of computer-guided therapeutics into the training regimen will be commonplace in the future. Hospitals are increasingly using electronic ordering74 and computerized anti-infectives-management programs have been shown to reduce costs and to improve the quality of patient care for critically ill patients.75
Computers and electronic media also have the potential to add efficiency to the patient-physician encounter through computerized previsit-screening questions, visit reminders, and anticipatory guidance tips.76 The office of the future will have computers in the waiting or examination rooms to allow patients to create part of the history before seeing the provider. Some of this information may also be acquired using the Internet before a visit, moving a portion of the patient-physician encounter out of the office setting. The Internet also provides a tool for sharing information and concerns between pediatricians and families. It is likely that medical practices will each have their own web page, where patient queries can be addressed via preformed statements or personal replies.
Telemedicine applications show clear relevance for nonroutine patient encounters involving the management of the complex medical problems of children with chronic illnesses or in emergency situations, particularly in rural settings.77,78 The rapid transfer of detailed clinical information and images will enhance the phone consultations that traditionally have linked physicians with geographically distant specialists. Already, academic medical centers are using technology to consult with subspecialty experts. Electrocardiograms, ultrasounds, and other information could also be instantaneously provided to experts or transport coordinators to provide for appropriate management and consultation. In addition, visual and physiologic measurements from patients can be relayed using telemedicine application.
Computerized technology holds promise for physician education, both generic and patient-specific. Continuing medical education will need to use these technologies given the rate of change anticipated in the future and the need to rapidly disseminate new information. Professional chat-lines (including the AAP site, the developmental-behavioral pediatrics site, and others) can be a vehicle for active learning and sharing of experience.
The world of billing has become more complicated, and the computer holds many advantages from a billing perspective. The physician of the future, even in a salaried position, will have his or her compensation tied somewhat to productivity, however that is measured. Knowing how to manipulate scheduling programs can make the difference between a reasonable or unreasonable pace to the day. In addition, computers that accurately record the details of a physician's interactions will allow the pediatrician of the future to properly assess the quality of his or her care and to mold a practice environment that ultimately improves care.79 In the past, quality goals were ill-defined and usually measured by chart review, subject to multiple data error problems. Quality measures in the future will have a defined numerator and denominator, all accessible electronically.
Use of the computer provides pediatricians with the capability of
profoundly reducing the typical errors that occur daily in
practice.80 Visits that are missed, lab tests that are not
followed up, lost opportunities for immunizationsthese are all part
of the daily lives of practitioners. Computers can improve access to
selected information and avoid reliance on many persons' memories.
Computer-generated patient reminders are a typical example, with a
financial payoff for fewer missed appointments. Analogous physician
reminders can include pending lab results, immunization gaps, or any
miscellaneous data that need follow-upand can easily be programmed to
appear on the encounter record to remind the clinician of their
importance.
The legal issues involving confidentiality have become increasingly complex, however, since medical information stored electronically, in theory, can be accessed by anyone with the appropriate skills. All the advantages of electronic forms described above make the information easier to invade and use for nonmedical purposes.81 For example, employers could discover confidential material that could lead to discriminatory decisions. Computers also have the potential to be used to promote conformity to a lower standard of care if financial considerations are paramount over clinical concerns and the emphasis is on tracking the productivity of physicians, as measured only by number of patients (or relative value units), as opposed to improving quality of care. Lastly, communication through computers lacks many of the nuances of visual cues and voice inflection that must not be lost in the doctor-patient-family relationship.
SummaryThe Impact of New Capabilities for Data Management and
Communication
In the future, computers will become indispensable tools for the
primary care pediatrician for use in the patient-physician encounter,
rapid communication with patients, families and subspecialty services,
management in the office setting, and the pursuit of new knowledge and
training. These technologies also have their dangers. The pediatrician
of the future must, therefore, be comfortable with computers and
cyberspace.
The Generalist Pediatrician: The Impact of Changes in the Financing and Delivery of Child Health Services
Perhaps the least predictable and the most troubling factor affecting pediatrics care at this time is the impact of the widespread adoption of managed care over the last decade. The financing of health care strongly influences the organization and delivery of health care services. Predictions for the role of the generalist of the 21st century must take into account current reimbursement trends for health services and anticipate how public and private sector initiatives in the financing and organization of child health care services will affect child health care in the future. For the next decades, the pediatric community must also closely monitor several trends to assure that the quality of health care services to children is maintained, if not improved. These trends are described below and include the implications of anticipated changes on: 1) the structure of the health care system, and 2) the provision of preventive services to children, and 3) adequate, high quality care for children with chronic conditions.
While managed care has dominated the 1990s, no 1 clear vision of the future system for the financing and organization of health care services in this country has emerged. There are several new players emerging in the health care field including provider-based integrated delivery systems, community networks, and new large physician group practice arrangements.82 In addition, some large purchasing groups of employers have indicated interest in contracting directly with large provider units bypassing managed care plans.11 Most analysts conclude only that the pace of change can be expected to continue at an unprecedented rate over the next several decades.
It is anticipated, however, that the incorporation of small groups and solo pediatricians into larger pediatric or multispecialty groups will continue. This consolidation affords some economies of scale in the provision of health care, greater flexibility in the range of services offered, and more access for negotiations with health care plans and purchasers. It also offers pediatricians the opportunity to develop new models for the provision of health care services to children that build on our profession's current strengths and better addresses changing morbidity patterns.
Pediatricians will need to have an active voice, however, to assure the flexibility necessary to improve health care for children and families. Pediatricians will need to advocate for the critical analysis of productivity report cards that only recognize standard models of providing and measuring quality care, such as the number of office visits. Strategies that use a capitated reimbursement scheme to provide needed preventive care, anticipatory guidance, and behavioral and developmental counseling should be encouraged. Pediatric participation with school-based health centers, evening parent-education classes, and other health-focused community service organizations should also feed into the reimbursement equation. In addition, reimbursement rates must provide physicians with an adequate income, so that the practitioner's medical decisions on utilization are not influenced by personal economic considerations. In return, pediatricians will need to be efficient stewards of the health care resources attributed to children and demonstrate the added value of pediatricians in the provision of general health care services to children.
In addition, no matter what form or forms the financing and organization of children health services take in the future, the era of accountability has arrived. Cost-containment strategies including utilization review, primary care gatekeepers, risk sharing, and capitated reimbursement are increasingly used to hold health care providers accountable for costs. Clinical practice guidelines provide the background for devising some performance measures and allow managers to quantitate whether appropriate decision-making occurs and to determine whether new information is being incorporated into practice patterns. Physician profiling, patient satisfaction surveys, and performance measures are also used to provide a means of determining the worth of health care services purchased. As families become increasingly more comfortable with their role as consumers, health care will also need to be accountable for the needs and desires of families.
Some consensus on what defines appropriate care will need to be an increasing part of the agendas of medical professional organizations. Tools to assure accountability for the quality of the product employers and legislators purchase will continue to develop. These are sorely needed, for in some geographic areas, market forces are driving down health care expenditures toward the threshold where quality of care can no longer be maintained. Practical measures for quality of care for children must be developed and propagated. Quality measures being developed by the National Commission on Quality Assurance, the Pacific Business Group on Health, the Foundation for Accountability in Health Care, the Joint Commission on Accreditation of Health Care Organizations, RAND, and others,83,84 while in their infancy, provide such methodologies. Consumers, providers, and child health advocates will need to assure that tools developed adequately measure the quality of services provided to children and resulting outcomes. These tools will assist in monitoring the impact of business decisions.
A second major area of concern over the next several decades will be the role of health care plans in addressing both prevention as well as the biopsychosocial needs of children with chronic conditions. While older models, primarily staff or group model health maintenance organizations often stressed preventive care, many of the looser organizational models prevalent in managed care today do not share that focus. Preventive care, particularly in pediatrics, may have cost-saving advantages, but these are, for the most part, long-term. Many child health advocates caution that some managed care plans, with an unbalanced focus on profits and the use of capitation, negatively affect access to preventive care services. From a business perspective, preventive services may seem to be a poor investment given an average length of stay in a health plan of ~18 months.85
Pediatricians, with their in-depth knowledge of the health care needs of infants, children, and adolescents and their strong sense of advocacy, have an important role to play in assuring the delivery of preventive services as health care systems evolve over the next several decades. As mergers and consolidations of managed care organizations continue, pediatricians will need to advocate for cooperation between these plans for the covered lives in their community, highlighting the potential quality of care and financial benefits to these plans of cooperating with each other to promote a strong focus on preventive care. Employers who purchase health coverage may also play a role in promoting preventive services, because employers are increasingly calling for outcome measures that address employee absenteeism related to family illness.
Some models of managed care have created multiple disincentives and barriers to the provision of appropriate, quality care for the large numbers of children with chronic illnesses and/or disabilities, including mental health problems. Pediatricians, by virtue of their expertise, have always attracted higher proportions of children with chronic illness and disabilities into their practice panels compared with other providers. In the past, a primary care pediatrician who accepted care responsibility or case coordination responsibility for children with special health care needs was penalized only in terms of time lost from practice and inadequate reimbursement for services provided. In the present environment, children with special health care needs further penalize primary care practitioners as office productivity, referral profiling, and capitation models are increasingly used without reference to the numbers of children with chronic illness or disability in the physician panel. Given the increasing number of children with chronic illness, pediatrics must advocate strongly for enhanced models of care, appropriate time, practice flexibility, and adequate compensation with risk adjustment mechanisms.
Pediatricians will need to learn techniques from their internal medicine colleagues to appropriately use strategies that allow for flexibility in managing ch
