PEDIATRICS Vol. 111 No. 4 April 2003, pp. 730-734
Two National Surveys on Pediatric Training and Activities in School Health: 1991 and 2001
From the University of California, San Diego, Division of Community Pediatrics, La Jolla, California
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ABSTRACT |
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Objective. To determine from 2 surveys, in 1991 and 2001, 1) the proportion of pediatricians and which pediatricians report doing school health, 2) which school health activities are most commonly engaged in and whether this has changed, 3) whether training/education during residency influences doing school health later in practice, and 4) whether the amount or nature of residency training in school health (as reported by practicing pediatricians) increased over time, as recommended by various task forces.
Methods. Surveys were mailed to a 10% randomly selected group of the voting membership of the American Academy of Pediatrics.
Results. An estimated 50% to 70% of pediatricians report doing school health, and a consistent 20% report having had training in school health. The nature of school health work varies in urban, suburban, and rural areas, and pediatricians who practice in rural areas are more likely to be involved in school health. When resident education in school health is offered during residency, it is associated with a higher likelihood of pediatricians’ doing school health later in practice. Recent trainees report having more residency training in school health, yet fewer recent trainees report doing school health compared with their older colleagues.
Conclusions. The gap between those who do school health and have received education in school health during residency has continued over at least a 10-year period. Recommendations include specification of school health and community pediatrics competencies for the effective practice of pediatrics in the future.
Key Words: school health • community pediatrics
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INTRODUCTION |
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For >20 years, organized Pediatric Education Task Forces (FOPE I and II)1,2 have called for more education in residency programs concerning psychosocial, educational, and community pediatrics that would include school health content and sites. At the same time, anecdotal testimony from practicing pediatricians suggest that the pressures of managed care in some regions results in less time for community activities such as school health. A survey was completed in 1991 from a national sample of members of the Academy of Pediatrics. The present 2001 survey, nearly identical to the 1991 survey, was designed to answer the following questions: 1) Compared with 1991, what proportion of pediatricians and which pediatricians report doing school health? 2) Which school health activities are most commonly engaged in, and has this changed? 3) Does training/education during residency influence doing school health later in practice? 4) Has the amount or nature of residency training in school health (as reported by practicing pediatricians) changed over time, as recommended by various task forces?
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METHODS |
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The 10-item questionnaire was modeled almost exactly from the previous survey3 (both forms are available from the authors). Analysis of responses used frequency distributions and cross tabulations.
2 analysis was used to test the significance of proportional differences between groups. A logistic regression was used to assess the relative importance of residency education, year of completion of residency, and setting of practice (rural, urban, or suburban) on participation in school health activities.
Survey
The 2001 survey was mailed to 3500 pediatricians who composed a 10% random sample of the US voting membership. The total voting membership consists of 56% male and 44% female pediatricians. The randomly selected fellows reside in the continental United States, Hawaii, and Puerto Rico. The 1991 survey was mailed to 2245 pediatricians, indicating an increase in the American Academy of Pediatrics membership over the 10 years. Of the 3500 mailed in 2001, 44 were undeliverable and 1713 (49%) were returned. Of those surveys returned, some were marked deceased or retired; however, 1606 (46%) surveys included in the database had at least 1 question answered. These surveys yield the data found in the tables to follow (individual numbers vary as a result of variation in the number of responses to an individual question).
Follow-up of Initial Nonrespondents
A total of 156 (9%) of initial nonrespondents (1743) were contacted by telephone, fax, or e-mail, and their answers to key items were compared with initial responders to the survey. Nonresponders tended to be older, with more having completed residency training before 1967 (18% of nonrespondents, compared with 9% of responders). A total of 57% of nonresponders spent most of their time in general pediatrics, compared with 69% of responders. Nearly identical percentages (19.2% and 19.8%) reported having had school health training. Fifty percent of nonresponders indicated that they were involved in school health (compared with 70% of responders).
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RESULTS |
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Characteristics of Pediatricians
Tables 1 and 2 show the distribution of the sample by year of completion of residency and by specialty area of pediatrics. Two thirds in the 2001 survey had completed residency training by 1988 (10 years later than the 1991 survey). In the 2001 survey, 82% of respondents reported direct patient care as their primary activity, compared with 78% in the 1991 survey. As in 1991, most were in general pediatrics as seen in Table 2.
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The range of different specialty practice areas, although approximately the same (16% and 14%) in terms of percentages in both surveys, were more diverse in the 2001 survey than in the 1991 survey and included emergency medicine, infectious diseases, endocrinology, critical care, child abuse/forensic medicine, public health, nephrology, neurology, and internal medicine. Forty-one percent of respondents indicated that they had taken a fellowship, with 72% of them indicating that the fellowship was in a subspecialty area other than general ambulatory, developmental behavioral, or adolescent medicine (data not shown).
In 1991, pediatricians practiced in urban (55%), suburban (35%), and rural (11%) areas.3 By 2001, the distribution of pediatricians who responded to our survey was urban (42%), suburban (47%), and rural (11%), indicating a shift in the distribution of practicing pediatricians to suburban areas.
Participation in School Health Activities
In 1991, 77% of pediatricians reported involvement in some school health activity.3 However in 2001, 1120 (70%) of 1606 reported doing some school health activity (Table 3). The most frequently reported school health activity is sports related (preparticipation examinations and sporting events), followed by activities related to health and physical education, health promotion and employee health, special education services, providing primary care services, faculty in-service, and membership on committees and boards. Between the 2 surveys, types of activities have remained similar, with proportional increases in sports-related activities.
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Participation in School Health by Geographic Site of Practice
Of pediatricians practicing in rural areas, 86% reported doing school health, compared with 67% in suburban and 69% in urban areas. Table 4 shows differences in types of school health activities by practice site. Rural pediatricians do significantly more sports-related school health activities. They also report more school health activity in conducting student health instruction than do pediatricians in suburban or urban areas. The percentages of pediatricians whose school health activities involve providing school-based primary care services are 11% urban, 7% rural, and 6% suburban.
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In 1991, 20% of respondents reported payment for sports-related activities, and 25% indicated that they were paid for non-sports-related activities. By 2001, 18% reported payment for both sports- and non-sports-related activities. Generalist pediatricians were more likely than specialists to receive payment for school health activities (similar to the 1991 survey).
Participation in School Health by Area of Pediatrics
In the 2001 survey, 73% of generalist pediatricians reported participation in school health and also comprise 73% of pediatricians involved in school health. Almost all behavioral/development and adolescent medicine specialists and three fourths of allergists reported doing school health, although they contribute only approximately 9% to the total number of pediatricians engaged in school health. After generalist pediatricians, 13% of the pediatricians who do school health indicated other specialties (emergency medicine, infectious diseases, endocrinology, critical care, child abuse/forensic medicine, public health, nephrology, neurology, and internal medicine). Of these, 140 (63%) of 224 of these specialist pediatricians reported doing school health.
Resident Education in School Health and Later Participation in School Health Activities
In 1991, 19% of pediatricians reported that they had received some type of school health education during their residency. In 2001, this figure was virtually the same at 20%. When one examines when pediatricians completed their residency education (Table 5) and the presence of school health education during residency, there is a steady increase from 11% before 1967, 17% from 1978 to 1988, and 31% from 1989 to the present. In the 2001 survey, as in the 1991 survey, residency education in school health was significantly related to participation in school health activities in practice (Table 6).
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There is a decrease among the most recently graduated pediatricians reporting participation in school health (Table 7). However, residency education still makes a difference among this group of pediatricians, as seen in Table 8.
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Results of Logistic Regression Analysis
Evaluating 3 predictors (year of residency completion, setting of practice, and having had residency training in school health) on the dichotomous outcome of the participation in school health activities, we found that pediatricians who practice in a rural location are 3.6 times as likely to participate in school health than pediatricians who do not practice in a rural location. Pediatricians who have been offered school health training in residency are 2.9 times as likely to participate in school health as those without school health residency training, and younger pediatricians (completing residency more recently) are 0.7 times as likely to participate in school health than older pediatricians (completing residency earlier). Suburban and urban location is not significant in the model (Table 9).
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When school health training in residency was offered, 1991 respondents reported that it was required 51% of the time; by 2001 when offered, it was required for 45% of respondents. Educational content included principles of consultation, physicians’ roles in health education, learning disabilities/attention-deficit disorder, sports medicine, and other. There was remarkably little change reported in didactic content or practical experiences, with the exception of more sports examinations as a school health training experience among the more recent graduates.
Continuing Education Preferences
More pediatricians (75%) who are involved in school health activities reported a desire to have additional education or training than those pediatricians (49%) who do not participate in school health activities. Understanding implications of special education laws and mandates, interpretation of psychoeducational tests, and knowledge of state and school mandates for school health services and education were noted as topics by at least one third of those who desired additional education or training (Table 10).
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
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The return rate of the survey is nearly identical to the survey fielded in 1991. On the basis of the results obtained from initial nonrespondents to the 2001 survey, we can safely conclude that well over half or nearly 60% of all pediatrician members of the American Academy of Pediatrics have been involved in school health activities. A figure close to 20% reflects an accurate estimate of those who have had school health training in their residency. These estimates are close to other surveys of graduates4 and programs.5
Despite the obvious need for school and community involvement of pediatricians in helping to provide access to care for children, as well as the management of complex psychosocial problems, overall functioning of children with chronic illnesses, and the promotion of healthful lifestyle behaviors to prevent adult chronic conditions, these problems continue to vex the health system. These problems have been noted for >20 years, and estimates of the extent of the morbidity and chronic disease precursors continue to mount.6 Examples include the meteoric rise of obesity and only minimal improvements in school dropouts and educational failure. School health may be a convenient marker of 1 type of community involvement of pediatricians and might serve as a point of experience to those who hope to advance the role of community pediatricians.
Five years after the publication of FOPE I, a survey of pediatric residency programs failed to demonstrate any trend indicating an increased emphasis on training pediatricians in the "new morbidity."7 FOPE II was published in 2000, again calling for more preparation of pediatricians for school and community health work.2
This article documents a consistent low level of reported residency education in school health, although over the years, there is a demonstrable increase in the percentage of pediatricians who report having had such training. Although fewer younger pediatricians report doing school health activities as part of their practice, those who had residency exposure are more likely to report school health practice activity.
Who, then, is involved in school health, and what is their education or preparation? It is not surprising that generalist pediatricians compose the main workforce in school health. This is undoubtedly attributable to naturally occurring needs and demands arising from the communities in which pediatricians find themselves practicing. This is clearly shown by the differences in what rural pediatricians do compared with pediatricians in other locales. Except for the provision of school-based primary care, which is largely an urban event, rural pediatricians, perhaps as a result of scarcity of other resources, provide more service and consultation. The finding that older pediatricians are more involved in school health, despite having less formal training, relates to their more extensive experience and familiarity with their community resources and their patients needs, as well as their experiences with schools.
After general pediatricians, pediatric subspecialists who are not in adolescent medicine or developmental pediatrics compose a significant proportion of pediatricians involved in school health. It is suggested that they may be involved because of the nature of their specialty and the patients with whom they must deal in terms of patient educational needs or special requirements of their condition. Nonetheless, they may not have had specific information or education in school health as a part of their subspecialty education.
This report also suggests that there has been little change in the content or process of school health education during residency. This may be because descriptors of the educational activities were deliberately kept identical in the 2 surveys. However, one might have predicted fewer sports examinations and more consultation activities during the 10 years between the surveys.
The FOPE II Education of the Pediatrician workgroup8 concluded that, despite progress in many areas, pediatric educational programs continue to suffer from several important shortcomings: many programs lack resources for state-of-the-art educational technologies, few evaluations of the effectiveness of innovations are done, there is no organizational structure to define core competencies of pediatricians at all educational levels, there is no coordinated effort to ensure that curricula are designed and adopted to achieve these competencies, that faculty are trained (and available) to teach these competencies, and that program accreditation is linked to acquisition of these competencies. There is a need to increase efforts at education in school health to be included in existing general ambulatory and subspecialty rotations, because the evidence is overwhelming at present that specific school health blocks or even content do not seem to be a reality in many pediatric programs. Another possible alternative is to include school health in community pediatrics block rotations and longitudinal learning activities as espoused by newer initiatives in education of pediatricians for community work.9 The specific competencies for doing school health and community pediatrics need to be sharply defined so that curricular progress can be made; for example, sports medicine competencies should be included because many pediatricians are engaged in school-related examinations.
Haggery10 suggested that community pediatrics can be taught, but only practiced with great difficulty. This article supports his contention, given that fewer of the more recent graduates of residency programs are involved in school health. From this point, at least 2 implications follow. The first is that advocates for community and school health roles for pediatricians need to focus on practice barriers, constraints of managed care systems, and development of new models of pediatric involvement. The second is a leadership and expertise issue. As time proceeds, there will be fewer pediatricians who have the perceived time, experience, and skills to do school health if the present trends continue. This is especially true if no changes occur within training programs or factors that influence practice constraints.
School health is a rewarding and stimulating activity for many pediatricians; however, until organized pediatric education and care delivery systems can more effectively engage in the preparation and practice management for all pediatricians, the majority of those who are involved with school health will continue to do so without the benefit of specific education and preparation.
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ACKNOWLEDGMENTS |
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This study was supported in part by the Josiah Macy Foundation Grant for Synergy between public health and clinical medicine and the Center for Community Health, UCSD School of Medicine, and the American Academy of Pediatrics.
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FOOTNOTES |
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Received for publication May 16, 2002; Accepted Aug 20, 2002.
Reprint requests to (P.R.N.) Department of Pediatrics; University of California, San Diego, Division of Community Pediatrics, 9500 Gilman Dr, Department 0927, La Jolla, CA 92093. E-mail: pnader{at}ucsd.edu
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- Task Force on the Future of Pediatric Education. A collaborative project of the pediatric community. 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) :157 –212
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[Abstract/Free Full Text] - Leslie L, Rappo P, Abelson H, et al. Final report of the FOPE II pediatric generalists of the future workgroup. Pediatrics.2000; 106 :1199 –1223
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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