Published online January 2, 2007
PEDIATRICS
Vol. 119
No. 1
January 2007, pp.
e46-e52
(doi:10.1542/peds.2006-1819)
The Status of Academic General Pediatrics: No Longer Endangered?
Tina L. Cheng, MD, MPHa,
Diane Markakis, MSa and
Thomas G. DeWitt, MDb
a Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University, Baltimore, Maryland
b Division of General and Community Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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ABSTRACT
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Our study objective was to assess the current state of general academic pediatrics in the United States. A confidential survey of division directors was conducted. At the beginning and end of the survey period, programs were called to verify the director's name. Of 199 divisions surveyed, 119 were returned. The number of physician and nonphysician division faculty has grown from a mean of 12.1 (±8.2) and 1.7 (±1.8), respectively, 5 years ago to 15.6 (±11.7) and 2.1 (±2.6). Over a 15- to 18-month period, 21% of programs had a change in division director leadership. Over 90% of divisions rated the clinical care and education missions as "very important," with research and advocacy thus rated by 29% and 50%. Ninety-five percent of divisions have primary responsibility for residency continuity clinics, 51% residency program, and 64% medical student clerkship. The mean number of annual outpatient visits was 29 821 (26 487). Academic general pediatrics divisions have grown and play a large role in clinical care, education, and research at their institutions. There is a need for continued focus on recruitment, fellowship training, faculty development, and leadership development. Although these divisions are now well established, many continue to feel "endangered" because of funding uncertainties in supporting their missions.
Key Words: ambulatory care • community pediatrics • education • health care delivery/access • workforce
Abbreviations: AGP—academic general pediatrics • ACGME—Accreditation Council for Graduate Medical Education
In 1990, Haggerty1 published "The Academic Generalist: An Endangered Species Revived" followed in 1999 by Haggerty and Sutherland2 on "The Academic General Pediatrician: Is the Species Still Endangered?" These studies surveyed graduates of the Robert Wood Johnson General Pediatrics Academic Development Program, which trained >100 general pediatrics faculty. In the latter article, they concluded that, "the field of Academic General Pediatrics now is established. It is the responsibility of graduates of these and similar programs to produce creative research and expand fellowship programs, as well as to do good clinical care, if a vigorous field of Academic General Pediatrics is to be achieved."2
Much has changed since these studies, including increasing financial pressures on academic medical centers, increasing regulation of physician practice, residency training and research, increasing specialization, and less emphasis on primary care.3–7 The previous surveys involved graduates of a postresidency training program. There have been few published surveys of academic general pediatrics (AGP) divisions in the United States by which to assess progress in the field. The purpose of this study was to systematically survey division directors to assess the "endangered" status of AGP divisions in the United States.
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METHODS
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We conducted a confidential survey of division directors in academic general pediatrics. Divisions and directors were identified by calling all of the Accreditation Council for Graduate Medical Education (ACGME)–approved US pediatric residency programs. ACGME-approved programs were chosen to sample "academic" general pediatrics divisions, because we assumed that there had to be, at a minimum, teaching of residents. Beginning September 2005, the survey and cover letter were distributed by mail with a postage-paid envelope and e-mail. There were 3 mailings and e-mails of each over a 6-month period. Before the third mailing, programs were called a second time to verify division director name and address. This study was reviewed and exempted by the Johns Hopkins University Institutional Review Board.
The 3-page survey included questions adapted from the previous survey of Haggerty and Sutherland.2 The survey instrument sought to determine characteristics of the division, including date of establishment and number of faculty. The missions and clinical, educational, research, and administrative responsibilities of divisions and their revenue sources were also queried. Division directors were asked to list their top 3 successes and top 3 challenges in the last 5 years. The survey took <20 minutes to complete and was pretested for clarity of interpretation and ease of completion.
Initially, univariate analysis was performed on all of the survey items. 
2, Wilcoxon, and t test analyses were used to determine whether any differences existed by size of the residency program or number of faculty.
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RESULTS
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At the time of the survey, there were 199 accredited pediatric residency programs in the United States (excluding Puerto Rico). Surveys were mailed to the general pediatrics division director at each program with 119 surveys returned (response rate: 60%). Two stated that they did not have a general pediatrics division or equivalent (eg, a general pediatrics section) and, thus, were not included in the analysis. Controlling for location of programs, respondents were more likely to be from mid-Atlantic and New England regions (P = .042). However, there was no significant difference in the response rate based on residency program size. Recognizing that there may be >1 general pediatrics division associated with a residency program, the survey asked, "How many other general pediatrics divisions is your medical school affiliated with?" An additional 75 programs were identified but were not surveyed.
The division's name included the words "general pediatrics" for 79% of the divisions, "ambulatory" for 11%, "academic" for 9%, "community" for 5%, and "primary care" for 5%. The year of division establishment was queried, and cumulative growth of divisions over time is shown in Fig 1. Steady growth in division faculty number was seen over the last 4 decades. We asked about the number and rank of MD and non-MD faculty in their divisions 5 years ago and today (Table 1). The mean number of MD faculty per division 5 years ago was 12.1 ± 8.2 and 15.6 ± 11.7 today. Non-MD faculty included primarily PhDs and pediatric nurse practitioners. There was no significant difference in faculty numbers based on whether a division included or did not include adolescent medicine. Respondents indicated the reasons faculty had left their division in the past 5 years: personal reasons were noted for 38%, retirement for 14%, private practice for 14%, promotion to a leadership role outside the division for 13%, moved to other academic jobs or fellowship for 12%, layoffs for 6%, and other for 3%. By calling all of the programs on 2 occasions over a 15- to 18-month period, we found that 21% of programs contacted had a change in leadership with a new or interim general pediatrics division director.
Respondents indicated, "How important to your division are the following missions?" with response categories of "not very important," "important," and "very important" (Table 2). Table 2 also shows responses to, "What is your perception of the department/institutional financial support for this?" in categories of "too low," "just right," and "too much." There was no significant difference in Table 2 responses based on whether the division included or did not include adolescent medicine. The percentage of division revenue by mission is presented in Fig 2. Division responsibilities in clinical and teaching programs were assessed (Table 3). The survey queried whether the division or group had "primary" administrative responsibility or teaching responsibility in these programs.
All of the respondents except 1 had an outpatient clinic. Mean annual outpatient visits were 29821 ± 26487 (median: 23825; range: 0–200000). The mean number of pediatric residents attending continuity clinic at the institution's clinic was 36.7 ± 23.1 (median: 32) of the total number of residents (43.3 ± 24.0; median: 39).
In response to, "Does your division have a fellowship program focusing on clinical care, education or research?" 33 divisions (28%) stated that they had 
1 fellowship program. Of these fellowships, 26 (79%) were general pediatrics, ambulatory, community or health services, or outcomes research fellowships. The remainder were fellowships in sports medicine, adolescent medicine, or developmental behavioral pediatrics. For the general pediatrics fellowships, the duration of training was 1 year for 4%, 2 years 64%, and 3 years 32%. The majority of programs (76%) offered a master's degree or certificate. Of all the fellowships, the mean percentage of time in clinical work was 30.8% (median: 20%; range: 10%–80%). Many fellowships had multiple sources of funding, including federal or foundation dollars for 64% and hospital, departmental, or institutional support for 31% of fellowship programs. Other funding sources included clinical care, clinical contracts outside the division, endowment, and the department of health. Of all the respondents, 13% stated that their division planned to start a new fellowship within the next 2 years; three quarters of these new fellowships would be in divisions without current fellowships.
The mean number of "total new and renewal grants and contracts (research, education and service) contributing to the division budget in 2004–2005" was 7.6 ± 11.0 (median: 4; mode: 0; range: 0–60). Total direct costs demonstrated a bimodal distribution and are presented in Fig 3. Divisions with fellowship programs had more MD faculty (P = .033), more grants (P = .001), and more grant dollars (P < .001). Divisions with more grants and more grant dollars were more likely to state that research was a very important mission (P < .001; P < .001).
Figures 4 and 5 present the top 3 successes and challenges experienced by divisions in the past 5 years. Main successes included expansion and excellence in missions of clinical care, education, and research. Many different challenges were mentioned, with more than one third of cumulative responses noting funding problems generally or in supporting their missions. One fourth noted challenges regarding faculty time, salaries, or morale. Other challenges included difficult clinical systems, inadequate support staff, inadequate institutional support, inadequate space, and concerns about resident work hour regulations causing clinic scheduling problems, decreased resident teaching, and patient discontinuity.
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DISCUSSION
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This is one of the first published surveys of AGP divisions in the United States and provides a snapshot of the infrastructure leading research and teaching in pediatric primary care in this country and the training of future pediatricians in primary care. This survey provides a baseline from which to monitor progress and change. The survey demonstrates that AGP divisions have grown over the years, shoulder a large share of educational responsibilities in pediatric departments, and provide considerable outpatient and inpatient clinical care. Evidence of faculty growth is demonstrated by the increase in MD and non-MD faculty from a mean of 13.8 five years ago to 17.7 today. Consistent growth is further substantiated by Dungy and Dreyer’s survey of academic general pediatrics divisions in the mid-1990s, which found an average of 13.7 full-time and part-time faculty8 and Haggerty and Sutherland's2 survey of AGP fellowship-trained faculty conducted in 1996 that found an average of 9 division faculty. With the growth in AGP faculty and new divisions, some may suggest that AGP is no longer endangered in the United States.
The responsibilities of AGP divisions are many and for the majority involve inpatient, outpatient, and newborn nursery care; education of residents and medical students; and, for many, primary responsibility for adolescent medicine, child abuse, and hospitalist programs. These responsibilities have changed little since Haggerty and Sutherland's2 previous faculty survey except for less involvement in emergency and adolescent medicine services, 2 recently recognized subspecialties. Many divisions have very large clinical outpatient services (average annual visits: 29821). Presumably, these patients use hospital services and subspecialists thereby augmenting the institutional patient base. In addition, many AGP practices serve low-income communities where they assist in providing a safety net for children and adolescents, address social determinants of health, and support the institution's interest in good community relations.
This survey substantiates that AGP divisions continue to assume major teaching obligations in many departments of pediatrics. Most (95%) are responsible for resident continuity clinic. Despite the emphasis on community clinic settings, the institution's clinics serve as the continuity clinic for 85% of the pediatric residents. The majority of divisions also have primary responsibility for the residency program and medical student clinical clerkship at their institutions. In addition, division faculty are very involved in teaching in outpatient and inpatient units, normal newborn nursery, child abuse, and other programs and are likely responsible for a large proportion of the educational experiences of residents and medical students rotating through pediatrics. Although research was not a priority in many divisions, 29% rated this mission as very important. This group has garnered large numbers of grants, large research portfolios, and direct research fellowship programs.
However, despite progress, many argue that AGP remains threatened. Haggerty and Sutherland's 1999 article2 included 3 recommendations: (1) support more 3-year academic fellowships by private foundations or federal grants; (2) make more research funds available; and (3) increase support from academic leaders of pediatric departments to encourage academic generalists, reward their scholarly work, and not burden them with heavier service, teaching, and administrative loads than those in other divisions. Our survey demonstrated that years later the minority of AGP fellowships are 3 years in duration (32%), and funding remains a huge challenge. Health Resources and Services Administration Title VII, section 747 health profession training programs, were the most common federal source of fellowship funding mentioned. Recent deep cuts in Title VII funding threaten AGP fellowship training along with other primary care programs. Only 3 programs in this survey identified funding from other federal sources. Funding for research is similarly tight.
In addition to limited education and research funds, many respondents also expressed concern about funding their clinical mission generally, particularly related to Medicaid cuts and reductions in benefits. Decline in clinical revenue and reimbursement is a major concern of academic generalists, community primary care providers, and pediatric subspecialists9 alike and requires continued advocacy on the policy level. In addition, the growth in nonpediatrician providers of primary care (eg, pediatric nurse practitioners and physician assistants) challenges the role of the community pediatrician and the academic generalist with important implications for the education of future pediatricians.
Finally, although the survey was not able to assess pediatric department support of AGP compared with other pediatric divisions, the majority of respondents felt that departmental or institutional support of their education and research missions was inadequate. In Haggerty and Sutherland's survey2 of faculty, one third expressed lack of support by the leadership of their departments. This concern was often listed by division directors as one of their top 3 challenges.
Limitations to this survey must be considered. First, there are many potential ways to define and identify AGP divisions. We included AGP divisions identified through ACGME-approved residency programs. Respondents, however, identified other AGP programs at community sites that were not included. We felt that selecting divisions related to accredited pediatric residency programs was a legitimate way to define AGP divisions. Calls to residency programs did not mention >1 general pediatrics division, suggesting that our sampling strategy captured the main AGP divisions involved in residency training. These divisions would clearly have an educational mission, and most were related to a medical school. Second, although our response rate was reasonable, nonrespondent analysis revealed that certain geographic areas were less represented, perhaps affecting the generalizability of the results. Third, the survey only provides data on AGP divisions and does not provide comparisons for issues and challenges of other pediatric subspecialty divisions, which may or may not be similar. Finally, responses were self-reported, and the measures were not validated, although a pilot study of the survey found high face validity.
There are important implications of this survey. With growth in AGP divisions, attracting good students into the medical field generally and into pediatric primary care specifically must be emphasized. Similarly, as a consensus conference recently noted, defining, improving, and expanding fellowship training in AGP is key to attracting outstanding residents and strengthening generalism.7 Fellowship training and faculty development must continue to be priorities to support the critical missions of pediatric clinical care, education, and research.
The 21% turnover of AGP division directors over the 15- to 18-month period was similar to the turnover rate recently documented for pediatric department chairs (mean annual turnover rate: 17%).10 As noted for turnover of pediatric department chairs, AGP division director turnover can create divisional instability and challenges the clinical care, education, and research missions. This high turnover along with anecdotal observation of many AGP division director job openings difficult to fill suggests an urgent need for leadership development. Surveys of physicians in other pediatric subspecialties and in other venues have also identified the need for leadership and management training.11,12 Although this survey did not directly ask reasons for division director turnover, the challenges identified by division directors give insight into environmental factors contributing to high turnover.
Finally, AGP divisions contribute substantially to the care to children, discovery of new knowledge in primary care and health services, and in training the next generation of pediatricians. This clearly involves collaborations among academic generalists and with subspecialists on behalf of children, adolescents, and families. Despite continued concern about institutional support, AGP divisions have grown in size, including an increasing number of non-MD faculty, suggesting an ongoing and expanding commitment to academic activity. Although continued advocacy may be necessary to support the clinical care, education, research, and advocacy missions of academic general pediatrics, our survey suggests that divisions are no longer endangered but are established and make important contributions to critical missions.
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ACKNOWLEDGMENTS
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Partial funding for the mailing of the survey was provided by the Ambulatory Pediatric Association.
We thank Chuck Norlin, MD, and the members of the Ambulatory Pediatrics Association Division Director Special Interest Group who assisted in designing and piloting the survey and the survey respondents.
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FOOTNOTES
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Accepted Aug 9, 2006.
Address correspondence to Tina L. Cheng, MD, MPH, Division of General Pediatrics and Adolescent Medicine, Johns Hopkins University, 600 N Wolfe St, Park 392, Baltimore, MD 21287. E-mail: tcheng2{at}jhmi.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
This work was presented in abstract form at the Pediatric Academic Societies annual meeting, April 29, 2006; San Francisco, CA.
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PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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ABSTRACT
METHODS
