The Future of Pediatric Education (FOPE) II report summary1 is a thoughtful, prudent plan for the future of the education of general pediatricians. Yet, the summary takes a pessimistic view of the future for pediatric subspecialists (PSS) and has few useful recommendations to immediately improve the education of PSS.
We believe that PSS provide the best care for children with complex and advanced disease. Physicians who care for these special children on a part-time basis, without equivalent specialty training, will not usually be able to provide the same service, as suggested by parents' lack of confidence in skill of generalists in managing chronic illness (FOPE II summary, page 187) FOPE II summary accurately documents the decreasing numbers of PSS and the subspecialty residents (FOPE II summary, pages 185–186) from 27% of pediatricians to 18% over the past decade. The report notes that “a shortage of subspecialists, therefore, has grave implications for the improvement of child health” (FOPE II summary, page 189). We believe that implementation of the FOPE II summary is more likely to exacerbate than ameliorate these problems.
FOPE II supports PSS training generalists and adult subspecialists to assume some of the responsibilities for care of children with complex, chronic disease. We agree that some training of generalists to help provide medical care for children with special needs in underserved areas is important and those linkage relationships between PSS and generalists and adult subspecialists are essential.
We believe, though, that care of these children by generalists and adult subspecialists over the long-term will not be as effective as that of PSS. We are confident that the need for PSS in all regions of the United States will increase, not decrease, in the demanding, consumer-driven medical marketplace of the next few decades. Biotechnology is moving rapidly into new areas of pediatrics. Full-time PSS must now work hard to stay current with these major changes, much less part-time PSS. If PSS are forced from the pediatric landscape by financial pressures and lack of support, they will be reinvented in the next few decades. It is likely that many generalists and adult subspecialists doing part-time subspecialty work will eventually evolve into full-time PSS.
The FOPE II report's suggestions to improve PSS education and meet the challenges of declining numbers are ambitious long range goals but are not useful, realistic short-term goals. Increasing financial support should be sought aggressively from the National Institutes of Health for PSS fellowships, from Medicare for support of PSS training in all academic health centers (including freestanding childrens hospitals), and from philanthropy and industry. Yet, given the current political climate, these solutions can hardly be relied on. Similarly, the goals of limiting fellowships to centers of excellence, increasing grant applications, and supporting pediatrician scientists are critical for improving pediatric research, but fail to address the clinical needs of the US pediatric population, especially children with special health care needs.
The FOPE II summary appears to favor training a limited number of research-trained PSS who support their salaries and section activities by research grants. The inference may be drawn that clinical PSS are less desirable, especially those unable to support themselves by clinical billings. Without these clinical PSS, it is not clear how pediatric faculty can properly educate medical students, residents, general pediatricians, and adult subspecialists. Even now, not all medical schools and pediatric residency programs have a full complement of PSS for necessary instruction. It is also not clear how a limited number of PSS can maintain the regional and state systems of medical care for children with special health care needs.
FOPE II falls short in specific recommendations for educating subspecialty residents. We believe that pediatric department chairman and program directors should move to eliminate the recent bias against pediatric subspecialty training in their effort to promote primary care. Financial support of subspecialty training must be provided from departmental, institutional, philanthropic, and governmental sources, especially in centers of excellence.
Pediatric faculty should also encourage residents to train in undermanned PSS and help them obtain skills that will improve their academic viability. Fast-tracking PSS training programs should be implemented that may appeal to pediatric and surgical residents with substantial debts and/or less research-oriented career goals (eg, reviving 2 years of PSS training for fellows interested in a clinical PSS career and 4-year combined pediatric/subspecialty programs for certain PSS). Pediatric organizations should also strongly back PSS debt forgiveness programs.
Although not within the scope of FOPE II, we wish to draw attention to the critically important role played by pediatric surgical subspecialists of all surgical disciplines. These PSS have skills needed by children, generalists, and other PSS. It is even less appropriate to suggest that adult surgical specialists can replace pediatric surgical specialists than in other PSS. We must continue to support the training of these individuals and publicly recognize that their surgical skills are unique and irreplaceable.
For PSS, the FOPE II summary was a missed opportunity. It exhibits a lack of balance that is unfortunate. The report has a pessimistic outlook for PSS, especially clinical PSS, and suggests a low priority for improving their status. FOPE II should have been, and pediatric organizations should continue to be, equally supportive of generalists and subspecialists, both medical and surgical. This support should be clear and unequivocal and is especially important in the current health care marketplace where there is pressure on both medical and surgical subspecialists. Pediatric generalists and PSS need each other and children in the United States need both. Together generalists and PSS can provide the best care for all children.
- FOPE II =
- The Future of Pediatric Education II Report Summary •
- PSS =
- pediatric subspecialists
- 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
- Copyright © 2001 American Academy of Pediatrics