Role of the School Physician

History of Physicians in the School Setting

Physicians associated with schools have held a variety of titles over the years. For the purpose of this article, a school physician is any physician who serves in any capacity for a school district, such as, but not limited to, an advisor, consultant, medical director, volunteer, team physician, medical inspector, or district physician.¹ This statement does not address the role of physicians in school-based health centers² or the role of community pediatricians as private providers to school-aged children. Information on these topics is available on the American Academy of Pediatrics (AAP) Council on School Health Web site (http://www.aap.org/sections/schoolhealth/).

The tradition of a school physician dates back to the late 1800s, as parents and public officials recognized that public school facilities needed national systematic medical inspection.³ Over time, the role of the school medical inspector expanded to include containment of prevalent infectious diseases of childhood^3,4 and eventually as an important vehicle to manage universal immunization.⁵ Modern school physicians focus on the needs of individual children as well as the public health of the school community.^3,6,7 They often assist schools in accommodating students who have special health care needs, manage acute and chronic illness, and oversee emergency response, environmental health and safety, health promotion, and education.^8,9

Millions of children spend roughly 7 hours per day, 180 days per year, in school¹⁰ and may only visit their medical home once annually. In 1999, Dr Joycelyn Elders acknowledged the interdependence of health and education when she said, “You cannot educate a child who is not healthy, and you cannot keep a child healthy who is not educated.”¹¹ In addition, Bright Futures, a national health care promotion initiative, encourages public schools and public health communities to become partners in prevention efforts.¹² Despite the value of coordinating health and education, physicians are not effectively and consistently involved in schools across the nation. As a result, US children have varying levels of medical support and safety, depending on the community in which they live. Well-placed school physician expertise can contribute to the creation of policies and practices that provide sound, evidence-based structure to coordinated school health teams.

Current Laws Pertaining to the Physician in Schools

Currently, there is no single national set of school health laws. School health services are primarily regulated by state or local governments or individual school districts, and these regulations vary.^13–15 Some states mandate school physicians; most do not.^16,17 However, “no one has systematically identified the full range of relevant legal authorities pertinent to schools that may help shape the health of children and adolescents.”¹⁵

Federal law guarantees antidiscrimination and equal protection to individuals who have disabilities.^18–20 These laws require federally funded states to provide “related services,” such as school nursing, as part of a child’s Individualized Education Plan. However, the US Supreme Court ruled that school districts are not required to provide physician services for individual students, except for diagnostic or evaluative purposes for special education services.^13–15 This ruling’s broad interpretation has limited funding to schools for physician services, despite the fact that many states, and the AAP, established basic minimal health services schools should provide without established guidance for pediatrician involvement.^21,22

The AAP recommends that all schools have a registered professional school nurse, hereafter referred to as school nurse, to provide health services in schools.²³ The American Medical Association not only recommends that school health be provided by “a professionally prepared school nurse” but also that “health services in schools must be supervised by a physician, preferably one who is experienced in the care of children and adolescents. Additionally, a physician should be accessible to administer care on a regular basis.”²⁴

Despite a scarcity of laws addressing school physicians, pediatricians remain leaders in child health care and are integral members of the school health team.^22,25–29 Certainly, pediatricians need to know the laws that apply to their patients and themselves and will benefit from collaboration with their AAP chapter, state and local health departments, and school district to understand the laws specific to their role in the schools. However, the lack of uniformity of laws or standards of best practice for school physicians complicates the role physicians have in schools and results in a difference of health care for children based on the schools they attend.

Critical Knowledge Base for Physicians Working in the School Setting

Ideally, school physicians should be board-certified pediatricians or physicians with expertise in pediatrics.²⁴ In addition to basic training in child growth and development, disease processes, and well-child maintenance including adolescent and reproductive health and sports medicine, physicians who work with schools need additional expertise in key school health topics.^30–32 The degree of mastery required depends on the extent of the physician’s role with the schools. Overall, a school physician can become a positive liaison between the medical home, the family, and the school.⁸Table 1 contains a nonexclusive list of essential areas of expertise required of a school physician.

Current Roles and Relationships for School Physicians

The roles and types of relationships for physicians working in schools are broad. Involvement can range from fulfilling mandated services, serving as an advisor to a school health advisory group, or being the leader of a coordinated school health program. School physicians function based on the medical and social needs or demands of the community, the school district’s priorities, and state laws. School physicians not only bring value to the quality of health services but also may provide a cost savings to districts, with decreased liability from physician oversight of sound school health programs. For example, school physician–coordinated concussion management programs, established climate standards for outdoor activity, or guided anaphylaxis management protocols can potentially save lives, reduce morbidity, improve outcomes, and prevent potential costly litigation against school districts.^33–36 Because states fund schools on the basis of student attendance, a school physician can potentially save schools money by decreasing absenteeism through advocacy and education, such as in improved asthma or diabetes management.^37–40 The Council on School Health Web site (http://www.aap.org/sections/schoolhealth/) provides guidance on these activities and how pediatricians can work with schools (Table 2).

Physicians can have a professional relationship with schools in many ways, such as a full- or part-time employee, an independent contractor, or a volunteer on a school health advisory group. Where feasible, a school physician does not serve as a private physician for a child in that school district, however, because it can create a potential conflict of interest between the physician as representative/advocate for a patient versus the school.

Whatever the relationship, once a school district asks a physician to participate in hands-on medical practice for compensation in exchange for services, a clear definition of district expectations of the physician is essential. An agreement, accounting for laws governing the relationship of the physician to the public school district, should define indemnification and liability. It is critical that physicians understand the specifics of their relationship and that the legal implications are articulated clearly in a written agreement renewed periodically. Although community volunteerism is attractive, physicians should take some precautions before volunteering to serve as a school or team physician. It is essential that he or she knows and understands state laws that address whether a district has an obligation to hire a medical director. Regardless of the type of relationship, the physician should notify his or her professional liability insurance company of involvement in school health activities and determine whether the insurance covers such activities. If covered, this decision should be noted in writing. If a district has an obligation to provide compensation for physician services, this will allow the physician to schedule time for the school district and to improve the quality and consistency of service.

Recommendations

Given the contribution a school physician can make to the overall well-being of a child within the context of the school setting, the AAP recommends the following:

1. Pediatricians should advocate that all school districts have a school physician to oversee health services. The school physician’s roles and responsibilities should be well defined, fairly compensated, and outlined within a written contract.

2. Pediatricians should support their patients and local school health programs by working closely with the school health services team. In districts without school physicians, pediatricians should educate these districts about the benefits of having a school physician and work to foster private-public partnerships for school physicians.

3. School physicians should be experts in key school health topics and be educated about the medical-legal environment in which they practice. They need to provide proper notification of their role and responsibility to their medical liability insurer and should collaborate with their AAP chapter, state and local health departments, and school district to understand the laws specific to their role in the schools.

4. Community pediatricians should be knowledgeable about key school health topics and how to work effectively with schools their patients attend.

5. Pediatricians should consider becoming a school physician or serving on school boards or school health advisory groups to develop sound school health policies and community programs.

6. All physicians who work with school-aged children should recognize the value to the child when there is a comprehensive, coordinated team effort among the child’s medical home, the school, and family.

7. Pediatric medical investigators should consider further research to determine how comprehensive coordinated school health programs under the direction of a school physician can improve health care in schools and enhance the goals of the medical home without attempting to replace it.

8. AAP districts and chapters should support school health and school physicians and use the school physician’s expertise to advocate for important changes to state and local school health policy. In addition, AAP districts and chapters should advocate to develop and promote school health policies that benefit children by advocating for additional research on the benefits of school physicians in school health services.

Lead Authors

Cynthia DiLaura Devore, MD

Lani S.M. Wheeler, MD

Council on School Health Executive Committee, 2011–2012

Cynthia Devore, MD, Chairperson

Mandy Allison, MD, MSPH

Richard Ancona, MD

Stephen Barnett, MD

Robert Gunther, MD, MPH

Breena Welch Holmes, MD

Jeffrey Lamont, MD

Mark Minier, MD

Jeffery Okamoto, MD

Lani Wheeler, MD

Thomas Young, MD

Former Executive Committee Member

Robert Murray, MD, Immediate Past Chairperson

Liaisons

Mary Vernon-Smiley, MD, MPH – Centers for Disease Control and Prevention, Division of Adolescent and School Health

Linda Grant, MD, MPH – American School Health Association

Veda Johnson, MD – National Assembly on School-Based Health Care

Carolyn Duff, RN, MS, NCSN – National Association of School Nurses

Former Liaison

Linda Davis-Alldritt, RN, MA, PHN – National Association of School Nurses

Staff

Madra Guinn-Jones, MPH