academic general pediatrics: the state of the art tina l. cheng, md, mph

Academic General Pediatrics: Academic General Pediatrics: The State of the ArtThe State of the Art

Tina L. Cheng, MD, MPHTina L. Cheng, MD, MPH

http://www.ambpeds.org/site/index.htm

Clinical CareClinical CareEducationEducationResearchResearchAdvocacyAdvocacy

ACADEMICACADEMICGENERALGENERAL

PEDIATRICSPEDIATRICS

Academic General PediatricsAcademic General Pediatrics

1960: Association for Ambulatory Pediatric 1960: Association for Ambulatory Pediatric ServicesServices

1968: name change to Ambulatory Pediatric 1968: name change to Ambulatory Pediatric AssociationAssociation

1978: Robert Wood Johnson General Pediatrics 1978: Robert Wood Johnson General Pediatrics Academic Development Program trained over 100 Academic Development Program trained over 100 general pediatrics facultygeneral pediatrics faculty

““The field of academic general pediatrics now The field of academic general pediatrics now is established. It is the responsibility of is established. It is the responsibility of graduates to produce creative research and graduates to produce creative research and expand fellowship programs, as well as to do expand fellowship programs, as well as to do good clinical care, if a vigorous field of good clinical care, if a vigorous field of academic general pediatrics is to be academic general pediatrics is to be achieved.” achieved.”

Haggerty RJ & Sutherland SA. “The Academic General Haggerty RJ & Sutherland SA. “The Academic General Pediatrician: Is the Species Still Endangered?” Pediatrician: Is the Species Still Endangered?” Pediatrics Pediatrics 1999:104;137- 1421999:104;137- 142

The State of Academic General The State of Academic General Pediatrics Divisions: Pediatrics Divisions:

A National SurveyA National Survey

Ambulatory Pediatric Association Ambulatory Pediatric Association Division Director Special Interest Division Director Special Interest

GroupGroup

http://www.ambpeds.org/site/index.htm

Study AimStudy Aim

To assess the current state of academic To assess the current state of academic general pediatrics divisions in US medical general pediatrics divisions in US medical schools including their current missions, schools including their current missions, activities, successes and challengesactivities, successes and challenges

MethodsMethods

Confidential survey of US academic general Confidential survey of US academic general pediatrics division directors pediatrics division directors

Survey distributed by mail and email with three mailings of each over a 6 month period

Near the end of the survey period all programs were called to verify program director name and address

Results: General Pediatrics Results: General Pediatrics DivisionsDivisions

199 US general pediatrics divisions identified199 US general pediatrics divisions identifiedSurvey response rate 59% (118/199)Survey response rate 59% (118/199)

respondents more likely from programs in the mid-Atlantic andrespondents more likely from programs in the mid-Atlantic and New England (p=.043)New England (p=.043)

When asked “How many other general pediatrics When asked “How many other general pediatrics divisions is your medical school affiliated with?” an divisions is your medical school affiliated with?” an additional 75 divisions were mentionedadditional 75 divisions were mentioned

Results: What’s in a Name?Results: What’s in a Name?

Word in Division NameWord in Division Name %%

““General Pediatrics”General Pediatrics” 7979

““Ambulatory”Ambulatory” 1111

““Academic”Academic” 99

““Community”Community” 55

““Primary Care”Primary Care” 55

Results: Growth of DivisionsResults: Growth of Divisions

01020

3040

5060

708090

<1960 1960-69 1970-79 1980-89 1990-99 2000-

No.

Divisions

Results: Primary ResponsibilitiesResults: Primary ResponsibilitiesResponsibilities,% YesResponsibilities,% Yes

Administrative Teaching Administrative Teaching

Resident continuity clinic(s)Resident continuity clinic(s)Out-patient faculty practiceOut-patient faculty practiceEmergency serviceEmergency serviceUrgent care centerUrgent care center

Normal newborn nurseryNormal newborn nurseryIn-patient units In-patient units Hospitalist programHospitalist programBehavioral/Developmental service Behavioral/Developmental service Adolescent medicine serviceAdolescent medicine service

9595737310103838

67675959464632325050

9393686812123939

72727777424236365353

Results: Primary ResponsibilitiesResults: Primary ResponsibilitiesResponsibilities,% YesResponsibilities,% Yes

Administrative TeachingAdministrative Teaching

Residency program Residency program Medical student clinical clerkship Medical student clinical clerkship

Child abuse programChild abuse programEnvironmental health programEnvironmental health programChronic disease clinic(s)Chronic disease clinic(s)Other Other

51516464

4848131327272121

74748181

5555111126262020

Results: Division FacultyResults: Division Faculty

NOWNOWMean (SD)Mean (SD)

5 years ago5 years agoMean (SD)Mean (SD)

““How many How many MDMD faculty faculty are in your division?”are in your division?”

15.6 (11.7)15.6 (11.7)Median 13Median 13

12.1 (8.2)12.1 (8.2)Median 9Median 9

““How many How many non-MDnon-MD faculty are in your faculty are in your division?”division?”

2.1 (2.6)2.1 (2.6)Median 1Median 1

1.7 (1.8)1.7 (1.8)Median 1Median 1

Results: Division FacultyResults: Division Faculty% Full-time% Full-time Rank N (%)Rank N (%)

““How many How many MDMD faculty faculty are in your division?”are in your division?”N=1838N=1838

67% full-time67% full-time 207 (12%) Professor207 (12%) Professor323 (18%) Assoc Prof323 (18%) Assoc Prof916 (52%) Asst Prof916 (52%) Asst Prof244 (14%) Instructor244 (14%) Instructor 77 (4%) Other77 (4%) Other 98 (6%) Tenured98 (6%) Tenured

““How many How many non-MDnon-MD faculty are in your faculty are in your division?”division?”N=210N=210

75% full-time75% full-time

25% PhD25% PhD46% PNP46% PNP

16 (8%) Professor16 (8%) Professor13 (7%) Assoc Prof13 (7%) Assoc Prof28 (15%) Asst Prof28 (15%) Asst Prof21 (11%) Instructor21 (11%) Instructor115 (60%) Other115 (60%) Other6 (3%) Tenured6 (3%) Tenured

Results: General Pediatrics Results: General Pediatrics Division Director TurnoverDivision Director Turnover

Over a 15-18 month period, 21% of programs Over a 15-18 month period, 21% of programs had a change in leadership with a new general had a change in leadership with a new general pediatrics division director pediatrics division director

Results: Division MissionsResults: Division Missions

MISSIONMISSION ““How important to How important to your division are the your division are the following missions?”following missions?”%Not impt %V impt%Not impt %V impt

““What is your perception of What is your perception of the dept/institutional financial the dept/institutional financial support for this?”support for this?”%Too low %Just right %Too %Too low %Just right %Too muchmuch

Clinical CareClinical Care 1 941 94 23 35 2023 35 20

EducationEducation 1 971 97 61 17 161 17 1

ResearchResearch 24 2924 29 59 17 0 59 17 0

AdvocacyAdvocacy 8 508 50 47 17 047 17 0

AdministrationAdministration 4 284 28 39 29 039 29 0

Results: Division RevenueResults: Division Revenue

Administration9%

Endowment2%

Other7%

Education12%

Advocacy3%

Research10%

Clinical57%

Results: Outpatient ClinicsResults: Outpatient Clinics

Annual outpatient visits: Annual outpatient visits: Mean 29,821 (26,487), Median 23,825Mean 29,821 (26,487), Median 23,825 Range 0 – 200,000Range 0 – 200,000

Number of pediatric residents with continuity Number of pediatric residents with continuity clinic at the institution’s clinicclinic at the institution’s clinic Mean 36.7 (23.1), Median 32Mean 36.7 (23.1), Median 32 Total residents: 43.3 (24.0), Median 39Total residents: 43.3 (24.0), Median 39

Results: FellowshipsResults: Fellowships

Does your Division have a fellowship program Does your Division have a fellowship program focusing on clinical care, education, or research?focusing on clinical care, education, or research?

31% have a fellowship (36)31% have a fellowship (36) Of those, 76% offer a degreeOf those, 76% offer a degree

15% one yr, 50% two yr, 35% three yr15% one yr, 50% two yr, 35% three yr 65% funded by federal/foundation $65% funded by federal/foundation $ 32% funded by hospital/department32% funded by hospital/department

13% plan to start a new fellowship within 2 yrs13% plan to start a new fellowship within 2 yrs

Results: Grants and ContractsResults: Grants and Contracts

Total new and renewal grants and contracts Total new and renewal grants and contracts (research, education and service) contributing to (research, education and service) contributing to the division budget in 2004-05:the division budget in 2004-05:

Number of Grants and Contracts: Number of Grants and Contracts: Mean 7.6 (11.0), Median 4, Mode 0, Range 0-60Mean 7.6 (11.0), Median 4, Mode 0, Range 0-60

Total DirectsTotal Directs

Results: Grants and ContractsResults: Grants and Contracts

Total Directs:Total Directs:

0

5

10

15

20

25

0 $1-50K $50-250K

$250-500K

$500K-1mil

$1-5 mill >$5 mill

# Programs

Results: Reported Top Successes in the Results: Reported Top Successes in the Past 5 YearsPast 5 Years

Budgetary Stability5%

Other8%

Faculty growth, promotion,morale

12%

Admin systems4%

Education expansion/excel

23%

Community programs

7%

Research expansion/excel

11%

Clinical expansion/excel

30%

Results: Reported Top Results: Reported Top Problems/Challenges in Past 5 YearsProblems/Challenges in Past 5 Years

Staff support6%

Other13%

Clinical systems issues

9%

Faculty number/time17%

Lack of institutional support

8%

Resident work hours, continuity

4%

Faculty development, morale

6%

Faculty salaries3%

Funding clinical care9%

Funding research11%

Funding education5%

Funding issues general

9%


Staff support6%

Other13%


9%

Funding education5%

Funding research11%


Faculty salaries3%Faculty development,

morale6%


4%


8%Faculty number/time

17% Clinical systems issues

9%


Staff support6%

Other13%

Clinical systems issues

9%

Faculty number/time17%


8%


4%

Faculty development, morale

6%

Faculty salaries3%


Funding research11%

Funding education5%


9%

LimitationsLimitations

GeneralizabilityGeneralizability

No information on other pediatric divisions

ConclusionsConclusions

Academic general pediatric divisions are no longer Academic general pediatric divisions are no longer endangered in the USendangered in the US

The number of divisions have grown steadily

Division faculty have grown in number over the past five years

Divisions have a large role in clinical care, education and research

Haggerty & Sutherland’s 1999 Haggerty & Sutherland’s 1999 RecommendationsRecommendations

Support more 3 year academic fellowships by Support more 3 year academic fellowships by foundations or federal grantsfoundations or federal grants

Make more research funds availableMake more research funds available

Support from departments for academic Support from departments for academic generalists for scholarly work and not burdened by generalists for scholarly work and not burdened by heavier service, teaching and administrative loads heavier service, teaching and administrative loads than those in other divisions than those in other divisions

ConclusionsConclusions

Funding the missions of clinical care, education, and research are major challenges for divisions clinical care: Medicaid concerns education: Many programs funded by Title VII research: Federal funding concerns

ImplicationsImplications

With growth in general pediatrics divisions, faculty development, fellowship training, and pipeline efforts must be priorities

Division director leadership had rapid turnover suggesting need for leadership development

A forum to share strategies across programs is important

Future of Academic General Pediatrics

Future of Primary Care

http://www.jdhodges.com/posters/transfer.asp?id=311843

““Primary Care In Crisis: Current Pressures Primary Care In Crisis: Current Pressures and Threats to Primary Care as We Know and Threats to Primary Care as We Know It.”It.” The Future of Primary CareThe Future of Primary Care, Jossey Bass, 2004, Jossey Bass, 2004

““The End Of Primary Care,”The End Of Primary Care,” NY Times NY Times MagazineMagazine, April 18, 2004, April 18, 2004

““The Impending Collapse of Primary Care The Impending Collapse of Primary Care Medicine and Its Implications for the State Medicine and Its Implications for the State of the Nation’s Health Careof the Nation’s Health Care: A Report from the : A Report from the American College of Physicians,” January 2006American College of Physicians,” January 2006

FOPE II Determinants of FOPE II Determinants of Future Roles for Future Roles for

PediatriciansPediatricians

Roles for Pediatricians

Child and Family Health Needs

Health Care System

Scientific Advances

Present & Future Opportunities Present & Future Opportunities for Primary Carefor Primary Care

continuity providercontinuity providerhead of household in the medical home or team playerhead of household in the medical home or team playeradvocate addressing health disparitiesadvocate addressing health disparitieschronic care coordinatorchronic care coordinatornew morbidity manager/community collaboratornew morbidity manager/community collaboratorpublic health coordinatorpublic health coordinatorgenomic interpreter genomic interpreter web interpreter/telemedicine doctorweb interpreter/telemedicine doctorhospitalisthospitalisthealthcare quality and systems researchershealthcare quality and systems researchers

Cheng TL Pediatrics 2004; 113: 1802 - 1809.

Future of Academic General Pediatrics

Future of Primary Care

Primary Care Now and In the Primary Care Now and In the FutureFuture

CURRENT FUTURE

WHO Primarily Doctors & Nurse Practitioners

Interdisciplinary Teams

WHAT Individual Patient Oriented Individual Patient & Public Health Oriented

Organ Based Integration of Genes to Organs to Persons to Communities

WHEN Child Health Maintenance & Acute Care

Child Health Maintenance, Acute Care, Visits with Other Team Members, Group Visits, Other Sites.

WHERE Office Focused Community Based & Community Integrated

HOW Continuity through Visits & Phone

Continuity through Visits, Phone & Other Information Technology

Cheng TL Pediatrics 2004; 113: 1802 - 1809.

academic general pediatrics: the state of the art tina l. cheng, md, mph

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