Pediatrics in the Year 2020 and Beyond: Preparing forPlausible Futures

abstractAlthough the future of pediatrics is uncertain, the organizationsthat lead pediatrics, and the professionals who practice within it,have embraced the notion that the pediatric community must an-ticipate and lead change to ultimately improve the health of chil-dren and adolescents. In an attempt to proactively prepare for avariety of conceivable futures, the board of directors of the Ameri-can Academy of Pediatrics established the Vision of Pediatrics 2020Task Force in 2008. This group was charged to think broadly aboutthe future of pediatrics, to gather input on key trends that areinfluencing the future, to create likely scenarios of the future, andto recommend strategies to best prepare pediatric clinicians andpediatric organizations for a range of potential futures. The work ofthis task force led to the development of 8 “megatrends” that wereidentified as highly likely to have a profound influence on the futureof pediatrics. A separate list of “wild-card” scenarios was createdof trends with the potential to have a substantial influence but areless likely to occur. The process of scenario-planning was used toconsider the effects of the 8 megatrends on pediatrics in the year2020 and beyond. Consideration of these possible scenarios affordsthe opportunity to determine potential future pediatric needs, toidentify potential solutions to address those needs, and, ultimately,to proactively prepare the profession to thrive if these or otherfuture scenarios become realities. Pediatrics 2010;126:971–981

As a profession, pediatrics finds itself at the brink of its next evolution.Forces of change that once drove the profession are giving way to newones, and the speed of that change is accelerating rapidly. There isnear consensus among pediatric leaders that preservation of the sta-tus quo is not an option and that proactive adaptation to the complexchanging environment that surrounds and penetrates pediatrics isvital if it is to survive and thrive.1–3 Pediatrics must change, and it mustdo so strategically.

The need to better prepare for the future resonated strongly withthe American Academy of Pediatrics (AAP) Board of Directors, andin January 2008 it established the Vision of Pediatrics (VOP) 2020project to catalyze an innovative visioning and planning process forthe AAP. In this article we outline the VOP 2020 scope and method-ology and present 8 “megatrends” that were identified by the taskforce as most likely to profoundly influence the future direction ofthe profession. The accompanying article in this issue of Pediatrics4

offers a framework to assist the field of pediatrics in envisioning arange of possible futures with the hope of inspiring action that canlead to strategic change.

AUTHORS: Amy J. Starmer, MD, MPH, FAAP,a John C. Duby,MD, FAAP,b Kenneth M. Slaw, PhD,c Anne Edwards, MD,FAAP,d Laurel K. Leslie, MD, MPH, FAAP,e and Members ofthe Vision of Pediatrics 2020 Task ForceaGeneral Pediatrics, Children’s Hospital Boston, Boston,Massachusetts; bDivision of Developmental and BehavioralPediatrics, Akron Children’s Hospital, Akron, Ohio; cDepartmentof Membership and Strategic Planning, American Academy ofPediatrics, Elk Grove Village, Illinois; dPediatrics, Park NicolletHealth Services, Minneapolis, Minnesota; and ePediatrics andMedicine, Tufts Medical Center Floating Hospital for Children,Boston, Massachusetts

KEY WORDSpediatrics, future, leadership, innovation, change management

ABBREVIATIONSAAP—American Academy of PediatricsVOP—Vision of PediatricsHIT—health information technologyEHR—electronic health record

The opinions expressed in this article are those of the authorsand do not necessarily represent American Academy ofPediatrics policy.

www.pediatrics.org/cgi/doi/10.1542/peds.2010-1903

doi:10.1542/peds.2010-1903

Accepted for publication Aug 10, 2010

Address correspondence to Amy J. Starmer, MD, MPH, FAAP,Children’s Hospital Boston, 300 Longwood Ave, Boston, MA 02115.E-mail: amy.starmer@childrens.harvard.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2010 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

SPECIAL ARTICLES

PEDIATRICS Volume 126, Number 5, November 2010 971 by guest on August 19, 2018www.aappublications.org/newsDownloaded from

SCOPE AND METHODOLOGY

In establishing the VOP 2020 the AAPBoard of Directors appointed a taskforce with broad representation of theAAP membership and asked it to (1)identify the most critical forces likelyto shape the future of the profession,(2) envision what the day-to-day spe-cific results of these forces might befor pediatric clinicians, and (3) sug-gest opportunities to help individu-als and organizations prepare forpossible futures that might influencepediatrics.

To address the question of what forcesare most likely to shape the future ofpediatrics, the task force instigated 3data-collection efforts. First, the VOP2020 Task Force conducted an exten-sive literature review within and out-side pediatrics and reviewed other re-cent visioning and planning efforts.5–7

On the basis of this work, the taskforce identified 48 forces that werelikely to influence pediatric health andpractice. Second, the task force sentan electronic survey to all elected andappointed leaders of the AAP (n� 320[240 responded]) and asked them torank these 48 trends along two 5-pointscales that designated the overall im-portance of the trend in shaping thefuture and the likeliness that the trendwould actually occur. The task forcealso submitted a similar survey to theentire AAP membership (n � 60 000[4555 responded]; demographics ofthe respondents closely approximatedthe overall demographics of the AAPmembership). Third, members of thetask force conducted qualitative inter-views with thought leaders both withinand outside the profession of pediat-rics (n � 22). Interviewees repre-sented the perspectives of pediatricpractice, academic pediatrics, boardcertification, family practice, publichealth, psychologists, pediatric nurses,child health researchers, industry, andparents. Task force members consoli-

dated data from these 3 sources andidentified 19 trends that were consis-tently endorsed as having the greatestpotential influence on the future of theprofession (see Table 1). A separatelist of “wild cards” was developed tooutline trends that could have a sub-stantial influence but were deemed un-likely to occur (see Table 2).

The VOP 2020 then embarked on a pro-cess of envisioning the potential influ-ence of these trends on pediatrics. TheVOP 2020 chose to use scenario-planning to foster this process. Sce-nario-planning,8–13 originally designedby the Royal Dutch-Shell company, isincreasingly used by businesses, themilitary, and policy-makers to identifyand plan for a range of potential, plau-sible futures. Scenario-planning is par-ticularly effective when the goal is notto seek a single “answer” but to envi-

TABLE 1 Initial List of 19 Trends Generated by the VOP 2020

Domain Trend

Population/society The number of children with long-term chronic illnesses continues to increaseAn increasing number of families in the United States have health careinsurance through 1 program or approach or anotherThe number of children and parents from different cultures continues toincreaseThere is an increase in mental health concerns and conditions in children

The public and healthconsumers

Consumer data and information will exert greater influence over health carechoicesExpectations of families to play a larger role in making health care decisionsincreasesThe public’s growing desire for accountability and transparency continues toincrease

Health issues Focus on prevention increasesThe ability of science to effectively address major health problems of childrenincreasesThe number of parents seeking exemptions from immunizations continues toincreaseThe number of practices that provide family-centered, coordinated care(medical home) is increasing

Healthfinance/regulation

The US national policy- and decision-making culture is increasing its focus onfamiliesFair compensation for pediatric health care services increases

Workforce The number of potential career paths in pediatrics continues to expandWorkforce shortages in pediatrics persist

Practice issues The number of practices with EHRs continues to increaseThe number of practices working with community leaders/organizationscontinues to increase (public health, schools, etc)Number of alternative models and sites for children to receive care (retailbased clinics, etc) is increasing.The number of practices implementing quality-improvement initiativescontinues to increase (certification by National Committee for QualityAssurance, etc)

TABLE 2 Wild-Card Trends Identified Throughthe VOP 2020

Domain Example

Societal changes Large pandemic or majordiseaseWorld famine or droughtA disaster necessitatingresettlementWar on US soil

Health advances Gene therapy able to providetrue and effective curesChange in birth ratesUniversal health insuranceCure for autism

Economics US and global economiescollapseGreater disparities betweenrich and poorDecline or exponentialincrease in cost of highereducation

Work-life balance Access to high-quality childcare with job securityImplementation of a 56-hweek for residentsChanges in family planningpolicies

972 STARMER et al by guest on August 19, 2018www.aappublications.org/newsDownloaded from

sion and prepare for a variety ofpossibilities. In essence, scenario-planning parallels the thought processa neonatologist, for example, might fol-low when anticipating, planning, andpreparing for the uncertain future ofan extremely premature newborn in-fant. By applying the step-by-step pro-cess of scenario-planning (Table 3) toidentify possible future realities, thoseusing this process have the opportu-nity to be more prepared to “makestrategic decisions that will be soundfor all plausible futures.”10

One common method used to assessthe potential influence of various fac-tors in scenario-planning is to contrast2 trends in a matrix (with 2 axes yield-ing a 2-by-2 table) in which 4 differentfuture scenarios can be identified. Asevidenced in the example provided inFig 1, when crossing 2 trends, the 4

possible scenarios are described indetail and labeled in accordance withthe overall themes they create. Thisprocess can be repeated as often asnecessary to ensure that all the criti-cal trend combinations are addressed.

Using this methodology, the task forceconsolidated the 19 trends into 8 criti-cal megatrends that were anticipatedto have themost profound influence onthe future of pediatrics (see Table 4).The task force then reviewed eachof the megatrends on a unilateral axisto develop 3 possible futures: a “best-case,” a “worst-case,” and a “mostplausible” scenario. It is important tonote that the most plausible scenariorepresented the consensus of thegroup, given the known demographicsand realities of the current time. Inscenario-planning, it is essential toavoid considering the most plausible

TABLE 3 Steps for Successful ScenarioPlanning

Step 1: Identify the focal issue or decision: What iskeeping you up at night?Step 2: Identify the key forces in the localenvironment: What will decision-makers wantto know when making key choices? What willbe seen as success or failure? What are theconsiderations that will shape theseoutcomes?Step 3: Identify driving forces: What are the macroforces behind the forces listed in step 2?Step 4: Rank by importance and uncertainty: Towhat degree is the success of the focal issueor decision identified in step 1 important? Whatis the degree of uncertainty surroundingfactors and trends?Step 5: Create scenario logic: Map plausiblescenarios in a spectrum framework (an axis,matrix, or volume)Step 6: Flesh out the scenarios: Who? What?Where? When? Why? How?Step 7: Determine the implications: How does thedecision look in each scenario? Whatvulnerabilities have been revealed?Step 8: Conduct a strategic conversation toprepare for the future: Select leadingindicators, signposts, and adjustment plans

Adapted from Schwartz P. The Art of the Long View: Plan-ning for the Future in an Uncertain World. New York, NY:Doubleday; 1996.

FIGURE 1Scenario-planning, crossing trends: the 4 scenarios defined by combination of the 2 trends “scope of practice” and “quality.”

SPECIAL ARTICLES

PEDIATRICS Volume 126, Number 5, November 2010 973 by guest on August 19, 2018www.aappublications.org/newsDownloaded from

scenario as a “single-point forecast,”because the advantages of having con-sidered multiple scenarios would belost.8,10

The 3 scenarios for each megatrendare outlined in Table 5. We present be-low a brief summary of each of the 8megatrends, describe the contextualbackground related to the megatrend,and then highlight important themeswithin each scenario. For the sake ofbrevity, only a few key characteristicsof the 3 scenarios are presented in thetable and text for each megatrend; ad-ditional information is available on theVOP 2020 Web site (www.aap.org/visionofpeds). We particularly focus onthe controversial questions that we asa profession need to ask ourselves ifwe are to anticipate and lead change.The accompanying article4 provides aframework for this process and pre-sents proposed future actions identi-fied by the task force.

FINDINGS

Megatrend 1: ChangingDemographic and ClinicalCharacteristics of Children andFamilies

Current Context

The clinical, social, and cultural demo-graphic mix of children and adoles-cents (hereafter “children”) and theirfamilies is increasingly complex. Clini-cally, the prevalence of complexchronic health issues (eg, asthma,obesity, mental health and develop-

mental disorders) in children contin-ues to increase,14,15 and more childrenwith previously fatal disorders aresurviving into adulthood.16–21 Sociallyand demographically, the child popula-tion is projected to be increasingly di-verse by 2020.22,23 There is also evi-dence for growing disparities in childhealth. Families and children of immi-grant origin and people of color facesignificant barriers in accessinghealth care services including limitedresources, poverty, language barriers,lack of insurance, poor access despiteinsurance, and discrimination.24 At thesame time, children living in povertyare especially vulnerable to poorhealth outcomes including violence,abuse, and physical and mental healthproblems.25 Currently, more tradi-tional models of practice are strainedto provide innovative models of carethat feature more team andcommunity-based medical homes thatfocus broadly on these and other is-sues in child health.

Scenario Themes

The 3 scenarios presented in Table 5raise a number of issues for the field toaddress in preparing for 2020. Specif-ically, we as a profession need to grap-ple with how we will redefine the rolesof pediatricians, hospitalists, subspe-cialists, allied health professionals,families, and other child-serving pro-fessionals as well as the protocols,procedures, and settings in which wewill care for children. As a profession,will we endorse newmodels of care forchildren with chronic disorders thatare conducive to incorporating ad-vances in medical care while permit-ting the vast majority of children to bemanaged from home? Will we adoptthe AAP Mental Health Task Force’s callfor increased management of mentalhealth care in primary care settingsand advocate for new models of reim-bursement and care? How will we bal-

ance and distribute resources to en-sure the availability of preventativecare and the coordination of care forchildren with complex medical needsin a culturally sensitive and ethicallyfair way? The changing sociodemo-graphics of children and families alsoraise issues as to whether pediatricswill increasingly address health prob-lems that are rooted in sociodemo-graphic determinants of health and,therefore,may requiremore population-based prevention and interventionstrategies. The scope and extent towhich pediatric clinicians take ac-countability for these health issueswill, in part, define the long-term direc-tion of the profession.

Megatrend 2: Burgeoning HealthInformation Technology

Current Context

In 2010, health information technology(HIT) is being adopted at an accelerat-ing pace.26 Increased use is correlatedwith increasing pressure from govern-ment agencies and payers to requireelectronic health records (EHRs) todrive quality measurement and pay-ment.27 Concurrently, initiatives havebeen developed to advance patient-centered pediatric care through the in-creased exchange of information frommultiple sources and personalized pa-tient records.28 Consumer demandsare increasingly focused on personal-ized medicine, telehealth, and commu-nication technologies. Despite thesepressures, adoption and implementa-tion of EHRs in pediatrics lag behindother medical fields,26 and technology-based tools for shared decision-making and management are most of-ten limited to local demonstrationprojects. The profession and the pub-lic also struggle with ethical ques-tions surrounding health data andthe implications of providing infor-mation security.

TABLE 4 Eight Megatrends Identified Throughthe Scenario Process of the VOP2020

1. Changing demographic and clinicalcharacteristics of children and families2. Burgeoning HIT3. Ongoing medical advances4. Alterations in health care–delivery system(s)5. Growth of consumer-driven health care6. Dynamics of pediatric workforce7. Disasters (environmental, infectious,man-made)8. Globalism

974 STARMER et al by guest on August 19, 2018www.aappublications.org/newsDownloaded from

TABLE 5 Best-Case, Worst-Case, and Most Plausible Scenarios Identified Through the VOP 2020

Megatrend Worst-Case Scenario Most Plausible Scenario Best-Case Scenario

Changing demographic andclinical characteristicsof patients and familiesin the United States

US societal health attitudes and behaviorsunchanged; poor health outcomes;disparities increase

United States struggles to redefinepriorities and philosophies relatedto societal health issue

United States experiences a mass societalattitude shift toward a focus onpediatric health

Children lack preventive andcomprehensive care

Without focus on prevention andadequate coordination, overallpediatric health outcomes worsen

All children receive preventive,comprehensive, well-coordinatedhealth care

Children with chronic conditions andmental health needs lack coordinated,accessible care

Innovative demonstration projectsyield success for chronicconditions and mental healthissues; mass disseminationremains elusive

Mental health prevention and treatmentare integrated into primary carepediatrics

Exposure to environmental stress andtoxins increases

Pediatric providers fail to adequatelyaddress the impact ofenvironmental stress and toxins

Reduction of environmental stress andtoxins integrated into primary carepediatrics

Burgeoning HIT Disparities exist among practices andsystems regarding HIT adoption as thehigh cost of information-technologysystems slows implementation

Government-funded mandates,practice, and systemconsolidation drive acceleratedchange in design, development,and use of HIT

All physician practices and hospitalsystems operate off an EHR

Poor interoperability increases workloadand error

HIT adoption efforts highlightinteroperability and ethicalconsiderations as criticalchallenges

Public and private alliances create theframework for EHR interoperability

HIT systems not designed with qualitymeasurement in mind

Increased integration of HIT intoquality measurement andcontinuing medical education

Every physician uses HIT regularly tomeasure quality

Ongoing medical advances Cost to access new medical technologieswidens health disparities

Advances in medical knowledge, newdiagnostic tools, and treatmentoptions accelerate

Breakthroughs demonstrate that manylife-threatening illnesses can becontrolled or eliminated

Breakthroughs stagnate Providers struggle to validate,translate, and integrate newknowledge into practice

Alignment of federal funds with public andprivate alliances translatesbreakthroughs into practice

Practices unable to handle ethicalconsiderations inherent to newtechnologies and treatments

Medical technologies expand scopeof practice with emphasis onethics of need to counsel patientsregarding new treatment options

Discussions around medical ethics lead totransformational thinking and shiftingsocietal attitudes

Alterations in health care–delivery systems

Resistance to change widens gapsbetween health care delivery andsocietal needs

Prioritization of testing new caremodels

US health system invests heavily inprimary care prevention and medicalhome infrastructure, aligning paymentto preventive care

Health care payment systems prioritizeexpensive episodic acute caremanagement over preventive andchronic care coordination; providersunwilling to care for youth with chronicconditions

Innovative modeling and qualityprojects integrate criticalcomponents of the medical homemodel into practice

Rapid expansion and adoption of medicalhome models lead to lower costs, moreproviders, and improved outcomes

Scope-of-practice battles increasemistrust within the health system andamong consumers

Uncertainty remains regarding theappropriate scope of practice forvarious pediatric health careproviders

Physicians, nurses, and allied healthprofessionals work togetherseamlessly to provide high-quality cost-effective care

Growth of consumer-drivenhealth care

Misinformation confuses consumers,resulting in poor decisions and healthoutcomes and decreased trust

Individual practices make anincreasing investment in HIT toensure that patients and familieshave access to accurateinformation

Families gain easy access to high-quality,valid health information and assumemore responsibility for their child’shealth

Practices and health systems fail to investin consumer services, leading todissatisfied patients and families

Individual practices increaseinvestments in consumer servicesand facilitate communication,information exchange, reminders,and logistical access

Families connect with their providersthrough communication technology,improving quality of care

Practice and service outcome data aremanipulated as part of marketingcampaigns to drive patient business

Hospitals and health systems requiresharing of outcome data in thepublic domain

Publicly shared health systems dataincentivize practices to improve quality

SPECIAL ARTICLES

PEDIATRICS Volume 126, Number 5, November 2010 975 by guest on August 19, 2018www.aappublications.org/newsDownloaded from

Scenario Themes

In all identified scenarios for the year2020, significant pressure from gov-ernments, payers, and the public willaccelerate integration of critical tech-nologies into pediatric practice.Larger practices, in both academicand private settings, will develop stra-tegic HIT-implementation plans andsurge ahead of smaller practices,which will create enormous financialand time pressure to transform. Withgrowing disparities across systemsand networks, opportunities to link to

larger, coordinated systems of caremay seem increasingly attractive tomanage the ongoing burden of ex-pense and personnel time to develop,improve, and maintain HIT systems.Yet, how will the profession balancethis tension between interoperabilityand the need to allow healthy competi-tion between heterogeneous systems?In the years ahead, will the increasinguse of technology improve qualitymea-surement and the ability to provide de-monstrable evidence of a practice’sability to improve quality in a cost-

effective manner? Or, will the high costof HIT systems widen disparities ofquality among practices?

Megatrend 3: Ongoing MedicalAdvances

Current Context

Advances in medical knowledge, diag-nostic tools, and treatment options areaccelerating, creating entirely newfields of science, and fostering posi-tive health outcomes.29 Specifically,genomics, molecular biology, nano-

TABLE 5 Continued

Megatrend Worst-Case Scenario Most Plausible Scenario Best-Case Scenario

Dynamics of the pediatricworkforce

Significant provider shortages andmaldistribution contribute to poorhealth outcomes

Innovative solutions align resourcesto improve distribution ofphysicians in some areas

Primary care, medical subspecialty, andsurgical specialty workforce meetgrowing patient needs, and roles fornonphysician providers are clearlydefined to help meet these needs

Training does not prepare graduates Need for improved pediatric training,career development, andincreased accountability drivessome change

Pediatric training teaches future practicemodels and needs and is well funded

Work/life challenges and high debt driveincreasing number of pediatricians intoalternative careers

New practice models are developedto address personal needs ofpediatricians

Family, work, and work/life balance isachieved through debt-relief programsand innovative practice models

Disasters The frequency and intensity of disastersexceed expectations and resources

More frequent and intense disastersphysically and fiscally threatenpractices and their patients andfamilies

Societal and community preparationmitigate preventable disasters andminimize damage and loss caused bynatural disasters

Community response and resources arefragmented and isolated, leaving avulnerable population at extreme risk

Disaster preparation, mental healthcounseling, and communityservice connections increase indemand for both pediatriciansand patients

Children and families are prepared torespond to a disaster and haveadequate access to support services

Pediatricians disregard opportunities toincrease community planning andresponse

Pediatricians play a greater role inthe community disaster-responseteam and become an increasinglyhigh priority for all levels ofgovernment

Pediatricians and families advise all levelsof government in disaster-planning anduse health infrastructure to promotepreparation and safety

Globalism US health system remains isolated andignores global health delivery andoutcomes

Social and political effects ofglobalism grow, and policyformulation remains slow

US establishes a clear vision andresponsibilities as a cooperativemember of the global healthcommunity

US academic medical centers arerelatively isolated from one anotherand the rest of the world’s academiccommunities

Practices innovatively adapt toculturally diverse patientpopulations

Global communication networks andtechnologies expand health expertiseand opportunities for consults andWeb-medicine

Pediatric clinicians encounter more rarediseases as cultural diversity andworld travel increases

International sharing of pediatricresearch creates “centers ofcollaborative excellence”

Global, virtual research communities andcenters of excellence are optimized,providing resources for treatment ofrare diseases

US citizens search abroad as payersincentivize patients to seek inexpensive,quality care out of the country

US hospitals have difficultycompeting on global scale,improvement opportunities arisebut are not always implemented

US health care reform makes hospitals’price and quality competitive tointernational care options

976 STARMER et al by guest on August 19, 2018www.aappublications.org/newsDownloaded from

technology, computer simulation, arti-ficial intelligence, and robotics are allemerging as fields that are increas-ingly present.30 However, expenses todevelop new medical technology arehigh, which leads to disparity in healthoutcomes between those who can andcannot afford to pay themselves.31 Inaddition, access to medical informa-tion and diagnostic tools froma varietyof media has a tendency to prompt pa-tients to request diagnostic and treat-ment options regardless of whetherthey are medically appropriate and toshift some medical decision-making topatients themselves.32

Pediatric professionals are experienc-ing a dramatic change in scope ofpractice with a broader focus on pa-tient counseling and the need to helpfamilies interpret information and testresults.33 Although increasing levels ofevidence-based practice, outcomes re-search, and comparative effectivenessresearch exist, the implementationand acceptance of these findings istypically slower in coming.34

Scenario Themes

Advances in medicine will have pro-found implications on the health caresystem and the pediatric profession-al’s everyday life. As the pace of newbreakthroughs accelerates, the extentto which these novel treatment optionswill ultimately lead to elimination ofdisease and reduction of disparity re-mains unclear. How much will the costof new technologies widen the samehealth-disparity gaps that these newinnovations are seeking to eliminate?Will the integration of these new break-throughs stagnate as a result of inad-equate funding and partnerships to al-low incorporation of new technologiesinto practice? Although the use of newmedical advancesmay be a differentia-tor for families in choosing a practiceor provider, clinicians will struggle todetermine the relative validity and

value of new treatments as theyemerge without appropriate guidance.In this age of advancing technologies,pediatric providers will also increas-ingly encounter ethical dilemmas asthey help patients determine what canand should be reliably known and asthey work to ensure that clinical trialsare structured in such a way thatsafety and efficacy evaluations are pe-diatric focused.

Megatrend 4: Alterations in theHealth Care–Delivery System(s)

Current Context

The US health care–delivery system isinefficient, lacks uniform quality, andis unsustainable in its current form.34

Without change, many experts agreethat the result would be disastrous onan economic and societal level.34,35

Many believe that a new health care–delivery system should provide carethat shares responsibility between in-dividuals, integrated providers, andcommunities and that such a systemshould foster access to affordable,comprehensive, and high-quality cov-erage.2 Discussion and implementa-tion of a model to reshape the deliverysystem is challenging the values of ournation. Debate over these values andalignment to a new delivery system isforcing a slowing in implementation,because vast gaps exist between thestatus quo and the desired state. Chil-dren have traditionally been at partic-ular risk in these discussions, becausepolicies are most often developed witha focus on adults.36

Scenario Themes

The health care–delivery system as itcurrently stands is unsustainable.However, resistance to changemay im-pede the widespread implementationof promising care-delivery systemssuch as the medical home model. Theextent to which payment systems pri-oritize acute care management over

preventive services and care coordina-tion may further hamper the extent towhich providers are able to offer well-coordinated, high-quality care to chil-dren with chronic medical problems.As health care–delivery systems con-tinue to evolve, so too will the roles ofpediatric clinicians and subspecial-ists. Scope-of-practice and paymentdeliberations among pediatricians,subspecialists, and other health pro-viders are critical but may threaten toslow transformation within pediatricsif consensus cannot be reached.

Megatrend 5: Growth of Consumer-Driven Health Care

Current Context

Consumer involvement in health careis an expression of the growing publicdesire for a more accountable andtransparent US health care system.37

As consumers become involved intheir own health care, they greatly in-fluence the health care industry. Eightof 10 Americans regularly access on-line resources for health informa-tion.39 Widespread use of the Internetallows consumers to compare, coordi-nate, and purchase health services.Many consumers with Internet accessbase their health decision-making onmedical information available online.38

Although the use of online resourcesmay lead to better-educated consum-ers, Internet-acquired health knowl-edge is often not objective because itmay be decontextualized and, there-fore, easily misunderstood.39 As a re-sult of this available information, con-sumers may feel less confident in theirmedical providers,40 who have fewopportunities to challenge Internet-based information.

Scenario Themes

To remain competitive, pediatric clini-cians of the future will need to respondto the needs of informed and con-nected consumers. Consumers of

SPECIAL ARTICLES

PEDIATRICS Volume 126, Number 5, November 2010 977 by guest on August 19, 2018www.aappublications.org/newsDownloaded from

health care will become more involvedin their own health monitoring withnew devices and will accept more re-sponsibility for sharing health infor-mation and managing aspects of theircare. Although some practices andhealth systems will serve as “trustedhealth communication and educationcenters” through Web sites and otheradvanced communication and mes-saging technologies, others may fail toinvest in consumer services, therebyleading to dissatisfied patients andfamilies. To what extent will the misin-formation that stems from inaccurateor absent information result in poorpatient and family health decisionsand decreased trust? Will those prac-tices that commit to ensuring that pa-tients and families have easy access tohigh-quality, valid health informationcontribute to improved health out-comes and patient satisfaction? Pa-tients and families will also increas-ingly seek outcomes data beforeselecting specific providers. Avoidingmanipulation of these data while in-centivizing practices to engage inhealthy competition to improve qualitymay be a delicate balance.

Megatrend 6: Dynamics of thePediatric Workforce

Current Context

The pediatric workforce faces signifi-cant change in the future. As medicinehas evolved to be more inclusive of abroad demographic of physicians, therehas been a corresponding evolution ofthe workforce demands for innovation,flexibility, work-life balance, and diver-sity inacademicandpracticeoptions.41,42

This evolution has also occurred in thecontext of remarkable advances in thescience ofmedicine and technology, a fo-cus on safety, and quality improvement.As new medical advances and technol-ogy emerge at record pace,30,43 the needfor specialization and subspecializationacrossall professions ismore important

than ever. There is concern that pediat-ric residency training does not ade-quately prepare pediatricians for thesignificant diversity of practice set-tings.44 In addition, despite evidence thatsuggests thatmedical students frommi-nority backgrounds are more likely tocare for underserved patient popula-tions,45 there have not been substantialincreases in the proportion of medicalschool graduates from underrepre-sented minority groups over the past 30years.46,47 The challenge of increasingmedical student debt load is a key factorthat is affecting the ability to attract stu-dents fromdiversebackgrounds tomed-ical school and pediatrics.48 Also, thereexists a poor geographic distributionand limited number of pediatricians,subspecialists, and surgeons.49–51 Inturn, an increasing variety of provid-ers are giving care to children, mostnotably hospitalists and nursepractitioners.52,53

Scenario Themes

The structure of the pediatric work-force will continue to adapt and evolve;however, these changes may not bealigned with the changing nature andneeds of the health care–delivery sys-tem. Workforce shortages present asignificant challenge. In the future, willthese provider gaps lead to the devel-opment of innovative workforce mod-els that leverage technology, long-distance medicine, and the use ofallied health professionals to fill criti-cal care gaps? Or, will there be a per-sistent maldistribution and shortageof pediatric providers that lead toworsening health outcomes for chil-dren? To meet the needs of patientsand families, a team approach to careis widely accepted as the most viablesolution. Yet, this is not an easy transi-tion, because scope-of-practice issuesand shifting roles and responsibilitiescreate resistance to, and slow, change.Team models should be studied care-fully to determine the extent to which

they positively influence quality ofcare, patient and family satisfaction,and satisfaction of the pediatric work-force. To attract and retain a primarycare workforce, practices and sys-tems of care may develop innovativestaffing models that provide solutionsfor career and life balance such as job-sharing, off-hours e-medicine, use ofallied health professionals with physi-cian access and supervision, and debtmanagement. Medical schools and pe-diatric training programs will alsocontinue to evolve along multiple path-ways of depth, scope, philosophy, andquality, which in turn will influence thedegree to which pediatric providersare prepared to practice in the future.

Megatrend 7: Disasters(Environmental, Infectious, Man-made)

Current Context

An increasing frequency and severityof economic, nutritional, and environ-mental threats to the health of theworld’s children exist as a result ofnatural, environmental, and man-made disasters caused by globalclimate change, deforestation, popu-lation growth, pollution, species ex-tinction, and environmental toxins.30,54

A near doubling of the percentage ofpeople who live in urban areas has ledto an increased potential influence ofthese disasters.55

Most of the world’s children are in thecross-path of the most common disas-ters, particularly in the developingworld, and are extremely vulnerable tothe long-term effects of toxic water,air, etc.56 The physical and psychologi-cal influence of disasters has beenidentified as an increasing componentof pediatric practice as providersteach prevention and survival skillsand engage in emergency communityresponses.57 Yet, systems are lackingto prepare families to address chil-dren’s health needs in disasters.58

978 STARMER et al by guest on August 19, 2018www.aappublications.org/newsDownloaded from

Scenario Themes

Over the next 10 years, disasters willcontinue to occur as a result of imbal-ances in the Earth’s geophysical andgeopolitical climate, even as attemptsare made to correct these imbalances.In the future, the extent to which pedi-atricians, families, and governmentagencies prepare for and anticipatethese disasters will likely have a dra-matic influence on the ultimate re-sponse and outcome. Will communityorganizations and local governmentsbe prepared to minimize the impact ofnatural disasters and mitigate pre-ventable disasters? Or, will a lack coor-dination of community resources leavea vulnerable population at significantrisk as the frequency and intensity ofdisasters exceed expectation? The rolethat pediatric clinicians will play inthese responses will also be critical,because an increasing number of di-sasters will require that providers re-spond to ensuing medical and eco-nomic disparities aswell as increasingmental health needs that result fromeach catastrophe.

Megatrend 8: Globalism

Current Context

The vast majority of children in theworld (90%) live outside the UnitedStates in developing nations where en-vironmental hazards and infectiousdiseases are more common.59 Chil-dren’s health is increasingly influencedby globalization, industrial development,income growth and distribution, eco-nomic instability, availability of health re-sources, migration, and facilitation oftravel. Key health gains occur in coun-tries where globalization efforts are ap-propriately managed, whereas othercountries in which globalization effortsremain random continue to be more af-fected by issues of poverty, food insecu-rity, and social environmental hazards.60

Globalization fosters the spread ofacute infectious diseases as well as

chronic diseases such as obesity anddiabetes.30,61,62

Scenario Themes

In the future, pediatric professionalspossess an opportunity to determinethe role that pediatrics will play in en-suring an adequate distribution andavailability of global health resourcesand providers. Advances in communi-cation, medical imaging, and robotictechnologies will facilitate global med-ical consults with the world’s experts.As new communication technologiescreate broader opportunities to linkpediatrics in a global network, it will beimportant to assess ideal methods ofdelivery and to evaluate the social andpolitical implications of globalism.Global centers of excellence and vir-tual global learning communities maybe established more frequently in re-search and practice. Will the role ofthese centers be optimized in the fu-ture and prompt a better-coordinatedresponse across nations to promotehealth improvement? As health reformpushes forward in the United States, itwill be important to assess how UShospitals can best learn from globalpartners to offer high-quality, cost-effective care for all.

CONCLUSIONS

The work of the VOP 2020 Task Forcerepresents an innovative approach toproactive preparation for plausible fu-tures. The 8megatrends we have listedoffer a description of several possibletrends that were predicted to likely in-fluence the future of pediatrics. With aknowledge and understanding of theabove-described megatrends, pediat-ric clinicians have an opportunity andresponsibility to play an important rolein shaping the future of their careersand, collectively, of the pediatric healthcare–delivery system, as described inthe accompanying article.4

It is important to note several limita-tions of this work and methodology. Al-

though the task force was selectedwith the aim of representing manyviewpoints, all task force members in-evitably have personal biases that mayhave affected the content of this work.Particularly, we are aware that thetrends are heavily biased toward pedi-atric care in the United States. In addi-tion, our identification of a most plau-sible future for each of themegatrends should not narrow the fo-cus of discussion to the exclusion ofother possible futures. In fact, over thecourse of the project, changes oc-curred related to both the megatrendsand the wild-card trends that were notanticipated in the most plausible sce-narios. Nevertheless, the VOP 2020process served to catalyze changesin the AAP strategic planning pro-cess. We hope this article alsoprompts individuals and othergroups within the pediatric commu-nity to begin their own planning pro-cess to shape our future. By applyingthe methodology and skill set de-scribed in the accompanying article,4

those in the profession of pediatricshave the opportunity to collaboratein the creation of a new planning pro-cess for the future, for which thegoal is not to determine “the end” butinstead to anticipate, plan for, shape,and thrive in any end that may mani-fest itself as reality.

ACKNOWLEDGMENTSDr Starmer’s work on this project wassupported in part by the Health Re-sources and Service AdministrationNational Research Service Award inPediatrics (T32 HP10018), and Dr Le-slie’s work on this article was partiallysupported by theWilliam T. Grant Foun-dation (9443) and the Tufts Clinical andTranslational Science Institute (UL1RR025752). Funding for the VOP 2020Task Force was provided by the AAP.

Members of the VOP 2020 Task Forceincluded John Duby, MD, FAAP (chair),Jeff Kaczorowski, MD, FAAP (vice-

SPECIAL ARTICLES

PEDIATRICS Volume 126, Number 5, November 2010 979 by guest on August 19, 2018www.aappublications.org/newsDownloaded from

chair), Maria Britto, MD, FAAP, Chris-toph Diasio, MD, FAAP, Anne Edwards,MD, FAAP, Amy J. Starmer, MD, MPH,FAAP, Renee Jenkins, MD, FAAP, RobertKliegman, MD, FAAP, Danielle Laraque,MD, FAAP, Laurel K. Leslie MD, MPH,FAAP, Martin Michaels, MD, FAAP, andMarleta Reynolds, MD, FAAP. VOP 2020

thanks project consultants ThomasBoat, MD, FAAP, David Bergman, MD,FAAP, Edward Schor, MD, FAAP, BonitaStanton, MD, FAAP, Robert Walker, MD,FAAP, and Paul Wise, MD, FAAP. The taskforce acknowledges the outstandingcontributions to this work by AAP staff.Kenneth M. Slaw, PhD, designed the

process and facilitated the VOP 2020sessions, and Anne Gramiak, MPH, andSusan Flinn, MA, provided superb facil-itation and staff support. Last, wethank Tully Saunders for editorial as-sistance. To learn more about the VOP2020 project, please visit www.aap.org/visionofpeds.

REFERENCES

1. Cheng TL. Primary care pediatrics: 2004 andbeyond. Pediatrics. 2004;113(6):1802–1809

2. Schor EL. The future pediatrician: promot-ing children’s health and development. JPediatr. 2007;151(5 suppl):S11–S16

3. Wise PH. The future pediatrician: the chal-lenge of chronic illness. J Pediatr. 2007;151(5 suppl):S6–S10

4. Leslie LK, Slaw KM, Edwards A, Starmer AJ,Duby J; Members of the Vision of Pediatrics2020 Task Force. Peering into the future:preparing, envisioning, engaging, and re-shaping pediatrics in a changing world. Pe-diatrics. 2010;126(5):982–988

5. Jones MD Jr, McGuinness GA, Carraccio CL.The Residency Review and Redesign in Pedi-atrics (R3P) project: roots and branches.Pediatrics. 2009;123(suppl 1):S8–S11

6. American Association of Medical Society Ex-ecutives. Trends Identification Report. Mil-waukee, WI: American Association of Medi-cal Society Executives; 2009

7. Outlook 2009: recent forecasts from WorldFuture Society for 2009 and beyond. Futur-ist. 2008;42(6):29

8. Keough SM, Shanahan KJ. Scenario plan-ning: toward a more complete model forpractice. Adv Dev Hum Resour. 2008;10(2):166–178

9. Scearce D, Fulton K. What if? The art of sce-nario thinking for nonprofits. Available at:www.gbn.com/articles/pdfs/GBN_What If.pdf. Accessed September 8, 2010

10. Schwartz P. The Art of the Long View Plan-ning for the Future in an Uncertain World.Chichester, United Kingdom: Wiley; 2004

11. van der Heijden K, Bradfield RM, Burt G,Cairns G, Wright G. The Sixth Sense: Acceler-ating Organizational Learning With Scenar-ios. Hoboken, NJ: Wiley; 2002

12. Wack P. Scenarios: uncharted watersahead. Harv Bus Rev. 1985;63(5):73–89

13. Wack P. Shooting the rapids. In: Strategy:Critical Perspectives on Business and Man-agement. New York, NY: Taylor & Francis;2002:115

14. Perrin JM, Bloom SR, Gortmaker SL. The in-crease of childhood chronic conditions in

the United States. JAMA. 2007;297(24):2755–2759

15. Van Cleave J, Gortmaker SL, Perrin JM. Dy-namics of obesity and chronic health condi-tions among children and youth. JAMA.2010;303(7):623–630

16. Akinbami LJ, Moorman JE, Garbe PL, SondikEJ. Status of childhood asthma in the UnitedStates, 1980 –2007. Pediatrics . 2009;123(suppl 3):S131–S145

17. Ogden CL, Carroll MD, Curtin LR, McDowellMA, Tabak CJ, Flegal KM. Prevalence of over-weight and obesity in the United States,1999–2004. JAMA. 2006;295(13):1549–1555

18. Robison LM, Sclar DA, Skaer TL, Galin RS.National trends in the prevalence ofattention-deficit/hyperactivity disorder andthe prescribing of methylphenidate amongschool-age children: 1990–1995. Clin Pedi-atr (Phila). 1999;38(4):209–217

19. Foy JM, Kelleher KJ, Laraque D; AmericanAcademy of Pediatrics, Task Force on Men-tal Health. Enhancing pediatric mentalhealth care: strategies for preparing a pri-mary care practice. Pediatrics. 2010;125(suppl 3):S87–S108

20. Costello E. Primary care pediatrics andchild psychopathology: a review of diagnos-tic, treatment and referral practices. Pedi-atrics. 1986;78(6):1044–1051

21. Newacheck PW, Kim SE. A national profile ofhealth care utilization and expenditures forchildren with special health care needs.Arch Pediatr Adolesc Med. 2005;159(1):10–17

22. Federal Interagency Forum on Child andFamily Statistics. America’s Children inBrief: Key National Indicators of Well-being,2008. Washington, DC: US Government Print-ing Office; 2008

23. Federal Interagency Forum on Child andFamily Statistics. POP3, racial and ethniccomposition: percentage of US childrenages 0–17 by race and Hispanic origin, se-lected years 1980 –2007 and projected2008–2020. Available at: www.childstats.gov/americaschildren/demo.asp. AccessedFebruary 26, 2010

24. Javier J, Huffman L, Mendoza F, Wise P. Chil-dren with special health care needs: howimmigrant status is related to health careaccess, health care utilization, and healthstatus. Matern Child Health J. 2010;14(4):567–579

25. Aber JL, Bennett NG, Conley DC, Li J. The ef-fects of poverty on child health and develop-ment. Annu Rev Public Health. 1997;18:463–483

26. Menachemi N, Brooks RG, SchwalenstockerE, Simpson L. Use of health informationtechnology by children’s hospitals in theUnited States. Pediatrics. 2009;123(suppl2):S80–S84

27. Conway PH, White PJ, Clancy C. The publicrole in promoting child health informationtechnology. Pediatrics. 2009;123(suppl 2):S125–S127

28. Brinner KA, Downing GJ. Advancing patient-centered pediatric care through health in-formation exchange: update from the Amer-ican Health Information CommunityPersonalized Health Care Workgroup. Pedi-atrics. 2009;123(suppl 2):S122–S124

29. Osheroff J, Pifer EA, Teich JM, Sittig DF,Jenders RA. Improving Outcomes With Clin-ical Decision Support: An Implementer’sGuide. San Diego, CA: Elsevier Science; 2005

30. Cetron MJ, Davies O. 55 Trends Shaping To-morrow’sWorld Forecasts and Implicationsfor Business, Government, and Consumers.Bethesda, MD: World Future Society; 2008

31. Moonesinghe R, Jones W, Honoré P, TrumanB, Graham G. Genomic medicine and racial/ethnic health disparities: promises, perils,and the challenges for health care and pub-lic health policy. Ethn Dis. 2009;19(4):473–478

32. Technology-Enabled Innovations for Improv-ing Children’s Health. Santa Monica, CA:Children’s Partnership and Public HealthInstitute/Health Technology Center; 2009

33. Ginsburg PB; Center for Studying HealthSystem Change, Mathematica Policy Re-search I.Making Medical Homes Work: Mov-ing From Concept to Practice. Washington,DC: Center for Studying Health SystemChange; 2008

980 STARMER et al by guest on August 19, 2018www.aappublications.org/newsDownloaded from

34. Institute of Medicine. Crossing the QualityChasm: A New Health System for the 21stCentury. Washington, DC: National AcademyPress; 2001

35. Kaiser Family Foundation. Trends in HealthCare Costs and Spending. Menlo Park, CA:Kaiser Family Foundation; 2007

36. Wise PH. The rebirth of pediatrics. Pediat-rics. 2009;123(1):413–416

37. Robinson JC. Managed consumerism inhealth care. Health Aff (Millwood). 2005;24(6):1478–1489

38. Fox S. Online Health Search 2006. Washing-ton, DC: Pew Internet and American LifeProject; 2006

39. Eysenbach G, Powell J, Kuss O, Sa ER. Empir-ical studies assessing the quality of healthinformation for consumers on the WorldWide Web: a systematic review. JAMA. 2002;287(20):2691–2700

40. Bauman Z. Liquid Times: Living in an Age ofUncertainty. Cambridge, United Kingdom:Polity Press; 2007

41. Oliver TK Jr, Tunnessen WW Jr, Butzin D,Guerin R, Stockman JA, III. Pediatric workforce: data from the American Board of Pe-diatrics. Pediatrics. 1997;99(2):241–248

42. Merline AC, Cull WL, Mulvey HJ, Katcher AL.Patterns of work and retirement among pe-diatricians aged �50 years. Pediatrics.2010;125(1):158–164

43. Stevens A, Milne R, Lilford R, Gabbay J. Keep-ing pace with new technologies: systemsneeded to identify and evaluate them. BMJ.1999;319(7220):1291

44. Jones MD Jr, McGuinness GA, First LR, LeslieLK; Residency Review and Redesign in Pedi-atrics Committee. Linking process to

outcome: are we training pediatricians tomeet evolving health care needs [publishedcorrection appears in Pediatrics. 2009;123(4)1255]? Pediatrics. 2009;123(suppl 1):S1–S7

45. Saha S, Guiton G, Wimmers PF, WilkersonL. Student body racial and ethnic compo-sition and diversity-related outcomes inUS medical schools. JAMA. 2008;300(10):1135–1145

46. Association of American Medical Colleges.Minorities in Medical Education: Facts &Figures 2005. Washington, DC: Division of Di-versity Policy and Programs, Association ofAmerican Medical Colleges; 2005

47. Carrasquillo O, Lee-Rey ET. Diversifying themedical classroom: is more evidenceneeded? JAMA. 2008;300(10):1203–1205

48. Jolly P. Medical school tuition and youngphysicians’ indebtedness. Health Aff (Mill-wood). 2005;24(2):527–535

49. Werner R, Polsky D. Comparing the supply ofpediatric subspecialists and child neurolo-gists. J Pediatr. 2005;146(1):20–25

50. Buckley P, Madaan V. Leadership and pro-fessional workforce development. Psychi-atr Clin North Am. 2008;31(1):105–122

51. Durham SR, Lane JR, Shipman SA. The pedi-atric neurosurgical workforce: defining thecurrent supply. J Neurosurg Pediatr. 2009;3(1):1–10

52. Freed GL, Brzoznowski K, Neighbors K, La-khani I; American Board of Pediatrics, Re-search Advisory Committee. Characteris-tics of the pediatric hospitalist workforce:its roles and work environment. Pediatrics.2007;120(1):33–39

53. Kotzer A. Characteristics and role functions

of advanced practice nurses in a tertiarypediatric setting. J Spec Pediatr Nurs. 2005;10(1):20–28

54. Kellman B. Bioviolence: a growing threat.Futurist. 2008;42(3):25–30

55. United Nations. World urbanization pros-pects: the 2007 revision population data-base. Available at: http://esa.un.org/unup.Accessed June 1, 2010

56. Dilley M, Chen RS, Deichmann U, Lerner-LamAL, Arnold M. Natural Disaster Hotspots: AGlobal Risk Analysis. Washington, DC: WorldBank Group; 2005

57. Gold JI, Montano Z, Shields S, et al. Pediatricdisaster preparedness in the medicalsetting: integrating mental health. Am J Di-saster Med. 2009;4(3):137–1346

58. Gausche-Hill M. Pediatric disaster pre-paredness: are we really prepared? JTrauma. 2009;67(2 suppl):S73–S76

59. Division United Nations Publication. WorldUrbanization Prospects: The 2005 Revision.New York, NY: United Nations; 2006

60. Cornia GA. Globalization and health: resultsand options. Bull World Health Organ. 2001;79(9):834–841

61. Wild SH, Roglic G, Green A, Sicree R, King H.Global prevalence of diabetes: estimates forthe year 2000 and projections for 2030. Dia-betes Care. 2004;27(5):1047–1053

62. World Health Organization. Internationalspread of disease threatens public healthsecurity: the world health report 2007 fo-cuses on building a safer future. Available at:www.who.int/mediacentre/news/releases/2007/pr44/en/print.html. Accessed June 1,2010

SPECIAL ARTICLES

PEDIATRICS Volume 126, Number 5, November 2010 981 by guest on August 19, 2018www.aappublications.org/newsDownloaded from

DOI: 10.1542/peds.2010-1903 originally published online October 18, 2010; 2010;126;971Pediatrics 

and Members of the Vision of Pediatrics 2020 Task ForceAmy J. Starmer, John C. Duby, Kenneth M. Slaw, Anne Edwards, Laurel K. Leslie

Pediatrics in the Year 2020 and Beyond: Preparing for Plausible Futures

ServicesUpdated Information &

http://pediatrics.aappublications.org/content/126/5/971including high resolution figures, can be found at:

Referenceshttp://pediatrics.aappublications.org/content/126/5/971#BIBLThis article cites 42 articles, 18 of which you can access for free at:

Subspecialty Collections

_subhttp://www.aappublications.org/cgi/collection/child_health_financingChild Health Financinghttp://www.aappublications.org/cgi/collection/advocacy_subAdvocacyfollowing collection(s): This article, along with others on similar topics, appears in the

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtmlin its entirety can be found online at: Information about reproducing this article in parts (figures, tables) or

Reprintshttp://www.aappublications.org/site/misc/reprints.xhtmlInformation about ordering reprints can be found online:

by guest on August 19, 2018www.aappublications.org/newsDownloaded from

DOI: 10.1542/peds.2010-1903 originally published online October 18, 2010; 2010;126;971Pediatrics 

and Members of the Vision of Pediatrics 2020 Task ForceAmy J. Starmer, John C. Duby, Kenneth M. Slaw, Anne Edwards, Laurel K. Leslie

Pediatrics in the Year 2020 and Beyond: Preparing for Plausible Futures

http://pediatrics.aappublications.org/content/126/5/971located on the World Wide Web at:

The online version of this article, along with updated information and services, is

1073-0397. ISSN:60007. Copyright © 2010 by the American Academy of Pediatrics. All rights reserved. Print

the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,has been published continuously since 1948. Pediatrics is owned, published, and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it

by guest on August 19, 2018www.aappublications.org/newsDownloaded from