PEDIATRICS Vol. 105 No. 1 Supplement January 2000, pp. 163-212

The Future of Pediatric Education II: Organizing Pediatric Education to Meet the Needs of Infants, Children, Adolescents, and Young Adults in the 21st Century

	INTRODUCTION

Top Introduction

	EXECUTIVE SUMMARY

Introduction

THE FUTURE OF PEDIATRIC EDUCATION II (FOPE II) Project was a 3-year, grant-funded initiative, which continued the work begun by the 1978 Task Force on the Future of Pediatric Education. FOPE II takes a more in-depth look at issues relating to primary and subspecialty care, the role and education of nonpediatrician providers of child health care, and the financing of pediatric education. FOPE II was a project of the entire pediatric community; a Task Force, composed of leaders in pediatric education, was responsible for the overall direction of the FOPE II Project and for generating the final report. Throughout the course of the Project, the Task Force sought advice and input from a wide variety of knowledgeable and interested individuals and organizations.

In carrying out their charge, the Task Force was guided by 3 overarching goals:

• To evaluate the 1978 Report with respect to its relevancy to the education of pediatricians and others providing health care to children in the 21st century.
• To provide direction for the improvement of pediatric education, with special emphasis on workforce requirements, new instructional methodologies, and the financing of pediatric education.
• To recommend essential changes in the educational process to meet the current and future health care needs of all infants, children, adolescents, and young adults.

To achieve these goals, 5 topic-specific Workgroups were formed:

• The Pediatric Generalists of the Future Workgroup
• The Pediatric Subspecialists of the Future Workgroup
• The Pediatric Workforce Workgroup
• The Financing of Pediatric Education Workgroup
• The Education of the Pediatrician Workgroup

The 1978 Report was pivotal in addressing necessary changes for pediatric training in the late 1970s. It anticipated the need to increase residency training in the ambulatory setting; to incorporate more training in behavioral, developmental and adolescent issues; and to improve physicians' skills in working with other health professionals.

New forces have emerged since the release of the 1978 Report that will have a significant influence on the future of the specialty, including the changing demographic profile of the US population; an increase in the percentage of single-parent families; growth in the number of dual-parent families in which both parents work outside of the home; an increase in the number of children enrolled in day care; an increase in the number of uninsured children; a rise in youth-related violence; new diseases; technological advances; more pediatricians employed or working in groups; more pediatricians seeking a better balance between work and family; a major expansion of managed care; increased competition; pervasive strategies to limit costs and reduce reimbursements; and a shift in emphasis from inpatient to outpatient care.

This report examines these and other factors that have altered child health needs and pediatric practice over the last 2 decades and presents a vision of the scope of practice of the pediatrician of the future, including an evaluative process for the core competencies pediatricians will need to acquire during residency and the lifetime educational processes needed for the provision of quality pediatric services.

There are 5 key principles that guide all predictions and recommendations pertinent to the provision of optimal pediatric care in the future.

• The pediatrician is the best and most extensively trained professional to provide quality health care services to infants, children, adolescents and young adults within the context of their families, communities, and environments.
• All children should receive primary care services through a consistent "medical home," which is an approach to providing continuous and comprehensive primary pediatric care from infancy through young adulthood, with availability 24 hours a day, 7 days a week, from a pediatrician or a physician whom families trust. The medical home offers care that is accessible, affordable, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent.
• Pediatric training should continue to emphasize in-depth knowledge of normal development, childhood disease processes, evidence-based management, and technical skills, but should also embrace new areas that mirror the changing health care needs of children, including neurodevelopmental, behavioral, and genetic issues.
• Pediatric training should focus on providing a core foundation of attributes, skills, and competencies to all pediatric residentsregardless of their future career paths.
• A 36-month pediatric residency (33 months of pediatric residency training usually completed in 3 years) is only part of the continuum of learning for pediatrics; continuing medical education (CME), including the utilization of information system technology, will play an increasingly important role for pediatricians.

The Changing Pediatric Practice Environment

Changing Demographics The changing sociodemographic characteristics of children in the United States are likely to exert a substantial influence on the future health needs of the pediatric patient population. One negative trend over the past 2 decades has been the increased number of children living below the poverty line. Poor children are less likely to visit a physician and, thereby, have reduced opportunities to receive preventive or continuous care.

Biomedical Advances Since the publication of the 1978 FOPE Report, there has been significant scientific progress in reducing childhood health risks from medical conditions. Advances in molecular biology and genetics have occurred at a rapid rate and promise to affect substantially the diagnosis, treatment, and understanding of a number of pediatric conditions. Success in these arenas led to the establishment of the Human Genome Project in 1990, which will determine the entire sequence of the human genome by the year 2003. The detailed DNA information that will become available as a result of the Human Genome Project will offer a more complete understanding of the structure, organization, and function of DNA in chromosomes. By being able to identify individuals who are predisposed to a particular disease, pediatricians will be able to place much greater emphasis on prevention and intervention, whether by gene therapy techniques, avoidance of environmental comorbid factors, the development of new therapeutic agents, or other mechanisms.

Technological Advances There have been remarkable advances in information system technology since the issuance of the 1978 FOPE Report. In addition to enhancing physician efficiency and productivity, these new information technologies are reshaping the relationships among physicians, their patients, and other members of the multidisciplinary care team, and are enhancing the ability of pediatricians to provide and support health care for patients in rural and underserved areas.

Changes in Pediatric Health Care Delivery

Public and Private Sector Initiatives Political and economic forces have driven much of the change in pediatric practice since the 1978 FOPE Report, and such forces are likely to continue to influence pediatric practice in the 21st century. The role of the government as a primary purchaser of health care has resulted in a restructuring in the financing and organization of health care in an effort to control escalating health care costs. The widespread adoption of managed care in both the private and public sectors as a panacea for rising health care costs has also had a significant impact on pediatricians. Much like private insurance purchasers, state Medicaid programs are looking to managed care to cut costs, expand preventive services, and decrease use of emergency rooms and inpatient hospital facilities. As state and federal coverage for children's health services increases, the role of managed care may increase.

The Role of Prevention Prevention is a core value for pediatricians. Well-child care provides a vehicle for focusing on immunizations, and it allows pediatricians to promote healthy lifestyle choices, to monitor patients for physical and behavioral pathology, and to provide age-appropriate and individualized anticipatory guidance. Well-child care will continue to be an increasingly important part of the pediatrician's responsibilities in the 21st century. The growth of other child health professionals and technological innovations may, however, radically alter the manner in which well-child care is provided. Nonpediatrician child health professionals, for example, may provide a more prominent role in direct patient contact, while the media and the Internet are likely to become more significant sources for patient education.

Changing Patterns of Morbidity While pediatricians in past decades spent much of their time dealing with acute illnesses, providing care for patients with chronic conditions will play a more important role in the future. The number of children and adolescents with moderate-to-severe chronic medical conditions, requiring ongoing care, has increased over the last several decades. Although some of this reflects the growing incidence of certain conditions, such as asthma and acquired immunodeficiency syndrome (AIDS), much of the increase reflects improvements in life-prolonging medical and surgical care, which leaves children permanently dependent on complex medical interventions. In addition, a growing percentage of children are developing severe developmental-behavioral pathology, placing them in need of more intensive therapy. These trends highlight the need for careful attention in pediatric training to the evaluation and management of children with chronic conditions.

The Changing Child Health Care Team

Another factor likely to affect the role of pediatricians in the 21st century is the growth in the number of child health care professionals and an expansion of their professional responsibilities. Over the last 20 years, pediatricians have pioneered the use of a variety of nonphysician providers in their practices, forming alliances that have allowed for the integration of children's health care with related services. Other physicians, including family physicians and psychiatrists, have also played a role in meeting the health care needs of pediatric patients. These relationships will continue to evolve in the future.

Changing reimbursement patterns will further the creative use of an extended network of professionals to meet the health care needs of children. These providers will assume more responsibility for such activities as patient and family education and patient follow-up. Research will need to be done, however, to demonstrate the effectiveness of these partnerships and to address the appropriate ratio of providers to available patients.

Although the overlap between the roles of primary care pediatricians and family physicians will continue to create the potential for competition, there will be opportunitiesparticularly in underserved areasto implement cooperative models through which pediatricians and family physicians can work together to improve the health status of children.

The combined Internal Medicine/Pediatrics (Med/Peds) residency pathway will continue to influence the delivery of pediatric care. An indirect impact of Med/Peds will be to help maintain interdisciplinary integration within medical centers and to create new collaborative bridges with other fields outside the customary domain of pediatrics.

In the 21st century, the pediatric profession will grow to encompass a number of new and expanded functions and settings, including pediatricians providing care in managed care settings; pediatricians practicing in rural settings; pediatricians in the role of hospitalists; pediatricians as community consultants; school-based pediatricians; pediatricians in the role of home health providers; pediatricians practicing population-based, community medicine; and pediatricians in administrative medicine.

Changes in the Pediatrician Workforce

Underrepresented Minorities Over the past several decades, there has been an impressive increase in the number of American-educated and internationally educated pediatricians. However, much work remains in increasing the diversity of the profession; specifically, increasing the number of underrepresented minorities in pediatric training programs. The US Census Bureau projects that by the year 2020 nearly 50% of US children under age 18 will be African American, Latino, Asian American, or Native American¹; yet of the 1997 medical school graduates entering pediatrics programs, only approximately 15% were African American or Latino.²

Gender-related Issues

There is a clear and significant trend toward a workforce comprised predominantly of women pediatricians. Nearly two thirds of current first-year pediatric categorical residents are women.³ Female pediatricians on average work fewer hours than their male counterparts, primarily because they tend to assume much of the responsibility for child care, household needs, and the care of elderly parents. As a result, there may be a continued, gradual overall decline in productivity for the specialty as a whole, which will affect workforce projections.⁴

Changing Attitudes Toward Work and Family Recent surveys have pointed out that both younger male physicians and female physicians are reporting moderate levels of role conflict.⁴ The pediatric specialty, therefore, must not only consider the needs of women entering the field, but also the impact of the increasing number of young, dual-career couples, with 1 or both partners practicing medicine, who are attempting to balance multiple roles. The trend toward group rather than solo practice may help address some of the important work/family-related issues, but other steps should be explored, including nontraditional work hours, quality day care at or near the workplace, flexible policies for academic advancement, and job sharing.

Projections of Future Workforce Needs Recent analyses of the physician workforce have yielded widely disparate estimates about how appropriately physician supply will match the demand for physician services in the 21st century. The Task Force believes that no downsizing in the current number of general pediatricians being educated is required, and that no substantive growth in numbers is warranted. It will be important in the future, however, to develop effective strategies to increase the pediatrician-to-child population ratio in underserved areas.

The Role of Pediatric Subspecialists

Declining Interest in Subspecialization As of December 1998, 11 823 pediatric subspecialists had been certified by the American Board of Pediatrics (ABP) in 14 subspecialties, which represents just under 18% of all board-certified pediatricians.³ In recent years, there has been a decline in interest in pediatric subspecialization, which has been attributed to a number of changes in medicine, including a shift to managed care; an increased emphasis on primary care by payers; an increasing debt burden among residents; increasing subspecialty faculty dissatisfaction; and decreased research support. Efforts to address these issues will be important in ensuring an adequate supply of pediatric subspecialists in the future. In particular, because the majority of candidates taking ABP subspecialty examinations choose careers in academic settings, it will be essential in the future to identify strategies to enhance the attractiveness of careers in academic medicine. According to unpublished data from the ABP, in both 1997 and 1998, over 50% of subspecialists recertified in general pediatrics (52.7% and 55.1%, respectively). The data varies considerably, however, by subspecialty, from 79% for adolescent medicine diplomates, for example, to 36% for neonatologists (written communication, W. Tunnessen, 1999).

Training Issues Pediatric subspecialists need training in both inpatient and ambulatory settings. The increasing shift of patient care to ambulatory settings, however, requires that curricula be developed to ensure that residents have adequate exposure to the natural history of disease, as well as opportunities to experience the complexity of the psychosocial and financial issues that confront families and children who have chronic disease. To develop the skills necessary to succeed in the future, subspecialty training will need to focus on areas such as team leadership, consultative liaison, clinical outcomes, evidence-based clinical decision-making, critical pathways, cost and resource utilization issues, and information systems.

The Relationship Between Pediatricians and Subspecialists The respective roles of and linkages between generalists and specialistsparticularly primary care pediatricians and pediatric subspecialistsis an issue that will generate continued discussion in the years ahead. Research also is needed comparing the quality and cost of care provided to children by pediatric subspecialists as compared with adult subspecialists.

Future Scope of Activity Looking ahead, it is likely that pediatric subspecialists will continue to function in a wide variety of traditional roles in direct patient services, research, and education, as well as assuming new and expanded roles and responsibilities. To assume these multiple and varied roles, the pediatric subspecialist of the future will not only need to be educated to provide the highest standard of care for children, but also must acquire the skills necessary to conduct independent, funded research, to educate other health care providers, and to serve as the principal consultant to all health care providers involved in caring for children with severe, complex, or rare disease.

Financial Support of Trainees Residency training positions have traditionally been supported by hospital funds, whereas support for subspecialty fellowships has been obtained from multiple sources, including practice plans, hospital funds, foundations, and governmentally supported grants. Recent changes in support for graduate medical education (GME) by the federal government have markedly reduced support for training beyond the core years of primary training. These financial cuts, which were aimed primarily at decreasing the number of adult-based subspecialists, have simultaneously reduced support for the training of pediatric subspecialists. The shift to managed care, declining reimbursement for clinical services, and competition for care of patients with less acute or complex conditions, are likely to continue to challenge the financial stability of pediatric subspecialty programs in the future.⁵

The Education of the Pediatrician of the Future

Financing Pediatric Medical Education The ongoing transformation of the health care industry will have a number of effects on medical education, including increased pressure on faculty to generate revenues. Also, for medical schools located in competitive, managed care markets, there will continue to be fewer discretionary funds to support medical education.

An Educational Framework for Pediatric Education Medical education is properly viewed as a continuum, from medical school through residency, fellowship, and continuing education, with variations both in the content and the level at which that content is taught. Therefore, a coordinated and continuous oversight process needs to be established that will involve educators at all levels. The development of core competencies should logically derive from an assessment of the current health status and needs of children, within the context of their families and communities. This process should take into account advances in the biomedical and psychosocial sciences and the structure of the medical system in which health care is provided. In turn, these competencies should inform and guide the development of curricula for medical students, pediatric residents, fellows, and the continuing education of generalists and specialists in academics and community practice.

Future Trends in Medical Student Education in Pediatrics Several trends are forcing medical schools to review and revise their curricula. Today only the most severely ill children who require the highest levels of care tend to be admitted to hospitals, and those who are admitted rarely remain in the hospital through the whole course of their illness. This phenomenon, which has been attributed to the effects of managed care, changing patterns of disease, and advances in medical technologies and therapeutics, has also been experienced in the other primary care specialties. As a result, medical students who are trained primarily in teaching hospitals learn a great deal about a limited range of the most complex pathologies.

Trends in Pediatric Graduate Medical Education Today, residents still spend the majority of their time in hospital settings, usually in a tertiary care hospital. The underlying assumption has been that work in the hospital is similar to or generalizable to practice, thus making the hospital setting the appropriate principal learning environment. Although this assumption may be reasonable for subspecialty training, it is less true for primary care and is probably least true for pediatrics. It is appropriate, therefore, to ensure that the residency training of pediatricians continues to emphasize a well-thought out experience in ambulatory and community settings, where the majority of pediatricians will eventually work.

Continuing Medical Education Because the body of medical knowledge is constantly expanding, clinicians must accept the challenge of lifelong learning. Since the 1978 FOPE Report, the human learning process has become an intense area of research, and there has been a broadened understanding of how adults in general, and physicians in particular, learn. The intricate system for educating postresidency physicians that exists today has many strengths, but requires improvement and innovation to meet the challenges of pediatric care in the 21st century.

Conclusion

The FOPE II Project envisioned from its inception a bold and futuristic educational plan for pediatricians and other health care professionals that would prepare them to provide optimal care to infants, children, adolescents, and young adults in the 21st century. This plan was driven by the conviction that the changing landscape of health care delivery in the last 2 decades would require dramatic changes in the current roles and education of providers of pediatric care. Indeed, the 1978 FOPE Report identified areas in need of improvement and raised concerns about emerging new influences on the delivery of care to the pediatric population.

While examining these and several new issues, the FOPE II Project's Task Force discovered not only the scope of the critical work yet to be done, but also the level of success already achieved. It became clear that paving the way for pediatric education in the next century would be bold and futuristic, not by leading it into a completely new direction, but by making judicious adjustments to the course it has already followed.

Recommendations

The principles, concepts, and recommendations below, some of which originated in the 1978 Report of the Task Force on the Future of Pediatric Education, are intended to enhance current pediatric educational processes to prepare pediatricians of the future better for the new challenges they will encounter. Most importantly, however, it is hoped that implementation of these recommendations will ultimately benefit patients, whom the pediatric profession is entrusted to serve and protect.

In addition to the recommendations from the 1978 Report, which are being reaffirmed, the FOPE II Task Force offers the following new recommendations. The FOPE II Task Force believes that all of the 34 recommendations are important and deserve both immediate and ongoing consideration, and has decided, therefore, that they should not be prioritized.

• Pediatric medical education at all levels must be based on the health needs of children in the context of the family and community.
• Pediatricians have the most advanced education and training to provide the best care for infants, children, adolescents, and young adults. Whenever possible, they should provide this care directly. However, in many cases, other child health professionals are responsible for providing care to the pediatric population. Therefore, pediatricians should establish the standards for the medical care of children. Nonpediatrician providers must likewise be educated and trained according to these standards. Furthermore, access to pediatricians as consultants should be ensured via direct or distant mechanisms such as telemedicine.
• All children should receive primary care services through a consistent "medical home." A "medical home" is not a building, house, or hospital, but rather an approach to providing continuous and comprehensive primary pediatric care from infancy through young adulthood, with availability 24 hours a day, 7 days a week, from a pediatrician or a physician whom families trust.
• Pediatrics should take steps to enhance the scientific foundation of pediatric medical education and ensure that its programs (curriculum, teaching, and evaluation methods) are based on this science. Research centers for pediatric medical education should be established to develop and disseminate innovations in medical education, to collaborate with educators in other fields, and to enhance generally the profession's scientific knowledge about medical education. Faculty leadership in medical education should be encouraged.
• The goal of residency education should be to emphasize the knowledge, skills, experience, and attitudes necessary for a pediatrician in varied roles. Residents should be educated with a core curriculum so that pediatricians have a common foundation that defines the field. Pediatric residency education should remain 3 years in duration. Residency education needs enough flexibility to accommodate a broad range of initial competencies and individual career goals. There should be a future reassessment of the length of training after the development of core competencies and the evaluation of educational outcomes. Residency programs must ensure that all residents have designed and implemented an individualized professional education plan (CME) by the third year of residency training that incorporates anticipated needs for their future practice.
• Pediatrics should assume the leadership in establishing a process by which core competencies for educating pediatricians at all levels are continuously developed, revised, and evaluated. Program requirements, curricula, and evaluation systems, for both programs and learners, should be based on these competencies.
• Determining needed adjustments to the current Residency Review Committee (RRC) requirements must be the focus of all pediatric organizations on an ongoing basis. The duration and depth of training will continue to ensure that pediatricians are sufficiently differentiated from other child health professionals who care for children. Residents should be educated with a core curriculum so that pediatricians have a common foundation that defines the field and are prepared to address a broad spectrum of child health needs in a wide variety of practice settings.
• Pediatric program directors should work with pediatric department chairs to ensure that career counseling and mentorship assume more prominence in training programs.
• Because a pediatric workforce of the highest quality is essential, those residency programs whose graduates do not pass board certification examinations must be monitored carefully. Moreover, those programs where a significant percentage of graduates performed poorly on the certification examinations should be closed.
• The education of the pediatric subspecialist and academic generalist should provide a full range of clinical, teaching, and research experience. In many cases, this will require an extended period of research training and protected research time either before or after the individual attains faculty status.
• The Task Force embraces combined residency programs (eg, Med/Peds and psychiatry/child neurology) as a method of enhancing child health care opportunities.
• Education of subspecialists should be based in high resource centers of educational excellence, with core scientific teaching and adequate patient volume for fellows to develop a full range of cognitive and technical proficiencies. The educational process should be sufficiently broad-based to support lifelong learning and necessary career transitions and to ensure that subspecialty residents become competent educators.
• Every pediatric practitioner should have a "CME home" that will provide assessment of that individual's learning needs, access to local and national CME resources, and guidance in constructing a professional educational plan. A research project should be undertaken to set up pilot programs of the different models and to assess the efficacy and efficiency of each.
• CME programs will need to ensure that pediatricians learn management of pediatric problems within the context of evidence-based medicine and have rapid access to important new developments. The American Academy of Pediatrics (AAP) will need to continue to take the lead in ensuring quality CME programs for both pediatricians and subspecialists and experimenting with new educational strategies.
• Validated methodologies for determining costs of education at all levels should be used to estimate accurately the costs of medical student, residency, fellowship, and continuing medical education.
• A multipayer system should be created to fund the entire spectrum of medical education. Educational dollars should flow into a national medical trust fund administered by a nonpartisan mechanism.
• Medical student education should be centrally (not departmentally) supported at a level that will ensure innovative, comprehensive exposure for all students to the principles of child health care.
• Core pediatric residency education, including dual specialty (eg, pediatric neurology) training, should be supported fully for all required years by a multipayer mechanism.
• Pediatric residents and fellows at freestanding children's hospitals should receive the same level of federal support as those trained elsewhere.
• Federal formulas for GME reimbursement should be applied equally to pediatric core and subspecialty residents. Given the shortage of pediatrician-scientists, the National Institutes of Health (NIH) and other federal agencies, as well as foundations, should develop additional mechanisms to support research fellowship training in pediatrics.
• Unless funding of medical education can be separated from patient care revenues, Health Care Financing Administration (HCFA) regulations need to be modified either to allow subspecialty residents to bill for medical care or to allow teaching physicians to bill for care given by subspecialty residents.
• Research training in academic fellowships should be funded by the NIH and other federal agencies through their established training grant mechanisms. More research training dollars must be appropriated to meet these demands.
• Based on US Census Bureau population data middle (probable) projections, the United States will need 55 800 physicians (not full-time equivalents [FTEs]) in primary care pediatric practice by the year 2010.
• To fill the needs of the pediatric workforce, about 3000 pediatric residents should start pediatric training each year. This will require stabilization in the number of pediatric residents in the pipeline at the current level.
• As a nation, the United States needs to continue to develop effective mechanisms to increase the pediatrician-to-child population ratio in underserved areas.
• The number of pediatrician-scientists is critically low and remedies to increase their number must be implemented as rapidly as possible. Incentives to maintain an appropriate number of pediatrician-scientists should be considered (including federally sponsored loan forgiveness), to ensure that infants, children, adolescents, and young adults of 2010 have access to the knowledge developed by pediatrician-scientists.
• Extensive and effective efforts need to be made to increase the percentage of underrepresented minority pediatricians in practice and academic medicine.
• There has been a rapid increase in the number of women in pediatrics over the last 2 decades; however, strategies that meet the needs of women pediatricians (eg, mentoring, role modeling, flexible scheduling) are needed to promote the success of women in fellowship training and academia.
• Both practices and academic settings should consider coordinated schedules, fair leave policies, quality day care at or near the workplace, and flexibility in academic promotion, advancement, and in achieving partnership. Both men and women need multiple points of entry to these settings (including opportunities to reenter the academic track) to maintain an adequate supply of clinicians, researchers, and educators.
• Because of its focus on optimal development of children, pediatrics should lead the field of medicine in addressing role conflicts between professional and family responsibilities.
• Systems of care must be structured to facilitate rapid, ongoing communication and integration of care between general pediatricians with special interests and pediatric subspecialists. No one individual pediatrician can be expert enough to be up-to-date on the management of all conditions across the spectrum of subspecialties. Pediatricians have often developed special interests in the management of certain conditions, and this is appropriate.
• Health care delivery systems need to adopt empirically based, data-driven guidelines and quality of care measures developed by respected child health-related organizations. The same performance and outcome standards should apply to all child health professionals within their respective scopes of practice. All providers of children will need to acknowledge and adhere to these guidelines and measures.
• Pediatricians should collaborate with families and other child health professionals to identify and address challenges and barriers to the health and well-being of infants, children, adolescents, and young adults in the communities they serve.
• The FOPE II Task Force recommends that the oversight for implementation of the recommendations in this report be vested in the Federation of Pediatric Organizations (FOPO). The Task Force further suggests that FOPO hire an Executive Director and appropriate staff to coordinate implementation. Additionally, FOPO should consider delegating recommendations from this report to various, appropriate organizations within the pediatric community for implementation and monitoring.

The FOPE II Task Force affirms the following principles, concepts, and recommendations from the 1978 Report.

	FOPE I: Fundamental Educational Principles

• The pediatric community affirms the importance of education in both ambulatory settings and inpatient services.
• The purpose of undergraduate pediatric education is to help students learn to react with empathy and sound medical judgment in clinical situations involving infants, children, adolescents, and young adults. The student must learn how to do a history and physical examination on pediatric patients. The medical student must understand normal growth and development, the influence of the environment on health, and the principles of health maintenance.
• In the future, pediatricians will continue to manage both acute and chronic health problems of children and adolescents. They will use consultants when appropriate. They will provide or arrange health maintenance services for children and their families. They will educate and counsel families regarding the stages of normal development and identify early those health problems and risk factors that may adversely affect development.
• Pediatricians will be called on increasingly to manage children with emotional disturbances, learning disabilities, chronic illnesses, and other problems of a developmental, psychological, and social nature. They will provide increased amounts of health care to adolescents. They will be expected to manage their practices efficiently, collaborate with other members of the health care team, and use community resources to enhance the effectiveness of services to children and their families.
• The fundamental components of the pediatric residency remain: inpatient services, ambulatory training, care of the normal newborn, neonatal intensive care, subspecialty rotations, elective experiences, developmental and behavioral pediatrics, adolescent medicine, clinical pharmacology, community pediatrics and training in chronic illness, health maintenance, and medical ethics. These need to continue to be part of the RRC requirements for a pediatric residency.
• Although the incidence of some health problems has declined, others are appearing with increased frequency. There has been a dramatic increase in the recognition of child health problems associated with poverty, a deteriorating physical environment, changing family structures, and other social and psychological factors. There is growing evidence that encouragement of health promotion and changes in lifestyles may become more important than medical intervention in affecting morbidity and mortality.
• The general needs of children remain that they need to be valued, to be born healthy, to undergo optimal growth and development, to be raised in a nurturing environment, to learn the skills necessary for success, and to receive health assessment maintenance and anticipatory guidance.
• Children with serious health risks continue to be those from low-income families, children with handicaps, emotionally disturbed and depressed children, foster children, children of high-risk mothers, children in single-parent families, children of racial minorities, and children of unregistered aliens.

	FOPE I: Concepts

• Pediatric patients must have access to medical and dental treatment.
• Pediatric patients must also share in the advances made possible by biomedical and biopsychosocial research.

	FOPE I: Recommendations

• Biopsychosocial and developmental problems, such as early family adjustment difficulties and school failure, adversely affect the health of many children and adolescents. These problems are serious and very widespread. All pediatricians should have the skills to cope with them.
• The health needs of adolescents are being inadequately met. Pediatricians should take the responsibility for improving health care and research for this segment of the population.
• The care provided to children with chronic handicapping conditions continues to be problematic. Although pediatricians are uniquely qualified to provide this care, too many residency programs underemphasize this aspect of pediatrics. Reimbursement for this complex care must be available. (Words in italics were added by FOPE II.)
• Pediatric practice is essentially office-based primary care, while pediatric education often centers around inpatient tertiary care experiences. There needs to be continuous emphasis given to excellent ambulatory care experiences during the pediatric residency.
• In the future, pediatrics will increasingly be practiced in groups, which emphasize the health team concept. Therefore, pediatricians should be prepared to serve as members, as leaders, and as consultants in such health teams. Contact with nurses, nonpediatrician child health personnel, and other potential team members should be included in pediatric residency programs.
• All medical students should have a clinical experience of approximately equal length in pediatrics and internal medicine.
• Residency in pediatrics should be 36 months. Learning time should be apportioned on the criterion of the need for competence in both the biomedical and biopsychosocial aspects of pediatrics. The health needs of children and adolescents should be explicitly considered in planning the educational program. There should be increased emphasis on the biosocial aspects of pediatrics and adolescent health.
• Residency training programs should be flexible and provide for increasing levels of supervisory responsibility as the resident's medical judgment matures. Education should take place in a variety of environments, including ambulatory, community, and inpatient settings.
• Pediatricians must accept responsibility for developing a plan of personal continuing education. However, department chairs and program directors must recognize the responsibility of the teaching institution to provide continuing education opportunities suited to each pediatrician's needs.

	INTRODUCTION

Top Introduction

Since the early 1900s, pediatrics has evolved as the medical specialty focused on the provision of exemplary health care to infants, children, adolescents, and young adults. To establish and maintain excellence, pediatricians train for 3 years under expert supervision to care for children within the context of the family and larger community. Pediatric board certification, CME, and board renewal of certification are also in place to ensure quality lifelong learning.

The following FOPE II report presents a fresh look at the future of pediatric education. It also provides an opportunity to reassert many of the fundamental precepts of pediatric education that have evolved through the years. The reaffirmation of a number of the recommendations from the 1978 Report, along with the development of new recommendations to address emerging issues and trends, is a recognition of the need not to lose sight of the traditional, central role of pediatricians, while at the same time making necessary changes to respond to the realities of medical practice in the new millenium.

In 1976, when the first Task Force on the Future of Pediatric Education was formed, it was recognized that many of the important health needs of infants, children, adolescents, and young adults were not being met as effectively and as fully as they should be. Its primary goal was to identify these health needs and to point out the educational strategies required to prepare the pediatricians of the future to meet them.

The Task Force, which issued its report and recommendations in 1978, was a broadly representative group charged with exploring and evaluating the complex factors influencing pediatric education. Members of the Task Force represented 10 collaborating societies that shared a common concern for the welfare of children.

The 1978 Report on the Future of Pediatric Education was an impressive document that not only addressed the need for a 36-month residency that would broadly educate residents, but asserted the need to care for children using both a biomedical and a biopsychosocial/developmental approach. The report accurately anticipated a number of important issues and trends, including the need to increase the amount of time spent in residency training in the ambulatory setting; to incorporate more training in behavioral, developmental, and adolescent issues; and to improve physicians' skills in working with other health professionals.

However, there have been a number of significant developments since 1978 that have changed the environment in which pediatricians provide patient care, thereby prompting the need to take a fresh look at the future of pediatric education. These changes include:

• Trends in Society at Large: For example, a changing racial/ethnic profile, an increase in the percentage of single-parent families, growth in the number of dual-parent families in which both parents work outside of the home, an increase in the number of children enrolled in day care, an increase in the number of uninsured children, and a rise in youth-related violence.
• New Diseases and Medical Challenges: For example, human immunodeficiency virus (HIV), antibiotic resistance, bacterial contamination of food products, Type II diabetes in children, Kawasaki disease, and more infants weighing <750 g at birth.
• Technological Advances: For example, the Human Genome Project and gene therapy; more widespread usage of in utero ultrasound, magnetic resonance imaging (MRI), echocardiography, and extracorporeal membrane oxygenation (ECMO); and more effective injury prevention strategies, including automobile and bicycle safety.
• Changes in the Characteristics of the Profession: For example, the trend toward a pediatric workforce comprised primarily of women, more dual-career couples, more pediatricians employed or working in groups, and more pediatricians seeking a better balance between work and family.
• Changes in Health Care Delivery: For example, managed care; increased competition; public and private strategies to limit costs and reduce reimbursements; and a shift in emphasis from inpatient to outpatient care for an increasingly complex array of services.

Despite the many benefits that have been achieved through medical advances and an increased emphasis on prevention, several challenges remain. For example, the progress that has been made in disease prevention and treatment is balanced by an increase in many socioeconomic risk factors that have an adverse effect on child health. Injuries, homicides, and suicides remain the leading causes of mortality in children more than 1 year old and are a major challenge to those concerned about the health and well-being of children.

Despite the many changes that have taken place since the 1978 Report, the central role of the pediatrician as the primary health care provider for infants, children, adolescents, and young adults remains the same. This fact should not be overlooked as one considers the multitude of changes likely to affect pediatricians in the 21st century.

THE FUTURE OF PEDIATRIC EDUCATION II (FOPE II) Project, a 3-year, grant-funded initiative, continues the work begun by the 1978 Task Force on the Future of Pediatric Education. When first conceived in 1995 at a meeting of pediatric educators and clinicians, it was determined that the FOPE II process should not represent the views of any single organization or group of organizations. As such, FOPE II was designed to be a project of the entire pediatric community. The aim of FOPE II was to focus on the likely characteristics of children in the year 2010, to attempt to predict their health care requirements, and of primary importance, to recommend how pediatric education should be structured to meet those requirements. The overarching objective of the project was to ensure the continued provision of optimal pediatric care to patients in the 21st century.

The working group that stimulated the development of FOPE II agreed on a clear-cut set of Project goals:

• To evaluate the 1978 FOPE Report with respect to its relevancy to the education of pediatricians and others providing health care to children in the 21st century.
• To provide direction for the improvement of pediatric education, with special emphasis on workforce requirements, new instructional methodologies, and financing of pediatric education.
• To recommend essential changes in the educational process to meet the current and future health care needs of all infants, children, adolescents, and young adults.

To achieve these goals, a Task Force, composed of leaders in pediatrics, was formed (see Appendix A). All organizations in pediatrics were contacted for input, with members of virtually every pediatric organization serving on the Task Force. The Task Force was responsible for providing overall direction for the Project and for generating the final report. In addition, 5 topic-specific Workgroups were formed, with the Chairperson and Vice Chairperson for each Workgroup serving as members of the parent Task Force:

• Pediatric Generalists of the Future Workgroup
• Pediatric Subspecialists of the Future Workgroup
• Pediatric Workforce Workgroup
• Financing of Pediatric Education Workgroup
• Education of the Pediatrician Workgroup

The Task Force met 6 times over a period of 3 years. In addition, 2 meetings of the Vice Chairpersons, who were responsible for generating the individual Workgroup reports, were convened to discuss issues related to the content and format of the FOPE II Task Force Report. On average, each Workgroup met separately 3 times and held several conference calls during the 3-year period to develop and refine their reports and recommendations. Midway through the Project, a joint meeting of the Generalists and Subspecialists Workgroups was held to discuss some areas of overlap and to come to agreement on recommendations.

The Workgroups solicited information from a variety of sources ranging from federal agencies to medical student organizations and parent groups. Many individuals representing these groups attended either a Workgroup or Task Force meeting to share their expertise. Additionally, Project members gave grand rounds at many medical centers and made presentations at the meetings of numerous organizations to provide information and solicit input from the pediatric community. The FOPE II Project was a major discussion item at meetings of the AAP, ABP, Association of Medical School Pediatric Department Chairmen (AMSPDC), National Association of Children's Hospitals and Related Institutions (NACHRI), Pediatric Academic Societies (PAS) Annual Meetings, and others. The Task Force hosted 2 major open forums at the annual meetings of the AAP to solicit feedback on their Preliminary Recommendations (1997) and Draft Abstracts (1999). At these forums, leaders from pediatric organizations testified, and many individuals provided additional perspectives.

In carrying out their responsibilities, the Task Force and Workgroups examined various national data sets and conducted their own surveys. Throughout the course of the Project, surveys were sent to individual pediatricians, pediatric residents, pediatric residency program directors, pediatric department chairs, and other organizations in the medical community.

To promote awareness of the Project and to encourage participation in the process, the Task Force communicated frequently with the pediatric community. In addition to developing a FOPE II web page, the Task Force provided a variety of opportunities for interested individuals and organizations to submit data, to share their perspectives on issues affecting the future of pediatric education, and to comment on the preliminary recommendations of the Workgroups.

This report, which presents the final conclusions and recommendations of the Task Force, incorporates and synthesizes salient findings and recommendations from the 5 Workgroups. The report is organized into the following sections:

• Executive Summary
• Introduction
• The Changing Pediatric Practice Environment
• Changes in Pediatric Health Care Delivery
• The Changing Child Health Care Team
• Changes in the Pediatrician Workforce
• The Role of Pediatric Subspecialists
• Financing Pediatric Medical Education
• The Education of the Pediatrician of the Future
• Conclusions and Recommendations
• Appendices A and B
• References

Each of the major sections of the report preceding "The Education of the Pediatrician of the Future" is designed to provide information on changes that will affect pediatric education in the 21st century. These preliminary sections provide the contextual framework for the Task Force's discussion of the education of the pediatrician of the future as well as for the final conclusions and recommendations. The focus and subject of this report is the future of pediatric education, rather than the future of pediatrics as a specialty.

The Future of Pediatric Education II: Organizing Pediatric Education to Meet the Needs of Infants, Children, Adolescents, and Young Adults in the 21st Century

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	THE CHANGING PEDIATRIC PRACTICE ENVIRONMENT

Demographic and Societal Changes

The changing sociodemographic characteristics of children in the United States are likely to exert a substantial influence on the future health needs of the pediatric patient population. One negative trend over the past 2 decades has been the increased number of children living below the poverty line. In 1978, the year of the original FOPE report, there were an estimated 9.9 million children (15.9% of all children under the age of 18) living in poverty; by 1997, the number had grown to 14.1 million (19.9%).⁶ Although children under 18 made up one fourth of the total population in 1997,^6,7 they comprised nearly 40% of the total number of people living in poverty.⁸

The majority of children under 18 living below the poverty line are found in single-parent, female-headed families. In 1997, these families comprised 61% of the nearly 5.9 million families with children under 18 living in poverty. In contrast, married-couple families and those headed by single-male parents constituted about 32% and 7%, respectively, of the total number of these families.⁹ Children of color are disproportionately represented in poor, single-parent homes. In 1997, 55% of Africa American children and 63% of Latino children lived with single mothers whose incomes fell below the poverty level, compared with 37% of white, non-Latino children.¹⁰

Economic status and race/ethnicity affect health status in critical ways. Issues such as infectious diseases, inadequate housing, lack of nutritious food, and environmental pollutants are more likely to threaten the health of poor children. Poor children are also less likely to visit a physician, and thereby have reduced opportunities to receive preventive or continuous care. Children who live in rural and inner-city areas with concentrated poverty pose even greater challenges to the delivery of well-child and other health care services.

Family structure in the United States has also changed substantially since the 1970s. Many more children now spend their childhood in step, blended, sequential, or foster families, and many more are homeless. In 1978, 11.7 million children (18.5% of all children under the age of 18) lived with only 1 parent, compared with 19.8 million (27.9% of all children under the age of 18) in 1997.¹¹ Divorce affects over 1 million children each year, and an equal number of infants are born into single-parent families.¹² In addition, almost 500 000 children in the United States are in foster care at any one point in time.¹³

Cultural and ethnic diversity have increased over the past 20 years and are projected to increase even more in the 21st century. The Census Bureau projects that by 2020, nearly half of US children under age 18 will be African American, Latino, Asian American, or Native American. Latinos will comprise 21% of the US population, surpassing African Americans (18%) as the largest minority group.¹

These changing demographics are likely to have implications for the utilization of medical services, as well as for the acceptance of interventions by caregivers. In addition, other special populationsincluding homeless children, children in migrant families, and children in foster carewill reflect even more cultural and ethnic diversity and will require sensitive attention from the pediatricians and other child health professionals who provide care for them.

Families in the United States today also face a number of challenges that were not as prevalent 20 years ago. For example, the increasing geographic mobility of the US population leads to a consequent lack of social connections. On average, 1 out of every 5 families moves each year, limiting both extended family as well as community support for family units.¹⁴ Second, mothers are increasingly working outside the home, with the numbers doubling since 1970. Indeed, 69% of all mothers of children younger than 18 years old were in the labor force in both 1997 and 1998, and this number will undoubtedly rise under welfare reform.¹⁵

Parents are trying to balance multiple roles, often in isolation from neighbors, community institutions, and extended family. As a result, well-child care needs to address childrens' and parents' emotional needs, as well as their time limitations for accessing clinical visits. Pediatricians caring for children will also need more education in child health and development issues related to day care and after-school program attendance.

Biomedical Advances

Since the publication of the 1978 Report, scientific progress in reducing childhood health risks from medical conditions has continued. The introduction of Haemophilus influenzae vaccines has reduced the incidence of this high-morbidity acute infection; the varicella vaccine promises to do the same for this low-morbidity, but ubiquitous, disease. New vaccines like the chickenpox and respiratory syncytial virus vaccines have the potential to dramatically reduce hospitalizations. Alterations in recommendations for sleep positioning have reduced rates of sudden infant death. Growing recognition of the importance and cost-effectiveness of prevention is illustrated by the acceptance by third-party payers of the 1994 Bright Futures health supervision guidelines and the AAP periodicity schedule.

Much of pediatric acute care today involves the diagnosis and management of infectious diseases. Development and release of new vaccines in the next decade will greatly impact pediatric morbidity and mortality secondary to acute infectious illnesses. New vaccines or monoclonal antibodies anticipated or recently introduced include the conjugated pneumococcal vaccine, respiratory syncytial virus monoclonal antibody, and group B streptococcal conjugated vaccine. The introduction of these vaccines could potentially decrease otitis media episodes, acute infectious disease-related office visits, and hospitalization rates for infants and children.

Advances in molecular biology and genetics have occurred at a rapid rate and promise to affect substantially the diagnosis, treatment, and understanding of a number of pediatric conditions. The success in these arenas led to the establishment of the Human Genome Project, which began in 1990 as a coordinated effort of the US Department of Energy and the National Institutes of Health to identify all of the more than 100 000 genes in human DNA, and to determine the sequences of the 3 billion chemical bases that make up human DNA.

The goal of the Human Genome Project, which appears to be ahead of schedule, is to determine the entire sequence of the human genome by the year 2003.¹⁶ As of July 1999, more than 7700 genes have been mapped to particular chromosomes, and tens of thousands of human gene fragments have been identified and assigned to positions on chromosome maps.¹⁷ Once compiled, this information will be stored in databases from which data can be retrieved for interpretative analysis.

The detailed DNA information that will become available as a result of the Human Genome Project will offer a more complete understanding of the structure, organization, and function of DNA in chromosomes. Genes involved in many diseases will be identified and analyzed as either direct or indirect contributors to pathophysiology. By being able to identify individuals who are predisposed to a particular disease, pediatricians will be able to place much greater emphasis on prevention and intervention, whether by gene therapy techniques, avoidance of environmental comorbid factors, the development of new therapeutic agents, or other mechanisms.

Although the Human Genome Project holds many potential applications that will improve the prevention, diagnosis, management, and treatment of many pediatric conditions, it also will raise complex ethical issues. One of the unique aspects of the project is that funds have been earmarked to address the ethical, legal, and social issues that inevitably will emerge as a result of the study's findings.

With this explosion of knowledge and technology will come new educational needs and responsibilities. In addition to increasing physician understanding of the scientific principles involved, attention will need to be focused on the ethical implications associated with this new knowledge in such areas as genetic testing, carrier identification, prenatal diagnosis, gene therapy, and insurability. Pediatricians will need to serve as advocates for their patients, to discuss with them the implications of genetic testing, and to help them weigh the psychological, economic, and physical risks that might result from genetic testing against the benefits of earlier detection.¹⁸

Medical training in genetics has lagged far behind scientific advances, so many pediatricians have had limited training in genetics and are not fully prepared to deal with the complexity of the emerging information. It will be important, therefore, for medical schools, residency programs, and continuing medical education providers to expand course offerings and training opportunities in this area. Because scientific advances are likely to continue at a rapid pace in the 21st century, the availability of computerized databases that can serve as reference tools for pediatricians will be essential.

Despite the tremendous strides in the detection and treatment of disease discussed above, there has been an increase in many socioeconomic risk factors that have an adverse effect on child health. Injuries, homicides, and suicides remain the leading causes of mortality in children more than 1 year old and are a major challenge to pediatricians and others concerned about the health and well being of children and youth.¹⁹

Technological Advances

Several other advances over the last 2 decades have improved pediatricians' ability to manage better the health-related needs of the pediatric patient population. Changes in computer and media sciences in particular have revolutionized many areas in Western culture, including medicine. Information systems in pediatricians' offices now provide instant access to demographic data, immunization records, lists of recent diagnoses, and other important patient data. In addition, many physicians routinely use electronic media and the Internet for collecting data and imparting health information to families. Computer advances also are enhancing pediatricians' efforts to monitor and improve quality of care, to increase efficiency, and to enhance communication between the various levels of the health care delivery system.

Ongoing advances in telemedicine have the potential to revolutionize how pediatric care is delivered in the future.^20-23 These technologies will also play a role in reshaping the relationships among physicians, their patients, and other members of the multidisciplinary care team. As these technologies become more sophisticated and widely disseminated, pediatricians will likely be able to manage larger numbers of patients. This increase in productivity could result in the need for fewer physicians, both generalists and subspecialists, to meet health care demands. Also, new information technologies will enable pediatricians to provide and support health care when distance separates participants. This offers an exciting opportunity to address the problem of the unequal geographic distribution of physicians and the lack of access to pediatric and other health care services in rural and urban America.

Competition in the health care industry has encouraged the dissemination of telemedicine. Integrated delivery systems are aggressively seeking competitive advantages and have been willing to explore the use of new technologies to support this goal.^24-26 Ongoing advances in telemedicine (ie, telecommunication, multimedia, and information technologies) are likely to change dramatically how pediatric care is delivered in the future.^20-23 In addition to enhancing pediatricians' efforts to monitor and improve quality of care, telemedicine offers the potential to increase efficiency and to enhance communication between pediatricians and other members of the child health care team. Also, it is likely that these technologies will play a role in reshaping the relationships among physicians, their patients, and other members of the multidisciplinary care team.

From a patient care perspective, a significant impact of emerging new technologies will be a dramatic increase in access to health information on the part of patients and their families. As the volume of health information on the Internet expands, more and more patients and their families will be acquiring medical information from sources other than their pediatrician. This may mean that pediatricians will encounter more patients and families who are better informed on pediatric health issues. In some cases, however, pediatricians may have to correct misinformation or clarify conflicting information that patients and their families have received. Monitoring the results of these studies will provide an early indication of factors that will influence the adoption and evolution of telemedicine.

Conclusion

Many of the changes that are taking place in the medical practice environment have implications for the future of pediatric education. The changing sociodemographic characteristics of children in the United States will require a broader awareness of and sensitivity to multicultural health issues. Increased scientific knowledge, particularly as a result of the Human Genome Project, will prompt more emphasis during all phases of pediatric education on prevention and intervention and will require that more attention be paid to the ethical, legal, and social issues that will arise in such areas as genetic testing, prenatal diagnosis, and gene therapy. Finally, ongoing advances in telemedicine will require that pediatricians be trained in the capabilities and limitations of such technology and in how to use such technologies to promote an effective child health care team, working collaboratively for the ultimate benefit of pediatric patients and their families.

The Future of Pediatric Education II: Organizing Pediatric Education to Meet the Needs of Infants, Children, Adolescents, and Young Adults in the 21st Century

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	CHANGES IN PEDIATRIC HEALTH CARE DELIVERY

Public and Private Sector Initiatives

Political and economic forces have driven much of the change in pediatric practice since the 1978 Report, and such forces are likely to continue to influence pediatric practice in the 21st century. The role of the government as a primary purchaser of health care has resulted in a restructuring in the financing and organization of health care in an effort to control escalating health care costs. The widespread adoption of managed care in both the private and public sectors as a panacea for rising health care costs has also had a significant impact on pediatricians. Much like private insurance purchasers, state Medicaid programs have looked to managed care to cut costs, expand preventive services, and decrease use of emergency rooms and inpatient hospital facilities. States continue to rely on managed care as they expand coverage of children's health services.

Health insurance coverage provided through public sector programs is particularly important in pediatrics for several reasons. First, about one fifth of all children in the United States live at or below the federal poverty level and use publicly funded health care services when these services are available.²⁷ The federal-state Medicaid coalition, or Title XIX of the Social Security Act, has provided substantial funding of health services to low-income children since 1965. The last half of the 1980s witnessed steady expansion of Medicaid services, to the point that 25% of the pediatric population under 21 were enrolled in the Medicaid program at some time during 1995.²⁸

Second, employer-based coverage for infants, children, adolescents, and young adults has decreased steadily over the last decade, while the number of uninsured has risen.^29,30 This decrease in health insurance coverage has been attributed to employers dropping health insurance coverage for dependents or increasing employees' costs for coverage, as well as workers moving into businesses that traditionally have not offered health insurance.³¹

Lastly, the State Child Health Insurance Program (SCHIP), Title XXI, passed in 1997, extends health benefits to children in low-income families not eligible for Medicaid. About 7 million childrenalmost three quarters of uninsured childrenare eligible for Medicaid or SCHIP-funded state health insurance programs.

Although it is impossible to predict precisely how the health insurance market will evolve in the 21st century, it is likely that the implementation of managed care strategies in both the private and public sectors will continue. Managed care may need to change, however, to survive.^32,33 Consumer demand will push some of these changes, by advocating for patient protection, health plan accountability, and quality assurance.³⁴ For example, there has recently been a public backlash against managed care that has resulted in legislation specifying lengths of stay after delivery, ensuring availability of emergency care, limiting gag rules, and promoting patient rights.

The Role of Prevention in Health Care Delivery

Prevention is a key component of pediatric care. Currently, more than 20% of visits to pediatricians are for screening examinations, preventive care services, and anticipatory guidance.³⁵ Pediatricians spend much of their time in these activities, which has evolved over the years from the so-called "physical" to the "Health Maintenance Visit." These visits allow pediatricians to promote healthy lifestyle choices (eg, safety and nutrition); monitor patients for physical and behavioral pathology; provide age-appropriate and individualized anticipatory guidance to avert risk-taking behavior patterns; and better understand a child within the context of the family and community.

Well-child care will continue to be an important part of the pediatrician's responsibilities in the 21st century, particularly in response to a growing desire on the part of parents for more information and support on many child health issues.³⁶ The growth of nonpediatrician child health professions and technological innovations may, however, radically alter the manner in which well-child care is provided. For example, nonpediatrician child health professionals may provide a more prominent role in direct patient contact, and the media and the Internet are likely to become more significant sources for patient education.

Recent advances in pediatric knowledge have broadened the scope of pediatric preventive care. For example, as knowledge of the importance of early brain development continues to increase, preventive care needs to include measures to restore and enhance developmental potential. Also, pediatric preventive efforts will focus on guiding or modifying parental and child behavior to improve outcomes. Preventive measures that focus on infant sleep positions and the hazards of secondary smoke inhalation are examples. In addition, prevention of morbidities common in adulthood requires lifestyle interventions in childhood.

Changing Patterns of Morbidity

Although pediatricians in past decades spent much of their time dealing with acute illnesses, the care of patients with chronic conditions is now beginning to dominate many pediatric practices. Current estimates of the number of individuals younger than 21 years old with chronic illnesses and other disabilities vary somewhat, depending primarily on the breadth of the definition one uses. Approximately 2 million children meet stringent definitions based on the level of severity of the condition.³⁷ A broader definition of disability, based on findings from the National Health Interview Survey on Disability (1994-1995), identifies between 15% to 18% of children as having ongoing chronic health conditions (developmental, physical, or mental) that affect functioning or require compensatory services to maintain functional level.³⁸ Among children with chronic conditions, approximately half have developmental disabilities, mental health impairments, or psychological conditions, ranging from common diagnoses like attention deficit hyperactivity disorder (ADHD) to severe psychiatric disorders. A wide range of chronic physical conditions make up the other half, with moderate and severe asthma accounting for almost one third of such conditions.³⁹

Pediatricians can thus expect that 1 in 10 children will have a moderate to severe long-term health condition. Of this group, almost half will have mental retardation, developmental disabilities, or significant mental health problems. The other half will consist of children with a variety of chronic medical diseases including asthma, diabetes, sickle cell anemia, and cystic fibrosis. Currently, only 5 chronic conditions occur in children with relatively high frequency: asthma, recurrent otitis media, adolescent depression, ADHD, and developmental disabilities (primarily mental retardation and cerebral palsy).

The number of pediatric patients with moderate to severe chronic medical conditions requiring ongoing care has increased over the last 2 decades. Although some of this reflects the growing incidence of certain conditions, including asthma and AIDS, much of the increase reflects improvements in life-prolonging medical and surgical care. Because of technological advances, there are increasing numbers of survivors of previously fatal conditions such as organ failure and childhood cancer.⁴⁰ Some of these children are permanently dependent on complex medical interventions, and many experience serious developmental or emotional morbidity.^40,41 Pediatricians must address the long-term complications of such diseases and treatments, as well as the unique developmental and behavioral needs of children who are affected. Long-term survivors of prematurity and childhood malignancies are altering the profile of pediatric health care, and necessitating decisions about who will provide care as such patients transition into adulthood.

In addition, although behavioral and developmental issues are hidden in the context of most patient encounters in pediatrics, a growing percentage of children are developing more severe developmental-behavioral pathology, placing them in need of more intensive therapy. One study estimated the rate of significant behavioral pathology in children between ages 9 and 17 at 9% to 13%.⁴²

At the same time, infectious disease experts warn that a number of chronic infectious diseases present potential problems for children in the future. Tuberculosis and AIDS rates increased over the last 2 decades, and drug resistance is common in some parts of the country. Altered antimicrobial susceptibility patterns and increasing failure/relapse rates are being identified for streptococcal, staphylococcal, and other infections. Although some infectious diseases may be better controlled or even eradicated in the future, other pathogens will emerge and require more complex treatment regimens and a knowledge of community antibiotic resistance trends.

These changes have important implications for pediatric practice and education. To respond to the increasing percentage of children with chronic conditions, pediatricians may require additional emphasis in residency programs and CME courses on the unique requirements of children with special needs. With respect to developmental-psychological pathologies, practitioner surveys have identified a lack of confidence in their ability to identify and treat these problems as a major barrier to care.^43-45 The evolution of new tools, including symptom checklists and the Diagnostic and Statistical Manual for Primary Care (DSM-PC), along with postgraduate education in this area, can allow pediatricians to become more knowledgeable in managing these cases. Families of children with chronic medical needs have reported variable access to care and confidence in their specialty providers, and have also commented on inadequate attention to parental concerns by primary care providers.⁴⁶ Clearly, improved partnerships between families, pediatricians, and pediatric subspecialists (medical and surgical) must be developed to ensure an effective response to these concerns.

Also essential to the enhancement of pediatric health care delivery is recognition and implementation of the concept of the "medical home," through which all children should receive primary care services. A "medical home" is not a place, but rather an approach to providing continuous and comprehensive primary pediatric care from infancy through young adulthood, with availability 24 hours a day, 7 days a week, from a pediatrician or other physician whom families trust. The "medical home" offers care that is accessible, affordable, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally effective. Under this model, pediatricians and parents act as partners to identify and access all of the medical and nonmedical services needed to help children and their families achieve their maximum potential. Integral to this concept is the continuity of this relationship over time.

Pediatricians of the future will need to be educated for this role and will need to establish community standards for the management of both routine and complex patients in the "medical home." This role is based on their education and experience delivering health care to children and on their knowledge of the latest evidence-based research. Because the "medical home" concept is not limited simply to pediatric care, a "medical home" for children should be the goal of all providers who care for children.

Conclusion

Managed care and other changes in the US health care delivery system are affecting not only practicing pediatricians, but also the entire medical education process. Changes in Medicaid policy, particularly those involving a shift to managed care, will require educators to sensitize medical students and residents to a different mode of medical practice, one that involves operating within fixed resources, with financial risk related to resource utilization. Well-child care will continue to be an important focus of pediatric education, but within the context of the new, broader, multidisciplinary team. In addition, changing patterns of child morbidity will require increased attention in pediatric education to the management of chronic, rather than acute, illnesses, because chronic conditions will dominate more and more pediatric practices in the future. Finally, the pediatric medical education system will need to emphasize the concept of the "medical home," through which all children should receive primary care services.

The Future of Pediatric Education II: Organizing Pediatric Education to Meet the Needs of Infants, Children, Adolescents, and Young Adults in the 21st Century

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	THE CHANGING CHILD HEALTH CARE TEAM

Another trend likely to affect the role and scope of pediatricians in the 21st century is the growth and changing characteristics of the available pool of child health care professionals. Over the last 20 years, pediatricians have pioneered the use of a variety of providers in their practices, forming alliances that have allowed for the integration of children's health care with related services. There are a number of reasons that pediatricians work collaboratively with a wide spectrum of health care professionals, for example, seeing a large number of patients who require frequent visits; performing multiple procedures on a daily basis (eg, immunizations, vision and hearing screenings, laboratory analyses, developmental screenings, blood pressure monitoring); triaging large numbers of telephone queries; and interacting with a variety of private and public agencies that provide services to children.

Nurses have played a vital collaborative role in pediatric practices, by tracking care for children with chronic illnesses, supporting acute care services for children, guaranteeing office follow-up and coordination, and developing case-management services. Pediatricians have also long been dependent on a variety of other professionals to allow them to provide care and services to their patients. For example, pediatricians have worked in concert with nutritionists, social workers, psychologists, occupational therapists, physical therapists, and speech therapists to provide specific, necessary health-related services to children. Other physicians have played a role in meeting the health care needs of pediatric patients, as well, including family physicians, emergency department physicians, psychiatrists, and pediatric subspecialists. These relationships are likely to continue and, if anything, will become even more essential in the future.

Traditional Extenders

Nurses and Medical Office Workers Future opportunities for nurses and medical office workers in the context of the pediatric practice are many, because they will be needed by pediatricians to help improve access to care, quality of care, and practice efficiency. They will, for example, ensure compliance with treatment, collect data on q