The health care reform debates of 2009-2010 focused attention on a problem unique to pediatrics: in marked contrast to adult medicine and surgery, the pediatric workforce does not have sufficient subspecialists to serve the needs of our population.1 As one of the many pediatric professional groups identifying the need for more pediatric subspecialists, the American Academy of Pediatrics describes the reality familiar to all pediatric chairs, practicing community pediatricians, and parents of children needing pediatric care in the United States. Even in regions with pediatric subspecialists, patients must wait between 5 weeks and 3 months to get an appointment with a pediatric subspecialist, and average wait time to see a pediatric neurologist is 9 weeks. An appointment with a developmental-behavioral pediatrician, experts in assisting children living with autism-spectrum disorders, requires a wait of 13 weeks. Sixty-eight percent of primary care pediatricians practicing in rural communities and 49% of nonrural pediatricians reported dissatisfaction with waiting times for appointments with pediatric subspecialists.2 The relative scarcity of pediatric subspecialists is not a new problem, nor is the contrast of the pediatric situation with that of adult medicine. More than a decade ago, these issues were directly addressed by the Pediatric Subspecialists of the Future Workgroup of the Second Task Force on Pediatric Education, which observed, “Calculated from US census values of 1996, there are no more than 4 ABP [American Board of Pediatrics]–certified pediatric subspecialists per 100 000 people.”3(p1224) Noting the differences in workforce composition between pediatrics and internal medicine, the task force recommended, “It is important to rationalize workforce needs separately for pediatric vs internal medicine subspecialties.”3(p1224) Accordingly, the task force recommended what has become the standard for pediatric subspecialty training: “at least 3 years of fellowship training. . . . ”3(p1243) In this issue of the Archives in the article titled “Sustaining Excellence in Pediatric Care,” Rosen4 details the stark reality of the current pediatric subspecialist-to-child ratio and significant geographic maldistribution highly skewed in favor of large cities and against rural areas (eg, on average nationally 1 pediatric pulmonologist per 100 000 children, with 5 states housing almost 1 million children having none). Even more sobering, despite the substantial rebound in pediatricians entering subspecialty training over the past decade (a 79% increase),5 Rosen's calculations do not predict relief in the future. Indeed, given the age distribution of current subspecialists and the scarcity of fellows in training (with unfilled positions in virtually all the subspecialty fellowships), the situation is likely to worsen, in some cases substantially. Rosen's analyses clearly demonstrate that as impressive as these increases may be, they do not address the need; the demand for the available fellowship positions is simply not there. More than a decade has passed since the pediatric community brought attention through FOPE II (Future of Pediatric Education II) to the need for greater access to pediatric subspecialty care. Access remains highly problematic, and there is little reason to be sanguine about the future. What must the pediatric community do? Securing the scaffolding First, as Rosen appropriately notes, we must maintain the infrastructure supporting subspecialty training and practice. The Children's Hospitals Graduate Medical Education Program brings much-needed support for fellowship support to the hospitals, training about one-half of all pediatric subspecialists. The Children's Hospitals Graduate Medical Education Program is authorized through the autumn of 2011; it is critical to the pediatric workforce that at least this degree of support be continued. Likewise, Medicaid and the State Children's Health Insurance Program coverage (reauthorization through September 2013) must be maintained as a safety net for children.6 The National Institutes of Health Loan Repayment Program is of great importance to support the future generations of subspecialist and generalist pediatric (and adult) physician scientists.7 Rosen suggests the need for loan repayment for pediatric subspecialists providing clinical care through a national service option in underserved areas. In fact, the vehicle to make available such support received widespread support from all major pediatric professional organizations and is included in Congress' historic Patient Protection and Affordable Care Act.8 Pediatric advocacy is needed to ensure appropriation of funds to fulfill the promise of this legislation. Innovative strategies Second, we must explore new or substantially revised strategies. Rosen discusses the possibility of shorter training periods as an option for some or all subspecialists. The current requirement of 3 years of training, including 1 year of research, as part of the requirements for pediatric subspecialty board certification was the outgrowth of the FOPE II belief in the need for sufficient time to master “core competencies, develop technical skills, and gain a foundation of research experience on which to build a successful academic career.”3(p1242) It is time to reexamine this underlying assumption and, indeed, the American Board of Pediatrics has initiated a forum to reexplore this decision and contemplate other options for board certification in the subspecialties. The timing and proposed next steps of this initiative are uncertain, but clearly decisions regarding the length of subspecialty training and decisions regarding the research requirements—more, less, or the same; consistent or variable across subspecialties—are likely to impact the numbers and distributions of pediatricians entering the subspecialties. Particularly intriguing is the notion that was raised in FOPE II regarding intermediary subspecialty training: Some generalists may wish to obtain clinical training in a subspecialty area and may serve an extremely important role in health care delivery to a specific population. These individuals should be considered pediatric generalists with additional clinical training in a specific subspecialty and should work with pediatric subspecialists within an integrated system.3(p1242) How could this be done in a fashion that could serve as a real career track for these generalists with additional clinical training in a specific subspecialty? How could it both increase access to care (especially in underserved areas) and at the same time not undermine subspecialty training and research? In other words, would this in fact be a good alternative or complementary, and if so, how do we make it happen since 10 years later it has not yet happened in any substantial form? Third, the pediatric community must use technology to increase access, to increase reimbursement for subspecialists, and to decrease total health care costs. Thoughtful utilization by primary care pediatricians and/or patients of long-distance communication (e-mail, telephone, telecommunication) with subspecialists should be aggressively explored and supported by the pediatric community. This could be done to decrease unnecessary visits to subspecialists, at the same time providing timely support to community pediatricians and access to families. Reimbursement for these activities will be essential for their success. Explorations toward effecting this outcome have been initiated and are being met with some success. A time for action Rosen's analysis is at once concerning and emboldening. Our community of practitioners, scholars, and teachers must act to maintain and strengthen an infrastructure that supports the health and well-being of children; we must recognize structures and policies that support systems designed for adults are not and will not be the same as those needed for children. Correspondence: Dr Stanton, Children's Hospital of Michigan, Wayne State University, Department of Pediatrics, 3901 Beaubien, Ste 1K40, Detroit, MI 48201 (firstname.lastname@example.org). Financial Disclosure: None reported. References 1. Freed GLStockman JA Oversimplifying primary care supply and shortages. JAMA 2009;301 (18) 1920- 1922PubMedGoogle ScholarCrossref 2. American Academy of Pediatrics, America's Children Need Access to Pediatric Subspecialists. http://www.aap.org/workforce/Sec5203FactSheet.pdf. Accessed November 15, 2010 3. Gruskin AWilliams RG McCabe ERB et al. Final report of the FOPE II Pediatric Subspecialists of the Future Workgroup. Pediatrics 2000;106 (5) 1224- 1244PubMedGoogle Scholar 4. Rosen D Sustaining excellence in pediatric care. Arch Pediatr Adolesc Med 2011;165 (5) 388- 391Google Scholar 5. American Board of Pediatrics, Workforce Data 2009-2010. https://www.abp.org/abpwebsite/stats/wrkfrc/workforce09. Accessed November 12, 2010 6. Center for Children and Families, The Children's Health Insurance Program Reauthorization Act of 2009. http://ccf.georgetown.edu/index/cms-filesystem-action?file=ccf%20publications/federal%20schip%20policy/chip%20summary%2003-09.pdf. Accessed November 17, 2010 7. Extramural Loan Repayment Programs NIH, (LRP) Notice Number: NOT-OD-10-105. http://grants.nih.gov/grants/guide/notice-files/NOT-OD-10-105.html. Accessed November 14, 2010 8. American Academy of Pediatrics, AAP Works to Implement the Health Reform Law. www.aap.org/advocacy/washing/mainpage.htm. Accessed November 16, 2010
Archives of Pediatrics & Adolescent Medicine – American Medical Association
Published: May 2, 2011
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