1. Academic General Pediatrics: The State of the Art Tina L. Cheng, MD, MPH

2. Clinical Care EducationResearchAdvocacy

3. ACADEMICGENERALPEDIATRICS

4. Academic General Pediatrics 1960: Association for Ambulatory Pediatric Services 1968: name change to Ambulatory Pediatric Association 1978: Robert Wood Johnson General Pediatrics Academic Development Program trained over 100 general pediatrics faculty

5. “The field of academic general pediatrics now is established. It is the responsibility of graduates to produce creative research and expand fellowship programs, as well as to do good clinical care, if a vigorous field of academic general pediatrics is to be achieved.” Haggerty RJ & Sutherland SA. “The Academic General Pediatrician: Is the Species Still Endangered?” Pediatrics 1999:104;137- 142

6. The State of Academic General Pediatrics Divisions: A National Survey Ambulatory Pediatric Association Division Director Special Interest Group

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

8. Methods Confidential survey of US academic general pediatrics division directors Survey distributed by mail and email with three mailings of each over a 6 month period Near the end of the survey period all programs were called to verify program director name and address

9. Results: General Pediatrics Divisions 199 US general pediatrics divisions identified Survey response rate 59% (118/199) respondents more likely from programs in the mid-Atlantic and respondents more likely from programs in the mid-Atlantic and New England (p=.043) New England (p=.043) When asked “How many other general pediatrics divisions is your medical school affiliated with?” an additional 75 divisions were mentioned

10. Results: What’s in a Name? Word in Division Name % “General Pediatrics” 79 “Ambulatory”11 “Academic”9 “Community”5 “Primary Care” 5

11. Results: Growth of Divisions No. Divisions

12. Results: Primary Responsibilities Responsibilities,% Yes Administrative Teaching Resident continuity clinic(s) Out-patient faculty practice Emergency service Urgent care center Normal newborn nursery In-patient units Hospitalist program Behavioral/Developmental service Adolescent medicine service 957310386759463250936812397277423653

13. Results: Primary Responsibilities Responsibilities,% Yes Administrative Teaching Residency program Medical student clinical clerkship Child abuse program Environmental health program Chronic disease clinic(s) Other516448132721748155112620

14. Results: Division Faculty NOW Mean (SD) 5 years ago Mean (SD) “How many MD faculty are in your division?” 15.6 (11.7) Median 13 12.1 (8.2) Median 9 “How many non-MD faculty are in your division?” 2.1 (2.6) Median 1 1.7 (1.8) Median 1

15. Results: Division Faculty % Full-time Rank N (%) “How many MD faculty are in your division?” N=1838 67% full-time 207 (12%) Professor 323 (18%) Assoc Prof 916 (52%) Asst Prof 244 (14%) Instructor 77 (4%) Other 77 (4%) Other 98 (6%) Tenured 98 (6%) Tenured “How many non-MD faculty are in your division?” N=210 75% full-time 25% PhD 46% PNP 16 (8%) Professor 13 (7%) Assoc Prof 28 (15%) Asst Prof 21 (11%) Instructor 115 (60%) Other 6 (3%) Tenured

16. Results: General Pediatrics Division Director Turnover Over a 15-18 month period, 21% of programs had a change in leadership with a new general pediatrics division director

17. Results: Division Missions MISSION “How important to your division are the following missions?” %Not impt %V impt “What is your perception of the dept/institutional financial support for this?” %Too low %Just right %Too much Clinical Care 1 94 1 94 23 35 20 23 35 20 Education 1 97 1 97 61 17 1 61 17 1 Research 24 29 24 29 59 17 0 59 17 0 Advocacy 8 50 8 50 47 17 0 47 17 0 Administration 4 28 4 28 39 29 0 39 29 0

18. Results: Division Revenue

19. Results: Outpatient Clinics Annual outpatient visits: Mean 29,821 (26,487), Median 23,825 Mean 29,821 (26,487), Median 23,825 Range 0 – 200,000 Range 0 – 200,000 Number of pediatric residents with continuity clinic at the institution ’ s clinic Mean 36.7 (23.1), Median 32 Mean 36.7 (23.1), Median 32 Total residents: 43.3 (24.0), Median 39 Total residents: 43.3 (24.0), Median 39

20. Results: Fellowships Does your Division have a fellowship program focusing on clinical care, education, or research? 31% have a fellowship (36) 31% have a fellowship (36) Of those, 76% offer a degree Of those, 76% offer a degree 15% one yr, 50% two yr, 35% three yr 15% one yr, 50% two yr, 35% three yr 65% funded by federal/foundation $ 65% funded by federal/foundation $ 32% funded by hospital/department 32% funded by hospital/department 13% plan to start a new fellowship within 2 yrs 13% plan to start a new fellowship within 2 yrs

21. Results: Grants and Contracts Total new and renewal grants and contracts (research, education and service) contributing to the division budget in 2004-05: Number of Grants and Contracts: Mean 7.6 (11.0), Median 4, Mode 0, Range 0-60 Mean 7.6 (11.0), Median 4, Mode 0, Range 0-60 Total Directs

22. Results: Grants and Contracts Total Directs: # Programs

23. Results: Reported Top Successes in the Past 5 Years

24. Results: Reported Top Problems/Challenges in Past 5 Years

27. Limitations Generalizability No information on other pediatric divisions

28. Conclusions Academic general pediatric divisions are no longer endangered in the US The number of divisions have grown steadily Division faculty have grown in number over the past five years Divisions have a large role in clinical care, education and research

29. Haggerty & Sutherland’s 1999 Recommendations Support more 3 year academic fellowships by foundations or federal grants Make more research funds available Support from departments for academic generalists for scholarly work and not burdened by heavier service, teaching and administrative loads than those in other divisions

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

31. Implications With growth in general pediatrics divisions, faculty development, fellowship training, and pipeline efforts must be priorities Division director leadership had rapid turnover suggesting need for leadership development A forum to share strategies across programs is important

33. Future of Academic General Pediatrics Future of Primary Care

34. 1980

38. “Primary Care In Crisis: Current Pressures and Threats to Primary Care as We Know It.” The Future of Primary Care, Jossey Bass, 2004 “The End Of Primary Care,” NY Times Magazine, April 18, 2004 “The Impending Collapse of Primary Care Medicine and Its Implications for the State of the Nation’s Health Care : A Report from the American College of Physicians,” January 2006

43. FOPE II Determinants of Future Roles for Pediatricians Roles for Pediatricians Child and Family Health Needs Health Care System Scientific Advances

44. Present & Future Opportunities for Primary Care continuity provider head of household in the medical home or team player advocate addressing health disparities chronic care coordinator new morbidity manager/community collaborator public health coordinator genomic interpreter web interpreter/telemedicine doctor hospitalist healthcare quality and systems researchers Cheng TL Pediatrics 2004; 113: 1802 - 1809.

45. Future of Academic General Pediatrics Future of Primary Care

47. Primary Care Now and In the Future CURRENTFUTURE WHO Primarily Doctors & Nurse Practitioners Interdisciplinary Teams WHAT Individual Patient OrientedIndividual Patient & Public Health Oriented Organ BasedIntegration of Genes to Organs to Persons to Communities WHEN Child Health Maintenance & Acute Care Child Health Maintenance, Acute Care, Visits with Other Team Members, Group Visits, Other Sites. WHERE Office FocusedCommunity Based & Community Integrated HOW Continuity through Visits & Phone Continuity through Visits, Phone & Other Information Technology Cheng TL Pediatrics 2004; 113: 1802 - 1809.