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Pediatrics

ABSTRACT. Pediatrics, as practiced by practitioners, is and

will remain a primary care specialty even though the

composition of pediatric practice is changing.

Pediatric services presently are equitably provided to children of all economic strata, but there remain unmet needs that may reasonably be expected to be fulfilled in the future with the removal of financial and access barriers as well as increased public education. Pediatricians will be able to meet the projected increase in demand.

The increasing trend of pediatricians to practice in groups will continue. More and more of them will develop areas of special interest, but the percentage in purely subspecialty practice is not likely to increase. An arrangement of a group of pediatricians, all with some areas of special interest, working in conjunction with pediatric nurse practitioners or associates and with increased delegation of patient care activities, is likely to become the dominant practice pattern of the future.

Pediatricians make substantial contributions to the

better-ment of society through unpaid community services and

perceive a social responsibility, as evidenced by the large extent to which they care for Medicaid patients.

There should not be an expansion in the number of

subspecialty boards because this would decrease pediatrics’ commitment to primary care. There must be a continuation of society’s support of medical education that will not alter the supply and therefore the function of pediatricians.

It is important for the American Academy of Pediatrics to reassess its members’ functions periodically so it can contin-ue to be a dominant force in the planning of future child health care and better fulfill its goal of enhancing the welfare of the children of the nation. Pediatrics 62(suppl):625-680,

1978, pediatrics, pediatricians, primary care, child health care.

I. SUMMARY AND CONCLUSIONS

The American Academy of Pediatrics (AAP) authorized a detailed survey of its members to indicate the present status of pediatrics in medi-cal care delivery, as well as the projected role of pediatricians. The survey demonstrated that pedi-atrics is a field of dynamism and change in its mode of delivery of care-much like the dyna-mism exhibited by its patients.

Present Functions

The data on present functions indicate the following salient features:

1. Pediatrics as practiced by the practitioner is a primary care specialty (only 6% of practitioners are subspecialists), and an analysis of the patients seen per day by the pediatricians corroborates this role in primary care.

2. Twenty-three percent of pediatricians are in academic medicine, performing somewhat differ-ent roles than the practitioner, although they deliver about 10% of the pediatric care to chil-dren in the inner city.

3. The practice of pediatrics is not yet satu-rated; 16% of the general pediatricians classify themselves as not too busy and 98% take some new patients.

4. Pediatricians are delegating more patient care tasks than they did eight years ago.

5. Pediatricians provide reasonably well-dis-tnbuted care to all segments of the population including those in the lower one third of the economic level as well as those in rural areas.

6. Significant numbers of pediatricians see adolescents as well as provide perinatal counsel-mg as part of their practices.

7. All pediatricians work long hours (an aver-age of about 58 hours per week), with compensa-tion levels ($15.80 per hour) considerably below the average for the rest of medicine.1

8. Most pediatricians would again choose the practice of pediatrics and expressed satisfaction with all aspects of pediatrics except the afore-mentioned level of compensation.

9. The majority of pediatricians agree with the concept of the pediatric nurse practitioner or associate (PNP!A), although only 14% of the practitioners presently employ them. (The terms “PNA” and “PNP/A” are used interchangeably in this report.)

10. Younger pediatricians are more likely to employ PNP/As and accept this concept.

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11. A significant amount of time and thus financial contribution is provided by the pediatri-cian for the betterment of society through unpaid community service activities.

12. Pediatricians perceive a collective social responsibility, as evidenced by the fact that well over 80% of the practitioners care for Medicaid patients.

Projected Patterns of Practice

1. Pediatrics will remain a primary care specialty.

2. The percentage of pediatricians in academic medicine will not increase but most likely will decrease as the number of pediatricians increases.

3. A much larger number of pediatricians will develop areas of special interest, but the percent-age of pediatricians in purely subspecialty prac-tice is not likely to increase.

4. The trend of pediatricians to form or join groups will increase, with a concomitant decrease in the number of solo practitioners.

5. An increasing number of pediatricians will incorporate PNP/As into their practices.

6. A relatively new practice arrangement of pediatricians, all with some areas of special inter-est, working in conjunction with PNP/As is likely to become the dominant practice arrangement in the future.

7. Pediatricians will increase the amount of delegation of patient care activities but will keep these activities under their direct supervision.

8. With the increased number of pediatricians, there is likely to be even better distribution of pediatricians in those areas still underserved.

9. Pediatricians will become more involved in community health activities.

10. Pediatricians will be devoting a greater portion of their time to serving those patients for whom the primary problem requires the enhance-ment of the psychosocial adjustment, intellectual development, and the quality of the child’s life.

11. Pediatricians themselves are likely to see fewer patients per day, although the total number seen daily in the pediatrician’s office may not decrease.

12. With the development of areas of special interests, it is likely that there will be fewer referrals to tertiary care centers unless there is a drastic change in technological development requiring such referral.

13. There will probably be an adequate number of pediatricians to meet future patient care needs.

Critical Factors

To meet the above projections, the Committee feels several critical considerations should be addressed:

1. There should not be expansion in the number of subspecialty boards because this would decrease pediatrics’ commitment to primary care.

2. There must be a recognition by society of the importance of visits for counseling, school problems, allergic disorders, and other matters that enhance life quality. This recognition can be accomplished if adequate provision is made for third-party coverage of these services.

3. There must be a continuation of society’s support of medical education and training programs that will not markedly alter the supply and therefore the function of pediatricians.

4. With the dynamic, evolving nature of pedi-atrics, it is important for the Academy to reassess its members’ functions and opinions periodically so that the AAP can continue to be a dominant force in the planning of future child health care and thus better fulfill its goal of enhancing the welfare of the children of the nation.

II. INTRODUCTION

During the past decade, there has been increas-ing attention within society to enhancing the quality of life. Central to this concern is consider-ation in its broadest form of the health of the nation’s children. In a large measure, the develop-ment of public policy for child health is related to medical and medically related services.

In many countries, pediatrics is a consultative

specialty and the amount of primary care

provided by pediatricians is minimal. This is frequently the pattern where health care is nationalized. Whether this should be the trend in the United States is a matter of concern to patient and physician alike.

In order to assure care for all children in this country, especially for those who presently receive inadequate or no care by lack of access or for whatever reason, it is necessary for pediatri-cians to try to determine needs in terms of manpower and the effectiveness of that manpow-er to provide for the health care of children

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Acad-Objectives of the Survey

TABLE 1

COMPARISON OF RESPONDENTS TO PHASE I WITH TOTAL MEMBERSHIP: PERCENTAGE DISTRIBUTIONS BY PRACTICE STATUS, ACADEMY DISTRICT, YEAR OF BIRTH, AND YEAR

OF MEMBERSHIP

III. METHODOLOGY

emy of Pediatrics and a significant portion of care to the pediatric population is delivered by them, it was felt that information about these pediatri-cians obtained by a detailed three-phase survey of the AAP membership would reflect the care delivered by pediatricians.

The objectives of the survey were (1) to deter-mine the scope and extent of professional activi-ties of the Fellows of the AAP in the United States, (2) to trace changing patterns of pediatric practice (the term “practice” is used in its broad-est sense to refer to the totality of the pediatri-cian’s activities), and (3) to seek the opinions of the Fellows as to the desired future direction of pediatric practice.

A random sample of 2,000 members of the AAP was selected from a listing of 14,429 physician members of the Academy. Phase I questionnaires

(

see Appendix) sent to this sample of members asked primarily for factual information readily available, such as age, sex, and practice arrange-ments, for estimates on certain items on which records are not normally kept, and also for certain opinions and judgments. After two follow-up mailings and telephone contacts with nonrespon-dents, a total of 1,604 questionnaires was returned, a response rate of 80%.

The listing from which the sample was drawn indicated (1) birthdate, (2) date of Academy membership, (3) location by Academy district, (4) location by chapter, and (5) status by type of practice. On each of these items, the distributions of the respondents were extremely close to those of the total membership; the sample may there-fore be considered as highly representative of all the members (Table 1).

Because the Academy membership tapes were designed primarily for mailing lists, differential data distinguishing the candidates and affiliated members and other “ineligible” respondents were not available until the responses were received. It was anticipated at the onset, therefore, that all respondents would not be representative of the Fellows in the United States who were actively engaged in the practice of pediatrics. The intent, then, was to obtain about 1,500 valid replies; the 2,000 represented an oversampling to accomplish the goal. Thus, 296 questionnaires returned by affiliated members (pediatric surgeons, etc.), candidate members (pediatric residents), retired members, and pediatricians residing outside the

Total Phase I

Membership

(%) (N = 14,429)

Respondents

(%) (N = 1,604)

Practice status Direct patient care Teaching

Administration

68.1 4.4 6.0

70.2 3.9 5.9

Medical research 3.2 3.4

Physicians in training Unclassified

5.0 5.2

4.4 5.2

Inactive 3.5 3.2

Other 4.6 3.8

Total 100.0 IO().0

Academy district

0 0.1 0.9

1 8.0 8.6

2 12.6 11.2

3 13.0 11.6

4 15.1 15.9

5 8.8 8.7

6 12.2 12.5

7 9.4 8.9

8 7.8 8.0

9 12.7 13.4

Other 0.3 0.3

Total 100.0 100.0

Year of birth

1880-89 0.4 0.2

1890-99 2.5 2.0

1900-09 5.8 5.1

1910-19 12.5 13.2

1920-29 27.3 28.2

1930-39 30.4 30.2

1940-49 20.5 20.6

1950-59 0. 1 0.1

Other 0.5 0.4

Total 100.0 100.0

Year of membership

1930-39 3.2 2.5

1940-49 6.4 6.7

1950-59 18.9 19.1

1960-69 29.3 29.1

1970-75 38.1 38.5

Other 4.1 4.1

Total 100.0 100.0

United States were eliminated as not representa-live of pediatric practice in the United States, leaving a total of 1,308 usable responses to the phase I questionnaires.

To receive a phase II questionnaire, the member had to be an eligible respondent to phase I, and, in turn, to receive a phase III question-naire, he had to be a respondent to phase II; thus,

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TABLE 2

DIsmIBtrrIoN OF RESPONDENTS TO PHASE I, II, AND III QUESTIONNAIRES, BY SELECTED BA#{176}

Phase I (%) Phase II (%) Phase III (%)

Sex

Male 87.0 88.3 88.7

Female 13.0 11.7 11.3

Practice setting

Academic 23.2 21.6 21.0

Practitioner 76.8 78.4 79.0

Location of practice

Urban 59.7 56.7 56.0

Suburban 31.4 34.2 35.0

Rural 8.9 9.1 9.0

Primary employment

Solo 23.7 22.5 22.9

Mixed-specialty group

Single-specialty group Government

15.9 28.8 15.8

16.2 30. 1

15.1

16.7 30.4 14.6

Other 11.0 11.0 11.0

Combination 4.8 5. 1 4.4

Patient load Too busy About right Not busy enough

18.0 66.1 15.9

16.9 66.9 16.2

16.7 67.3 16.0 Net income

$49,999 48.4 48.0 46.8

$50,000 51.6 52.0 53.2

Maximum No. reporting 1,308 1,108 921

#{176}Determined from responses to questionnaires.

phase III respondents are represented in all three phases of the study (see Appendix).

Phase II questionnaires were mailed to the 1,308 respondents to phase I. As in phase I, two follow-up mailings and telephone contacts with nonrespondents were made, resulting in returns from 1, 1 14 members, representing a response rate of 85%.

Phase III questionnaires were mailed to those who responded to phase II, and, as before, tele-phone contacts were made after two mail follow-ups to nonrespondents to encourage maximum returns. These efforts brought in 926 responses, representing a return rate of 83% of the eligible respondents of the sample. A comparison of the characteristics of the respondents to the three phases based on six parameters is given in

Ta-ble 2.

The percentage distributions in Table 2 are very similar for all three phases. Academicians and females were somewhat underrepresented among the phase II respondents when compared with those who responded to phase I. This may be because of the deliberate focus on the practice

aspects of pediatrics in phase II. The small differences between phase I and II respondents and between phase II and III respondents do not affect the adequacy of the sample in representing the practice of pediatrics by the members of the AAP.

Inasmuch as the total number of members of the AAP is equivalent to more than 60% of all physicians who designated themselves as pediatri-cians in the American Medical Association (AMA) master file, the findings in this survey may be taken as representative of the total pediatric practice in the United States.

Terms Used in This Report

Academicians. Respondents who designated

themselves as primarily in academic medicine. This classification was accepted to mean a pedi-atrician who spends the major portion of his time as a member of the faculty of a medical school or other teaching institution.

Practitioners. Respondents who designated

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TABLE 3

DISTRIBUTION OF PEDIATRICIANS BY PRACTICE CATEGORY

Practice Category No. % of

Total

% of Subgroup

Academic medicine (academicians)

General pediatrics 61 4.7 20.3

General pediatrics with specific subspecialty 78 6.0 26.0 interest

Subspecialty practice 1 10 8.5 36.6

Other 51 3.9 17.1

Subtotal 300 23.1 100.0

Private or group practice (practitioners)

General pediatrics 674 51.9 67.5

General pediatrics with specific subspecialty 218 16.8 21.8 interest

Subspecialty practice 60 4.6 6.0

Other 47 3.6 4.7

Subtotal 999 76.9 100.0

Total 1,299 100.0 100.0

TABLE 4

SUBSPECIALTY INTERESTS NAMED BY PEDIATRICIANS AS THOSE THEY CURRENTLY EMPHASIZE OR WOULD LIKE TO EMPHASIZE

Acupuncture Hematology/oncology

Adolescence/adolescent medicine Hepatology

Allergy Human ecology

Ambulatory medicine Hypnosis

Anesthesiology Immunology

Behavioral problems/emotional problems Infectious diseases

Cardiology Intensive care

Cerebral palsy Learning disabilities

Child abuse Learning problems

Child advocacy Medical writing

Child psychiatry Mental retardation

Chronic diseases Metabolism

Clinical toxicity/poison control Neonatology/fluid electrolytes

Community health Nephrology

Community medicine Neurology/epilepsy

Communicable diseases Nutrition

Connective tissue disease Pathology

Counseling, adolescent Pharmacology

Counseling, genetic Preventive medicine

Counseling, parent Primary physician

Cystic fibrosis Public health

Dermatology Pulmonary medicine

Developmental/child development Radiology

Developmental disabilities Rehabilitation

Diabetes Renal diseases

Dysmorphology Research

Emergency medicine/trauma Rheumatology

Endocrinology School health

Ear/nose/throat School problems

Epidemiology Sexuality, human/child

Gastroenterology Sports medicine

General family practice Staff education

Genetics/birth defects Surgery, pediatric/cardiovascular

Gynecology Surgery, plastic

Handicapped children/rehabilitation/teratology Urology

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TABLE 5

PEDIATRICIANS CERTIFIED OR ELIGIBLE FOR SUBSPECIALTY BOARDS

Subspecialty Board Practitioners

(%) (N = 999)

Academicians

(%) (N = 300)

Total (%) (N = 1,299)

Allergy 6.8 5.0 6.4

Cardiology 2.0 9.0 3.6

Hematology/oncology 2.0 7.3 3.2

Neonatology 1.4 10.3 3.5

Nephrology 0.7 3.0 1.2

Other 2.7 9.0 4.2

Total 15.6 43.7 22.1

TABLE 6

AGE OF PEDIAmIcs&s.S BY PRACTICE STATUS

Age (yr) Practitio

(%) (N =

ners 995)

Academic (%) (N =

ians 300)

<35 15.4 24.7

35-44 32.2 32.3

45-54 31.6 28.3

55 20.9 14.7

Median age (yr) 45.8 42.8

solo or group. The respondents in this category classified themselves in one of the following classifications:

General Pediatrics. A pediatrician whose

practice was principally in primary child care without any particular area of special inter-est.

General Pediatrics With a Specific

Subspe-cialty. A pediatrician whose major practice was

in primary child health care but who also had an area of special interest. These physicians were not necessarily eligible for subspecialty board certification.

Subspecialty Practice. A pediatrician whose

major practice was confined to a subspecial-ty.

Other. Those who were unable to classify

themselves in any of the above classifications. PNA. In this report, refers to a pediatric nurse associate or pediatric nurse practitioner. Other abbreviations are PNP and PNP/A.

IV. PRIMARY PRACTICE, ACTIVITY,

AND SUBSPECIALTIES

Current Practice Groupings

About three quarters of the respondents desig-nated themselves as practitioners, and the other quarter reported they were in academic medi-cine. Two of every three practitioners were in general pediatrics, and nine of every ten were either in general pediatrics or general pediatrics with an area of special interest. Among the academicians, practice restricted to a subspecial-ty was more common than among practitioners. Table 3 shows that pediatrics is a specialty devoted largely to the total care of children. Less than one of 16 nonacademic practicing pediatri-cians (6.0%) was in subspecialty practice.

TABLE 7

AGE OF PEDIATRICIANS, BY PRACTICE CATEGORY

Age (yr) Academicians (%)(N=300)

Practitione rs (%)

r-General General Subspecialty Other

Pediatrics Pediatrics (N = 60) (N = 47)

(N = 672) With Specific

Subspecialty (N = 216)

<35 24.7 15.6 14.4 8.3 25.5

35-44 32.3 29.9 39.4 50.0 8.5

45-54 28.3 32.3 29.6 30.0 31.9

55 14.7 22.1 16.7 11.7 34.0

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TABLE 8

AGE AND SEX OF PEDIATRICIANS, BY PRACTICE CATEGORY

Practice Category and Sex

Age (yr,)

A

Median

r-<35 35-44 45-54 55

-‘

Total

,-‘---‘ ,__A__m Age (yr)

No. % No. % No. % No. % No. %

Practitioners

Female 22 15.4 28 9.2 26 9.0 13 6.7 89 9.6 43.2

Male 121 84.6 277 90.8 262 91.0 182 93.3 842 90.4 45.9

Subtotal 143 100.0 305 100.0 288 100.0 195 100.0 931 100.0 ...

Academicians

Female 17 24.6 24 26.7 15 19.0 5 11.9 61 21.8 40.8

Male 52 75.4 66 73.3 64 81.0 37 88.1 219 78.2 43.8

Subtotal 69 100.0 90 100.0 79 100.0 42 100.0 280 100.0 ...

Total

Female 39 18.4 52 13.2 41 11.2 18 7.6 150 12.4 42.1

Male 173 81.6 343 86.8 326 88.8 219 92.4 1,061 87.6 45.5

Total 212 100.0 395 100.0 367 100.0 237 100.0 1,211 100.0 ...

Subspecialty Interest

The respondents were asked to list subspecialty interests they now emphasize or would like to emphasize. In addition to space for checking the board-certified specialties of allergy, cardiology, hematology!oncology, neonatology, and nephrol-ogy, space was provided to list as many others as they wished to record. Seventy different special interests were named (Table 4).

Of the five subspecialties specifically listed, allergy was most frequently selected by practi-tioners and neonatology by academicians. Slightly more than one in three of the practitioners indicated an area of special interest other than the five listed, while more than half of the academic group named other specialty areas.

Board Gertification. Almost a quarter of the

respondents were certified or eligible for subspe-cialty boards (Table 5). Among practitioners, the largest percentage (6.8%) was represented by allergy, followed by cardiology, hematology! oncology, neonatology, and nephrology. Among the academicians, neonatology ranked first (10.3%), followed by cardiology, hematology! oncology, allergy, and nephrology.

Age and Sex

The median age of practitioners (45.8 years) was greater than that of academicians (42.8 years). Nearly 60% of the academicians were under 45 years of age, compared with less than half of the practitioners (Table 6).

Within the practitioner group, those engaged in any form of subspecialty practice (with or without accompanying general pediatrics) were younger than those working solely in general

pediatrics. Those practitioners in general pediat-tics combined with a specific subspecialty inter-est were closest in age distribution to the subspe-cialty group (Table 7).

One of every eight AAP members was female

(

Table 8). The median age of all women members (42. 1 years) was about three years less than that of men (45.5 years).

Income

The average annual net income from practice and teaching at the time of the survey was significantly higher for practitioners ($45,760) than for academicians ($36,812). Within the prac-titioner group, the mean income of those who confined themselves to a subspecialty ($52,368) was significantly above the average for general pediatricians ($45,315) (Table 9).

TABLE 9

MEAN Nr INCOME, BY PRACTICE CATEGORY

Practice Category No. of

Physicians

Mean Income

Practitioners

General pediatricians 662 $45,315

General pediatricians with 213 $47,394

subspecialty interest

Subspecialists 57 $52,368

Total 973 $45,760

Academicians

General pediatricians 59 $36,017

General pediatricians with 74 $40,000 subspecialty interest

Subspecialists 106 $35,472

Total 287 $36,812

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80

60

40

20

I

RURAL

SUBURBAN

U RBAN

TABLE 10

MAJOR PRACTICE LOCATION, BY PRACTICE CATEGORY

Children

Under Age 18 Pediatricians

Children per Pediatrician PRACTITIONERS

%

100,

ACADE MICIANS GENERAL GENERAL SUBSPECIALTY PEDIATRICS PED.

WITH SUBSPECIALTY INTEREST

FIG. 1. Major practice location, by practice category.

V. PRACTICE LOCATION AND TYPE

Reflecting the location of medical schools, 85% of the academicians reported they were in urban areas. Practitioners were almost evenly divided between urban (49%) and suburban (41%) loca-lions; 10% were in rural areas. For all respondents the distribution was urban, 57%; suburban, 34%; and rural, 9% (Table 10 and Fig. 1).

According to the 1970 census, 19.6% of all children in the United States under 18 years of age lived in rural farm and rural nonfarm

nonme-Practice Category Major Practice

Location (%)

Urban Suburban Rural

Academicians (N 247) 85.3 10.3 4.4

Practitioners

General pediatrics 43.8 44.6 11.6 (N = 672)

General pediatrics with 54.8 37.3 7.8 subspecialty interest

(N = 217)

Subspecialty (N = 60) 80.0 18.3 1.7

Other (N = 29) 63.0 23.9 13.0

Total (N = 978) 49.2 40.5 10.3

Total (N = 1,225) 57.4 33.6 8.9

tropolitan areas, and 80.4% lived in metropolitan and urban nonmetropolitan areas.2

While the area definitions in the census and in this survey may not be strictly comparable, some rough estimates can be made of the pediatrician! population ratios in 1975. For this purpose, it was assumed that the 66,255,000 children under age 18 in that year were distributed geographically as in 1970 and that the total number of pediatricians in the United States as reported by the AMA was distributed approximately the same as the respon-dents to this survey in 1975. The following are estimates based on the foregoing assumptions and should be considered only a rough indication of the disparate geographic distribution of pediatri-cians and population in 1975:

Urban and 53,269,000 20,684 2,575

suburban

Rural 12,986,000 2,046 6,347

Total 66,255,000 22,730 2,915

Time of Choice of Practice Location

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TABLE 11

PoI-r OF TIME IN CAREER WHEN CHOICE OF COMMUNITY FOR PRACTICE LOCATION WAS

MADE

Time Academic

(%) (N =

ians 1 79)

Practitioners (%) (N = 700)

Total (%) (N = 879)

Before medical school 4.4 8.0 7.3

During medical school 3.9 6.6 6.0

During internship/house staff 49.2 50.9 50.5

training

During military service 16.2 18.1 17.8

Other 26.2 16.4 18.4

Factors Influencing Choice of Location

For all respondents, “climate or geographic area” was most frequently specified (20%) in reply to the question as to what factors (up to three) were especially important in picking one location over others. Close together in second place (13%) were “income potential” and “having gone through medical school, internship, residen-cy, or military service near here.” For those who located in a rural area, the factor of “high medical need in area” was second among the factors (18%) and ranked higher than “income potential” (10%) (Table 12).

Practice Arrangements

Close to 90% of the practitioners indicated private practice as their source of professional income. Single-specialty groups were the most prevalent form (36%), with solo practice a close second (30%). Group practice (mixed and single) accounted for more than half (56%) of the practi-tioners. About 8% were employed by a

govern-mental agency (local, state, or federal) (Ta-ble 13).

VI. WORKING FUNCTIONS, HOURS

WORKED, AND PATIENTS SEEN

The extent to which pediatricians were

engaged in specific working-time activities is shown in Table 14. It should be noted that the

amount of time is not reported here but rather

whether or not these activities were entered into by the physicians.

Working Time

There were significant differences between practitioners and academicians in the distribution of working time in various activities, emphasizing the different role each fulfills (Table 15). Between two thirds and three quarters of the practitioners’ time was spent in direct patient care, compared to about one third for academicians. Those in general pediatrics spent less than a twentieth of their hours in teaching, whereas academicians devoted one fourth of their time to this activity.

TABLE 12

REASONS FOR CHOOSING PRACTICE SITE, BY PRESENT LOCATION OF PRACTICE

Reason Pre sent Location of Practice (%)

Urban Suburban Rural Total

(N = 920) (N = 822) (N = 207) (N = 1,949)

Income potential

Climate or geographic features of area

Having been brought up in such a

community

Influence of wife or husband

12.8 20.9 10.8

11.2

14.6 19.0 9.5

11.2

10.1 23.1 9.1

13.5

13.3 20.3 10.1

11.4

Influence of family or friends

High medical need in area

Influence of preceptorship program

Having gone through medical school, internship, residency, or military service

near here

8.2 8.4 0.9 13.5

8.3 7.7 0.4 14.2

6.3 17.8 1.0 5.3

8.0 9.1 0.7 12.9

Advice of older physician Other

4.4 9.0

5.8 9.4

4.8 9.1

5.1 9.0

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TABLE 13

PRIMARY SOURCE OF EMPLOYMENT, BY PRACTICE CATEGORY

Practice Category Employment (%)

Solo Mixed- Single- Government Combination Other Specialty Specialty

Group Group

Academicians (N = 298) 3.7 3.0 5.7 41.6 6.0 39.9

Practitioners

General pediatrics (N = 674) 31.2 19.4 38.7 5.8 3.9 1.0

General pediatrics with subspecialty interest 27.5 24.3 34.9 6.0 5.0 2.3

(N = 218)

Subspecialty only (N = 60) 38.3 18.3 30.0 6.7 3.3 3.3

Other (N = 46) 10.9 4.3 8.7 47.8 10.9 17.4

Total (N = 998) 29.9 19.7 36.0 7.8 4.4 2.2

Total (N = 1,296) 23.8 15.9 29.0 15.6 4.8 10.9

TABLE 14

PERCENTAGE OF PEDIATRICIANS INVOLVED IN SPECIFIED WORKING-TIME ACTIVITIES

Practice Category Marl- Working-Time Activity (%)

fllUlfl ,.- J,

No. Direct Talking Teaching Teaching Admin- Medical Corn- Corn- Other Patient to (in Office) (Outside i.stration Record munity munity

Care Patients Medical Office) and Keeping Services Services

on Students, Medical (Paid) (Not

Tele- etc. Committees Paid)

phone

Academic medicine 300 89.4 68.2 58.4 72.3 80.7 60.9 20.8 46.0 34.5

General pediatrics 674 99.8 96.5 47.0 51.5 74.6 84.8 24.2 51.7 5.3

General pediatrics with 218 99.1 97.2 54.9 70.9 77.5 87.3 18.3 54.9 12.2

specific subspecialty interest

Subspecialty practice 60 98.2 91.2 47.4 93.0 71.9 75.4 12.3 50.9 10.5

TABLE 15

MEAN PERCENTAGE OF WORKING TIME IN SPECIFIED ACTIVITIES

Activity Academicians (%) Practitioners (%) Total (%)

(N = 274) - A -‘ (\T 1,200)

General General Subspecialty

Pediatrics Pediatrics (N = 56)

(N = 657) With

Subspecialty (N = 213)

Direct patient care 33.3 76.4 71.6 67.2 64.8

Talking to patients on 3.5 8.8 8.6 5.8 7.3

telephone

Teaching in office 10.8 1.7 2.4 3.3 3.9

Teaching outside office 14.2 2.1 3.8 7.3 5.3

Administration and medical 15.7 3.1 4.4 6.2 6.3

committees

Medical records 4.2 4.6 4.7 4.6 4.6

Paid community service 2.9 0.9 0.9 1.6 1.5

Not paid community service 2.4 1.6 2.0 2.5 1.9

(11)

ACADEMICIAN

TELEPHONE 3.5% GENERAL PEDIATRICS

OTHER 0.8%

COMMUNITY

SERVICE

TEACHING

ADMINISTRATION &

MEDICAL COMMITTEES 3.1%

MEDICAL RECORDS 4.6%J TELEPHONE 8.8%

OTHER 13.0% !

COMMUNITY SERVICE 5.3%

MEDICAL RECORDS 4.2%

ADMINISTRATION &

MEDICAL COMMITTEES

TEACHING 25.0%

FIG. 2. Distribution of working time for general pediatrics practitioners and academicians.

Academicians spent about five times more time relatively in administration and serving on medi-cal committees than their practitioner colleagues (Fig. 2).

Thirteen percent of the time of academicians was reported in the category “other,” compared with 1% for the practitioners. This may reflect the fact that research was not listed as one of the specific activities and so academicians engaged in research reported this activity in the “other” category.

Direct Patient Care Activities-General Pediatricians

The distribution of time spent in direct patient care activities indicated the large degree to which pediatricians are presently involved in primary care. Only 2% of the general pediatri-cian’s time and 4% of the time of the

pedia-trician with a subspecialty interest was spent on consultations requested by other physicians (Table 16).

Practitioners spent about 10% of their time taking care of sick patients in the hospital. About a quarter of the time of those in general pediatrics and in general pediatrics with a subspecialty interest was spent in health supervision visits, and a third of their time was devoted to acute illness or injury care. Allergy was a relatively large part of pediatric practice; about 10% of the practition-ers’ time was spent in this field. The care of children with chronic diseases and the categories

of counseling and school problems each

accounted for about 4% of patient care time.

Health Supervision Visits

A third of the practitioners saw one or more of the parents prior to the child’s birth. About 40% at Viet Nam:AAP Sponsored on September 7, 2020

(12)

TABLE 16

MEAN PERCENTAGE OF TIME SPENT BY PRACTITIONERS IN SELECTED PATIENT CARE ACTIVITIES

Direct Care Activity General Pediatrics

(%)

Gener With S

al Pediatrics ubspecialty

(%)

Subspecialty (%)

Hospital-sick children 9 10 10

Hospital-newborns 7 7 2

Health supervision 24 21 2

Acute illness 35 28 3

Allergy 8 11 51

Chronic disease 3 4 4

Counseling 4 4 2

School problems 4 5 2

Consultation 2 4 18

Travel 4 4 3

Other 1 3 4

provided health supervision to persons over age 18, although only 1% of their time in health supervision visits was spent in this manner (Ta-ble 17).

Eighty-five percent of the practitioners who answered the question provided health supervi-sion to teenagers; this accounted for about 10% of their health supervision time. Since one fourth of the patient care time was spent in health supervision visits, about 2.5% of all patient care time was spent on teenage health supervision visits.

Counseling

Visits exclusively for counseling accounted for only a small portion of the pediatricians’ total time even though this service was provided to children in all age groups (Table 18). However,

this activity showed the third largest increase in patterns of practice in the past five years (Table 35).

Hospital Care

In general, there was no significant difference in the extent of hospital care by location of the physician or type of practice arrangement. Furthermore, there was little difference between urban and suburban practices in the time spent in delivering hospital-based services, although some-what greater use was made of the outpatient department by urban pediatricians (Table 19).

Hours Worked

Average hours worked per week, excluding time on call and time not actually involved in services, ranged from 55.6 for practitioner

subspe-TABLE 17

DISTRIBUTION OF PEDIATRICIANS BY PERCENTAGE OF TIME IN HEALTH SUPERVISION SERVICES

Practice Category and Activity

% of Time

k

r-None 10 or 10+ 11-40 41-70 71-100 No

Less Answer

Academicians

Prenatal 49.3 9.7 1.7 0 0 0 39.3

Birth-i yr 1-5 yr 6-12 yr

13-18 yr > 18 yr

16.3 14.3 16.3 22.3 46.3

8.3 8.0 12.3 20.7 12.7

20.0 33.3 26.7 15.3 1.7

10.7 4.0 4.7 1.3 0.3

5.7 1.3 1.0 1.3 0

39.0 39.0 39.0 39.0 39.0 Practitioners

Prenatal 58.2 30. 1 3.2 0 0 0 8.5

Birth-i yr 1-5 yr 6-12 yr 13-18 yr > 18 yr

4.1 3.1 4.8 12.0 52.8

4.7 7.0 27.8 54.9 35.6

43.6 75.7 56.3 23.6 1.6

32.9 5.3 2.4 0.7 1.0

6.0 0.4 0.2 0.2 0.3

(13)

TABLE 18

DI5mIBCTI0N OF PEDIATRICIANS BY PERCENTAGE OF TIME IN COUNSELING ACTIVITIES (EXCLUDING HEALTH SUPERVISION VISITS)

Practice Category and

% of Time

-Activity None 10 or 11-40 41-70 71-100 No

Less Answer

Academicians

Prenatal 49.7 13.0 3.7 0 0.3 33.3

Birth-i yr 13.3 14.7 24.7 7.3 6.7 33.3

1-5 yr 9.7 10.3 40.3 4.0 2.3 33.3

6-12 yr 9.7 13.0 33.3 8.7 2.0 33.3

13-18 yr 16.7 22.0 24.0 1.3 2.7 33.3

> 18 yr 46.3 18.0 2.0 0.3 0 33.3

Practitioners

Prenatal 54.7 28.8 3.4 0.7 0.2 12.2

Birth-i yr 10.1 20.1 36.6 16.8 4.0 12.4

1-5 yr 4.5 14.3 61.1 6.9 0.9 12.2

6-12 yr 3.9 20.8 51.3 9.6 2.2 12.2

13-18 yr 12.6 39.9 29.9 4.6 0.9 12.2

> 18 yr 60.1 23.8 3.1 0.4 0.3 12.3

cialists to 60.3 for general pediatricians with a subspecialty interest. The average for all respon-dents combined was 58.4 hours per week (Ta-ble 20).

Practitioners spent more than half their time in their offices, contrasted with only a quarter of their time for academicians, while academicians spent considerably more hours in teaching and in the hospital care of children than practitioners (Table 21). Less time was spent after hours by academicians seeing and talking to patients, but

they spent considerably more time in professional education and administration.

About 12% of the time of those in general pediatric practice was spent in patient care activities after office hours, about 7% to 8% in professional education, and between 3% and 4% in community service activities.

Mean total hours worked per week for various categories of pediatricians is given in Table 20. The average for practitioners over 55 years of age was very little less than the overall average.

TABLE 19

DISTRIBUTION OF PEDIATRICIANS BY PERCENTAGE OF TIME IN HOSPITAL CARE ACTIVITIES

Practice Category and Activity

% of Time

,.-None 10 or Less

11-40 41-70 71-100

-‘

No Answer

Academicians

Routine newborn 46.3 9.3 8.7 3.3 1.3 31.0

care

Sick inpatient care

(excluding

newborns)

Private outpatients

Other care

13.1

27.9 56.7

8.1

10.4 2.3

12.7

9.4 1.7

14.1

10.4 2.3

21.5

11.1 6.0

30.5

30.8 30.9

Practitioners

Routine newborn 10.2 10.4 25.8 26.8 20.1 6.7

care

Sick inpatient care

(excluding newborns)

Private outpatients Other care

4.3

39.3 87.2

13.8

37.6 2.4

32.9

11.7 1.3

26.9

2.3 0.5

15.6

2.7 2.1

6.5

6.4 6.5

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TABLE 20

AVERAGE HOURS WORKED PER WEEK BY SELECTED PEDIATRICIAN CATEGORIES

category Hours

All pediatricians 58.4

Acadeniic pediatricians 57.8

Subspecialty in allergy 57.2

Subspecialty in cardiology 61.2

Subspecialty in hematology 56.2

Subspecialty in neonatology 65.2

Subspecialty in nephrology 54.8

General pediatric practice 59.3

General pediatrics with subspecialt interest 60.3

Subspecialty practice 55.6

<35 years of age

All pediatricians 59.2

Academicians 59.5

Practitioners 59.0

>55 years of age

All pediatricians 53.6

Academicians 51.3

Practitioners 55.7

Number of Patients Seen

Physicians in general pediatric practice saw an average of 32.4 patients per weekday in hospital and office, more than twice as many as seen by those in academic medicine (14.1). Pediatricians with a subspecialty interest saw slightly fewer patients per weekday (29.8), and subspecialists even fewer (18.0) (Table 22).

In terms of number of patients seen by both physician and staff, the averages were 46.4 for general pediatricians, 47.3 for general pediatri-cians with a subspecialty interest, and 42.6 patients per weekday for subspecialists.

Night Calls. On the nights pediatricians in

general practice were on call and saw patients, they saw an average of 3.2 patients. The average was slightly less for general pediatricians with a subspecialty interest (2.8), but quite a bit less for subspecialists (1.5).

Forty-eight percent of the academicians saw patients on the nights they were on call, took telephone calls, and gave telephone advice.

General Pediatrician’s Day and Week

From the data on average percentage of time spent in various direct patient care activities and the average number of patients seen per day, it was possible to estimate the number of patients seen by the general pediatrician for each type of visit and to develop a composite of the working day and week (Table 23). To estimate the work-week, an average of five days was used based on the modal number of days off per week and modal number of Saturdays and Sundays worked (Ta-ble 24).

For these estimates, it was assumed that all visits took approximately the same amount of time except those for counseling and school problems, which were assumed as having taken about twice the time, and health supervision visits, which were assumed as having taken about

TABLE 21

MEAN HOURS WORKED PER WEEK IN SPECIFIED ACTIVITIES

Activity Academicians General General Subspecialty

(N = 300) Pediatrics Pediatrics (N 60)

,____.A___._m (N = 674) Wit/i

Mean % Subspecialty Mean %

Hours Mean % interest Hours

Hours (\T = 218)

r---Th

Mean %

Hours

Office 14.5 25.1 35.2 59.4 33.3 55.2 29.3 52.7

Hospital 16.5 28.5 8.1 13.7 8.8 14.6 10.8 19.4

Teaching 12.7 22.0 1.5 2.5 2.3 3.8 3.9 7.0

After hours seeing patients 1.9 3.3 3.4 5.7 3.0 5.0 2.4 4.3

After hours talking to patients 1.3 2.2 3.8 6.4 4.0 6.6 1.8 3.2

on telephone

Professional education 6.3 10.9 4.0 6.7 5. 1 8.4 4.5 8.1

Community services requiring 1.8 3.1 0.9 1.5 1.0 1.7 0.5 0.9

pediatric expertise

Community service not requir- 0.7 1.2 0.8 1.4 1.0 1.7 0.9 1.6

ing pediatric expertise

Professional meetings 2.1 3.6 1.6 2.7 1.8 3.0 1.5 2.7

(15)

15 or more telephone calls on the nights they were on call, and only 5% of them received no calls (Table 27). Subspecialists and academicians received fewest telephone calls when on call. The median number of telephone calls per night on call was as follows:

General pediatricians 8

General pediatricians with subspecialty interest 9

Subspecialists 4

Academicians 3

Attitudes Toward Changes in Activities

The respondents were asked, “If there were no financial constraints, would you increase, de-crease, or not change” eight listed activities? The majority of the general pediatricians would like to increase the time they spent in teaching, both in and outside their offices, and between a fourth and a third would like to increase their communi-ty service activities, which currently occupied between 3% and 4% of their time (Table 28).

More than half would like to decrease medical record keeping and talking to patients on the

TABLE 24

DAYS OFF PER WEEK AND SATURDAYS AND SUNDAYS WORKED PER MONTH (IN PERCENTAGE OF TOTAL

PEDIATRICIANS)

TABLE 23

ESTIMATED AVERAGE No. OF PATIENTS SEEN BY GENERAL PEDIATRICIANS PER DAY AND PER WEEK, BY TYPE OF VISIT

Days Off Per Week

Saturdays Worked Per Month

Sundays Worked Per Month

0 7.6 11.2 24.7

#{189} 7.4 7.3 19.6

1 22.4 21.2 10.0

1#{189} 22.5 7.2 16.6

2 27.6 23.7 17.0

2#{189} 5.9 1.5 0.4

3 2.9 7.4 2.5

3#{189} 0 0.3 0.2

4 0 16.8 4.1

N/A 3.7 3.4 4.9

TABLE 22

AVERAGE No. OF PATIENTS SEEN PER DAY AND PER NIGHT

Patients Seen Acaden

A

iicians General Pediatrics

.&

General Pediatrics With Subspecialty

Interest

.

Suhspecialty

, .

Physician Physician and Staff Alonc’

r-Physician and Staff

._

Physician Physician Alone and Staff

-,‘

Physician Alone ,.

Physician Physician and Staff Alone

Weekday 36.2 14.1 46.4 32.4 47.3 29.8 42.6 18.0

Saturday 19.0 14.9

Sunday 7.7 7.4

Per night for all on call 1.2 2.5 2.3 0.9

Per night for those who see patients

2.4 3.2 2.8 1.5

one and a half times the time for the other types of visits.

In an average week, the general pediatrician made 17 visits to sick children and 13 visits to newborns in the hospital. In his office, he person-ally saw 31 children for health supervision visits, 70 for acute illness or accidents, 15 for allergies, 6 with chronic diseases, 4 for counseling, and 4 with school problems. In addition, he had an average of two consultations a week.

Nights on Call

Eighty-nine percent of all pediatricians were on night call; of these, about 12% were on call every night of the week. These may represent solo practitioners or subspecialists who had no trade-off arrangements. About one of every three gener-al pediatricians and the same proportion of gener-a! pediatricians with a subspecialty interest were on call more than every other night (Tables 25 and 26).

Night Telephone Calls. Nearly 15% of the

general pediatricians reported that they received

Type of Visit Per Weekday Per Week

Hospital-sick children 3.47 17.35

Hospital-newborns 2.69 13.45

Health supervision 6.16 30.80

Acute illness and injury 13.90 69.50

Allergy 3.08 15.40

Chronic diseases 1.17 5.85

Counseling .78 3.90

School problems .78 3.90

Consultation .39 1.95

Total 32.4 162.1

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TABLE 25 TABLE 26

No. OF NIGHTS ON CALL (IN PERCENTAGE OF PHYSICIANS

IN SPECIFIED PRACTICE CATEGORIES)

Practice Category No. of Nights

0 1 2 3 4 5 6 7 Total

Total pediatricians 11 21 23 14 8 7 4 12 100

Academic pediatricians 26 20 14 14 3 3 2 18 100

General pediatricians 6 21 26 16 10 8 5 9 100

General pediatricians 5 25 29 13 6 9 3 10 100 with subspecialty

interest

Subspecialty practice 14 10 9 5 16 5 7 34 100

pediatricians

telephone. These accounted for about 12% of their time. Two thirds of the pediatricians would not change the amount of time they devoted to direct patient care; 24% would increase this activity and 14% would decrease it.

VII. FUTURE ROLES OF PEDIATRICIANS

A major focus of the survey was on the opinions of pediatricians relating to the role of the practice of pediatrics in the immediate future. The survey probed for the satisfaction gained from pediatric practice, opinions on the role of the pediatrician in primary child health care, the preparation and certification of future pediatricians, and the role of pediatric nurse associates in conjunction with pediatricians in delivering child health care. These four general topics were pursued in 16 statements presented to the respondents, who were asked to indicate their agreement or dis-agreement with each. In general, the practitioner and academic groups held similar views on each statement, differing only in the relative strength of the respective agreements and disagreements.

TABLE 27

No. OF TELEPHONE CALLS PER NIGHT ON CALL (IN

PERCENTAGE OF PHYSICIANS IN SPECIFIED PRACTICE CATEGORIES)

Practice Category N o. of Teleph one Calls

0 1-4 5-9 10-14 15 or Median More

Total pediatricians 12 32 26 19 1 1 6

Academic pediatri- 30 55 10 4 1 3

cians

General pediatricians 5 24 31 25 15 8

General pediatricians 5 18 37 20 20 9 with subspecialty

in-terest

Subspecialty practice 16 62 17 5 0 4

pediatricians

No. OF PATIENTS SEEN ON NIGHT CALL (IN PERCENTAGE OF PHYSICIANS IN SPECIFIED PRACTICE CATEGORIES)

Practice

Category

No. of Patients

A

r-0. 1 2 3 4 5 6 7 8

Total pediatri- 28 26 17 10 5 3 2 1 9

cians

Academic pedia- 52 28 7 2 0 1 0 0 8

tricians

General pedia- 19 26 19 14 6 4 2 1 10

tricians

General pedia- 19 24 24 9 6 5 2 1 9 tricians with

subspecialty interest

Subspecialty 44 37 7 5 5 0 0 0 0

practice

pediatricians

Satisfaction Gained From Pediatrics

Practice

A decided majority of the practitioners agreed that current practice is intellectually challenging. Academicians also expressed this sentiment but less emphatically, with 10% failing to offer an opinion. Professional satisfaction gained from the child health supervision aspect of pediatric prac-tice was overwhelmingly expressed by both academic and practitioner groups. A somewhat less emphatic but nonetheless clear majority agreed that pediatrics as generally practiced is satisfying. Three of every four practitioners and one in two academicians held this opinion (Ta-ble 29).

TABLE 28

CHANGES IN SPECIFIED ACTIVITIES DESIRED BY GENERAL

PEDIATRICIANS

Activity % Who Would

increase Decrease Not Change

Teaching in office 56.0 2.9 41.1

Teaching out of office 55.2 2.7 42.1

Unpaid community 37.2 5.6 57.2

services

Paid community ser- 26.8 3.5 69.7

vices

Providing direct pa- 24.1 14.2 61.7

tient care

Administration and 1 1 .4 32.7 55.9

committee work

Talking to patients on 3.6 54.6 41.8

telephone

Medical record keep- 1.6 56.0 42.2

(17)

Patient Load

Too busy (N = 209)

About right (N 761)

Not busy enough (N = 184)

Mean Age (yr)

Would C/loose Would Not Choose Pediatrics Again Pediatrics Again P

Mean No. of Years in Practice

Would C/loose Would Not Choose Pediatrics Again Pediatrics Again P

TABLE 29

Ai-rITUDES ON SATISFACTION GAINED FROM PEDIATRIC PRACTICE

Statement % Who Agree

Acadein icians Practitioners Total (N = 238) (N = 878) (N = 1,116)

General pediatrics as currently practiced

is intellectually challenging

48.3 68.6 64.2

I gain professional satisfaction from child health supervision aspects of pediatric practice

64.3 84.2 79.9

Pediatrics as generally practiced is sat-isfying

51.7 74.9 69.9

Pediatricians receive adequate financial compensation for the services they de-liver

35.7 37.3 37.0

Only a third of the respondents considered the financial compensation a pediatrician receives for medical services adequate.

An overwhelming majority would have wel-corned more complex problems in their child patients, but this judgment should be viewed in the context of the reported responses, discussed below, referring to the emphasis on primary child health care and not having pediatrics become a consultation specialty.

Choosing Again. A more general measure of

satisfaction with pediatrics is found in the replies to a series of questions on the respondents’ choices if they had to do it over again .When asked if, at the same time in life they chose to become physicians, they would again so choose, nearly all (96%) who answered the question responded

yes.

When those pediatricians who classified them-selves as general, general with a subspecialty interest, or subspecialist within an academic or private practice setting were asked. “Would you choose to become a pediatrician again?” their replies were as follows:

Academicians Nonacademicians Total

--- ---

p----No. % No. % No. %

Yes 209 91 738 82 947 84

No 21 9 158 18 179 16

Thus, pediatricians appeared to be satisfied with their profession.

Differences in patient load were significantly related to the degree of affirmative response, with the most “yes” replies from those who character-ized their patient load as about right.

% That Would Choose Pediatrics Again

80 86 73

Age was a significant factor in the choice of becoming a pediatrician again. Both academi-cians and practitioners who would not so choose

were older on the average than those who

answered in the affirmative.

Academicians 43.0 46. 1 .05

Practitioners 45.5 47.7 .01

The number of years in practice correlated significantly in the same direction as age for practitioners but not for academicians.

Academicians 12.8 15.1 NS

Practitioners 15.1 16.9 .05

Those who would not become pediatricians again had been in practice longer than those who would again take up this specialty.

Income was also a significant factor in the choice to become a pediatrician again for academicians but not for practitioners.

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TABLE 30

ATTITUDES ON PEDIATRICS IN PRIMARY CARE

Statement % Who Agree

Academicians (N = 238)

Practitioners (N = 857)

Total (N = 1,095)

The major practice of pediatricians

edu-cated in the next ten years should be the provision of primary health care to children

70.2 84.0 81.0

Pediatrics should evolve essentially into a consultation specialty

28.2 17.9 20.1

In the future, family physicians should

deliver the greater share of primary

child health care

24.4 12.7 15.3

In the future, pediatricians should deliver the greater share of primary child health care

54.2 77.6 72.5

Pediatricians should be qualified to take care of people beyond the presently

accepted pediatric age limit of 21

years

20.6 20.8 20.7

Mean Income rejected the proposition that pediatrics should

r- -‘ become a consultative specialty. While

academi-Would Choose Would Not Choose cians held these views less emphatically, a Pediatrics Again Pediatrics Again P convincing majority was found in both groups.

Academicians $35,697 $42,576 .01 Three of every four respondents disagreed with

Practitioners $45,981 $45,545 NS the statement that family physicians should deliv-The mean income of academicians who would er the greater share of primary child health care choose pediatrics again was lower than those who (Table 30).

would not. Two of every three respondents rejected the

proposition that the age group of pediatric

Role of Pediatricians in Primary Child patients be extended beyond 21 years of age; this

Health Care view was essentially identical for the academic

An overwhelming majority of the respondents and practitioner groups. Nearly three of every felt that the major role of pediatrics is the four respondents agreed that pediatricians should provision of primary child health care and deliver the greater share of primary child health

TABLE 31

DISTRIBUTION OF TIME PEDIATRICIANS SPEND IN GENERAL PRACTICE OF PEDIATRICS BY PRACTICE CATEGORY

Time Academicians (%) Practitioner s (%) No Total (%)

(N = 300) r-. - Answer (%) (N = 1,324)

General General Subspecialty Other (N 21)

Pediatrics Pediatrics Practice (N 47)

(N = 674) With (N 60)

Subspecialty Interest (N = 218)

25% or less 16.7 0 1.8 28.3 6.4 4.0 5.7

26%-50% 12.0 0.4 11.5 1.7 4.3 0 5.1

5i%-75% 7.3 2.2 28.4 0 6.4 0 7.7

76%-iOO% 26.0 96.7 57.8 1.7 40.4 24.0 66.6

None 32.3 0 0.5 68.3 31.9 12.0 11.9

(19)

TABLE 32

ATTITUDES ON TRAINING AND CERTIFICATION

Statement % Who Agree

Academicians Practitioners Total (N = 238) (N = 857) (N = 1,095,)

i;Tl the future, pediatricians should be 50.0 51.2 51.0

qualified to practice both general pedi-atrics and a pediatric subspecialty

Some period of postresidency experience 55.0 69.2 66.1 in general pediatric care should be a

requirement for eligibility to take the final portion of the examination for the American Board of Pediatrics

In principle, I favor a recertification pro- 71.4 62.8 64.7

gram for pediatricians

Most pediatricians currently entering 47.1 50.1 49.4

general pediatric practice are ade-quately trained for this type of practice

In residency programs, pediatricians 79.0 57.4 62.1

should have experience in working with PNAs

I would welcome the opportunity to see 79.8 76.9 77.5

more children with complex problems

care, with the academicians less emphatic than the practitioner group.

Eighty-eight percent of the respondents spent tinie in the delivery of primary child health care; 6% spent less than 26% of their time in general pediatrics; and two thirds spent more than 75% of their time in such practice (Table 31).

Preparation and Certification of Future

Pediatricians

While holding the clear judgment that pedia-tricians educated in the future should have primary child health care as their major practice activity, the respondents expressed a preference for future pediatricians being qualified to

prac-tice both general pediatrics and a pediatric subspecialty (Table 32).

Evidence of the commitment to general pediat-rics is found in the fact that two of every three respondents felt that some period of experience in general pediatric care postresidency should be required for eligibility for the final portion of the examination for the American Board of Pediat-iics. Here again, the practitioner group held a stronger view on this issue than the academic group. In both groups, there was definite opinion in favor of some recertification program for pediatricians.

Less than half of all respondents considered pediatricians presently entering general pediatric

TABLE 33

ArFITUDES ON ROLE OF PEDIATRIC NURSE ASSOCIATES (PNAs)

Statement % Who Agree

Academicians Practitioners Total (N = 238) (N = 857) (N = 1,095)

In the future, PNAs working in conjunc-tion with physicians should be

increas-ingly involved in the delivery of pri-mary child health care

72.2 48.5 55.0

In residency programs, pediatricians should have experience in working with PNAs

79.0 57.4 62.1

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(20)

%

(f,’,7 819)

14.4

65.2

17.3 3.1

Yes No

62.2 18.2

69.9 26.3

68.5 24.9

Already Have

19.6 3.9 6.6

Academicians (N = 115)

Practitioners (N = 664)

Total (N = 779)

practice to be adequately prepared. There was a strong feeling that pediatric residents should have experience working with PNAs (Table 32).

Role of PNP/As in Delivering Primary

Child Health Care

There was general agreement that, in the future, PNP/As working in conjunction with physicians should be increasingly involved in the delivery of primary child health care. The academic group expressed nearly a three-to-one majority in favor of this idea, while the practition-er group was considerably less emphatic on this point (Table 33).

VIII. AREA OF SPECIAL INTEREST

As was demonstrated earlier, pediatricians held a clear preference for the provision of primary child health care, but there was a sizable interest in developing an area of special interest (Table 34). An area of special interest pertains to those physicians who, by virtue of additional study, interest, direction, special courses, even residen-cies, or a combination of these, devoted a portion of their time to and emphasized a special interest such as allergy, cardiology, and nephrology. These physicians were not necessarily eligible for subspecialty board certification.

When asked, “If you were given the time and financial remuneration, would you be interested in developing a subspecialty interest?” 68% said “yes,” 7% stated they already had such an inter-est, and only 25% replied negatively.

Academicians (N = 143)

Practitioners (N = 691)

Total (N = 834)

Interest in Developing a Subspecialty Interest (%)

Excluding the “already have” replies, the

breakdown was as follows:

Yes (%) No (%)

77.4 22.6 72.6 27.4 73.3 26.7

Among the choices of 578 respondents who would be interested in developing a subspecialty interest, allergy ranked first (16.3%), followed by child development counseling (13.3%). More than half of the academicians and one third of the practitioners expressed areas of special interest outside those of the five subspecialty boards (Table 34).

Additional evidence of the desire to develop areas of special interest is found in the responses to the preferred practice setting. Two thirds expressed a preference for providing pediatric services in conjunction with a pediatric generalist who had a subspecialty interest.

Prefer to Provide Pediatric Services in Conjunction With:

Pediatric generalist

Pediatric generalist with a

subspecialty interest

Pediatric subspecialists

Family practitioners

Total 100.0

Another indication of support for the concept of area of special interest is evident from the responses to the question, “I would welcome the opportunity to see more children with complex problems.” “Yes” replies were received from 77% of the practitioners and 80% of the academi-cians.

IX. CHANGING REQUESTS FOR CARE

General Pediatricians

The respondents were asked whether they had noted a significant increase, decrease, or no significant change in the past five years in the demand for nine listed practice activities.

Most outstanding is what has happened to the demand for services in connection with school problems (e.g., learning disabilities). Sixty percent of the general pediatricians reported an increase for such services and only 4% a decrease. The second largest increase was in the demand for care for children with allergies (40%), with only 5% reporting a lesser demand. A significant increase in counseling was reported by 38% and a decrease by 5%, with 57% indicating no change (Table 35).

Two other areas where those who experienced increases outweighed those who reported de-creases were acute illness or injury and health supervision visits, but the majority saw no signif-icant change in the demand for these.

References

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