Providing pediatric subspecialty care: A workforce analysis. AAP Committee on Pediatric Workforce Subcommittee on Subspecialty Workforce

Outpatient pediatric cardiology consultations in a tertiary academic hospital

Objectives

Cardiac diseases in the pediatric population can be congenital or acquired. If the diagnosis and treatment are early, the chance for survival increases. Thus, this study aimed to determine the indications for pediatric cardiology consultations in a single tertiary hospital in Jeddah, Saudi Arabia.

Materials and Methods

This study was conducted in 2020-2021 at a tertiary center in Jeddah, Saudi Arabia. Patients younger than 14 years of age who were referred by outpatient clinics or those who presented to the emergency department and needed outpatient cardiac evaluation were included in this study. Inpatient referrals were excluded. The Statistical Package for the Social Sciences version 21 was used for statistical analyses.

Results

A total of 416 referred patients were included in this study. New patients accounted for 74% of the referrals, while known patients accounted for 26%. The median age was 2.728 years, with 56.3% being male participants. The three most common reasons for referral were: evaluation of cardiac function (21.6%), follow-up evaluation of fetal/neonatal diagnosis (19.5%), and heart murmurs (16.8%).

Conclusion

Most of the referrals were new patients. Of those who underwent echocardiography, 48.2% had abnormal results. We recommend further studies to help guide the direction of the residents' education and to provide better patient healthcare services.

Survey of centers performing cardiovascular magnetic resonance in pediatric and congenital heart disease: a report of the Society for Cardiovascular Magnetic Resonance

BACKGROUND

There are few data on practice patterns and trends for cardiovascular magnetic resonance (CMR) in pediatric and congenital heart disease. The Society for Cardiovascular Magnetic Resonance (SCMR) sought to address this deficiency by performing an international survey of CMR centers.

METHODS

Surveys consisting of 31 (2014) and 33 (2018) items were designed to collect data on the use of CMR for the evaluation of pediatric and congenital heart disease patients. They were sent to all SCMR members in 2014 and 2018. One response per center was collected.

RESULTS

There were 93 centers that responded in 2014 and 83 in 2018. The results that follow show data from 2014 and 2018 separated by a dash. The median annual number of pediatric/congenital CMR cases per center was 183-209. The median number of scanners for CMR was 2-2 (range, 1-8) with 58-63% using only 1.5T scanners and 4-4% using only 3T scanners. The mean number of attending/staff reading CMRs was 3.7-2.6; among them, 52-61% were pediatric or adult cardiologists and 47-38% were pediatric or adult radiologists. The median annual case volume per attending was 54-86. The median number of technologists per center doing CMRs was 4-5. The median scanner time allocated for a non-sedated examination was 75-75 min (range, 45-120). Among the 21 centers responding to both surveys, the mean annual case volume increased from 320 in 2014 to 445 in 2018; 17 (81%) of the centers had an increase in annual case volume. For this subgroup, the median attending/staff per center was 4 in both 2014 and 2018. The median scanner time allotted per study was unchanged at 90 min. The mean time for an attending/staff physician to perform a typical CMR examination including reporting was 143-141 min.

CONCLUSION

These survey data provide a novel comprehensive view of CMR practice in pediatric and congenital heart disease. This information is useful for internal benchmarking, resource allocation, addressing practice variation, quality improvement initiatives, and identifying unmet needs.

The Pediatric Workforce: Recent Data Trends, Questions, and Challenges for the Future

The future of the pediatric workforce has been the subject of significant dialogue in the pediatric community and generated much discussion in the academic literature. There are significant concerns regarding the ability of pediatricians to meet the growing demands of our pediatric population. Over the past 5 years, there has been a decline in the percentage of doctor of osteopathic medicine students who pursue a career in pediatrics but an equally important increase in the number of pediatric positions that are filled by doctor of osteopathic medicine students and international medical graduates. Although there has been an increase in the number of pediatric positions offered in the National Resident Matching Program, the last 4 years have seen a significant increase in the number of unfilled pediatric positions. A number of pediatric subspecialties struggle to fill their training positions, and those with low match rates may have 20% to 40% fewer applicants than positions. The pediatric vision for the future must include a commitment to a comprehensive strategic planning process with the many organizations involved across the multiple stages of the educational continuum. It is time to elucidate and address the questions raised by the workforce data. Developing solutions to these questions will require a careful planning process and a thoughtful analysis of the pediatric workforce data. Establishing this as an important priority will require a major collaborative effort between pediatric academic and professional organizations, but the future benefit to the nation's children will be significant.

Perspectives of Young Otolaryngologists on Pediatric ENT and the Future of the Field in Turkey

Objective

The purpose of this study was to examine the current status and the future of pediatric otolaryngology in Turkey by evaluating the opinions of young otolaryngologists on pediatric otolaryngology.

Methods

The study included 224 otolaryngology physicians who were senior residents registered with the Turkish Otolaryngology and Head-Neck Surgery Association (TORL-HNS). The physicians were in their last two years of otolaryngology training (154 physicians) or had completed their residency training and were in their first year of otolaryngology practice (70 physicians). They were approached via e-mail and Short Message Service (SMS) in October through December 2019 with a descriptive letter and asked to voluntarily complete an online questionnaire consisting of total 25 questions in five sections.

Results

The online questionnaire was sent to 224 physicians, and 109 (49%) participated in the survey. All 109 participants answered all the questions. Overall, 71 participants (65.1%) were in training for residency and 38 (34.9%) were in their first year of expertise. According to their professional interests, the participants listed rhinology (45 participants, 41.3%), head and neck surgery (27 participants, 24.8%), facial plastic surgery (19 participants, 17%), otology-neurotology (16 participants, 14.7%), and laryngology-phoniatry (2 participants, 1.8%) as their first preference for subspecialty. Pediatric otolaryngology was never a first choice among the participants, although four (3.7%) listed pediatric otolaryngology as their second preference.

Conclusion

The aim of this study was to shed light on the current and future status of pediatric otolaryngology in Turkey. We believe the establishment of exclusive pediatric otolaryngology clinics under the umbrella of general ear, nose and throat (ENT) clinics and the foundation of officially approved fellowship programs would bring this subspecialty field to its deserved and desired level in our country.

Assessing the Association Between Maternal Education and Access to Pediatric Specialty Care

Background. Timely access to pediatric specialty care continues to be a pervasive issue. We aimed to identify factors associated with unmet pediatric specialty care needs by assessing the association with maternal level of education. Methods. A sample was extracted from the 2011-2012 National Survey of Children's Health, which identified a subset of patients with unmet specialty care needs. Logistic regression models determined the strength of association between our sample and maternal level of education. Results. An estimated 12.5% of US children had unmet specialty care needs. Independent of confounding variables, children with mothers educated at a level of high school or less were 41% more likely to have unmet specialty care needs compared to those with mothers who were educated at a level greater than high school. Conclusions. Maternal level of education can be used as a risk factor to assess whether a child will have unmet specialty care needs.

Profile of the Pediatric Infectious Disease Workforce in 2015

BACKGROUND

Almost 20 years have elapsed since the last workforce survey of pediatric infectious disease (PID) subspecialists was conducted in 1997-1998. The American Academy of Pediatrics Section on Infectious Diseases in collaboration with the Pediatric Infectious Diseases Society sought to assess the status of the current PID workforce.

METHODS

A Web-based survey conducted in 2015 collected data on demographics, practice patterns, and job satisfaction among the PID workforce, and identified factors related to job placement among recent fellowship graduates.

RESULTS

Of 946 respondents (48% response rate), 50% were female. The average age was 51 years (range, 29-88 years); 63% were employed by an academic center/hospital, and 85% provided direct patient care; and 18% were not current PID practitioners. Of the 138 (21%) respondents who had completed a PID fellowship within the previous 5 years, 83% applied for <5 PID positions; 43% reported that their first position was created specifically for them; 47% had 1 job offer, and 41% had 2 or 3 job offers; 82% were employed within 6 months; and 74% remained at the institution of their first job. Respondents who were practicing PID full-time or part-time (n = 778) indicated desiring more focused training in immunodeficiencies (31%), transplant-related care (31%), and travel/tropical medicine (28%). Overall, 70% of the respondents would "definitely" or "probably" choose PID again.

CONCLUSIONS

Most respondents were satisfied with their career choice in PID. Most of the recent fellowship graduates were employed within 6 months after training. We identified potential areas in which the PID community can focus efforts to maintain the pipeline and improve satisfaction among its physicians.

Workforce Trends and Analysis of Selected Pediatric Subspecialties in the United States

OBJECTIVE

To update pediatric subspecialty workforce data to support evidence-based legislation and public policy decisions by replicating the American Academy of Pediatrics' 1998 Future of Pediatric Education (FOPE II) workforce survey.

METHODS

A descriptive and comparative analysis of survey responses from 9950 US pediatric subspecialists who completed an electronic survey.

RESULTS

Pediatric subspecialists are working fewer hours and spending less of their time in direct patient care than they did in 1998 but the mean hours worked differs significantly according to subspecialty. Most subspecialists continue to be board-certified, white, non-Hispanic men, although the percentage who are women and from minority groups has increased. The proportion of subspecialists practicing in an academic medical center has increased since 1998. Thirty percent of pediatric subspecialists reported appointment wait times of >2 weeks and pediatric subspecialists in developmental pediatrics, endocrinology, and neurology identified much longer wait times than other subspecialists.

CONCLUSION

The demographic and practice characteristics of pediatric subspecialists have changed since the FOPE II survey and access to subspecialty care in a family's community remains a challenge. However, pediatric subspecialties are not monolithic and solutions to workforce shortages will need to take into account these differences to improve access to subspecialty care.

Illness Severity of Children Admitted to the PICU From Referring Emergency Departments

OBJECTIVES

To compare patient factors and outcomes among children admitted to PICUs from referring versus children's hospital emergency departments (EDs).

METHODS

Pediatric patients (<19 years old) admitted to PICUs from referring and children's hospital EDs from July 1, 2011 to June 30, 2013. We compared demographic and clinical factors, including severity of illness as measured by a recalibrated Pediatric Index of Mortality, version 2 score.

RESULTS

Of 80 045 children from 109 PICUs, 35.6% were admitted from referring EDs and 64.4% were admitted from children's hospital EDs. Children from referring EDs had higher illness severity (Pediatric Index of Mortality, version 2-predicted risk of mortality, 3.1% vs 2.2%, P < .001), were more likely to be mechanically ventilated within their first hour in the PICU (28.4% vs 23.4%, P < .001), and had higher observed mortality (3.3% vs 2.1%, P < .001). Once adjusted for illness severity and other confounders in a multivariable logistic regression model, there was no difference in the odds of mortality between children from referring and children's hospital EDs (odds ratio: 0.90; 95% confidence interval: 0.79 to 1.02, P = .09) CONCLUSIONS: Children transferred to PICUs from referring EDs had higher illness severity on arrival compared with children admitted from children's hospital EDs. Variations in patient selection for transfer or pretransfer treatment at referring EDs may contribute to the greater illness severity of transferred children. Referring hospitals may benefit from leveraging existing resources to improve patient stabilization before transfer.

Current Issues Affecting the Practice of Pediatric Orthopaedic Surgeons: Results of the 2014 Workforce Survey of American Academy of Pediatrics Section on Orthopaedics

INTRODUCTION

The opinions of the pediatric orthopaedic workforce are shaped by market forces, regulatory processes, and local experience. The purpose of this report is to summarize the findings of the recent Workforce Survey of the American Academy of Pediatrics (AAP) Section on Orthopaedics (SOOr). This submission has been reviewed and approved by the Board of Directors of the Pediatric Orthopaedic Society of North America (POSNA).

METHODS

In 2014, the AAP generated a survey to assess perceptions of pediatric orthopaedic surgeons about current issues that affect practice. The survey was sent to 856 POSNA and 141 AAP-SOOr members. Responses were topically organized to report current workforce composition, practice patterns, and perceptions about electronic medical records (EMRs).

RESULTS

Responses were collected from August to December, 2014, from 496 (50%) survey recipients including 83 of 141 (59%) AAP-SOOr members and 413 of 856 (48%) POSNA members. Analyses were restricted to the 397 respondents who reported that they are currently practicing pediatric orthopaedics. Nearly all of these (390/391, 100%) indicated that they provide direct patient care and work an average of 60 hours per week. Many (105/378, 28%) indicated that they would soon limit their practice or retire. A majority (299/394, 76%) indicated that they face competition in their geographic area, predominantly due to pediatric orthopaedic subspecialists (269/299, 90%). Major business changes had recently occurred or were anticipated by 21% of participants. Respondents reported that use of EMR makes them less efficient (252/397, 63%) and interferes with the patient-physician relationship (172/397, 43%).

DISCUSSION

This workforce survey suggests that pediatric orthopaedic surgeons are concerned with challenges of competition despite concurrent increasing volume and complexity of referrals. External processes such as EMR changes are perceived to negatively impact practice efficiency and satisfaction.

Parental and Pediatricians' Perception of Need for Subspecialty Training in Pediatric Emergency Medicine for Delivering Emergency Care to Pediatric Patients

The quality of pediatric emergency care may depend on the competence of the emergency department physicians. It is important to know whether parents and general pediatricians associate the quality of pediatric emergency care with the pediatric emergency medicine (PEM) training of the emergency department physicians. We designed the study to determine parental and pediatricians’ opinion and expectation in regard to this question. Most of the surveyed parents’ and pediatricians’ recognize the importance of PEM training and believed that physicians trained in PEM can provide better emergency care for children. However, 53.8% of parents, especially Spanish speaking and with Medicaid/no insurance coverage, believe that the emergency care provided for their children by general pediatricians and PEM physicians is equivalent. The results of our study could be utilized by accredited PEM planners in the creation of strategies to ensure the quality of emergency care for children population.

The Effects of Rural Residence and Other Social Vulnerabilities on Subjective Measures of Unmet Need

To determine whether self-reports of unmet need are biased measures of access to health care, the authors examine the relationship between rural residence and perceived need for physician services. They perform logistic regression analyses to examine the likelihood of reporting a need for routine preventive care and/or specialty care using data from the National Survey of Children with Special Health Care Needs. Even after controlling for factors known to be associated with evaluated need, parents of rural children were less likely to report a need for routine or specialty services. Poor children, those whose mothers had less education, and those who were uninsured in the previous year were also less likely to perceive a need for physician services. Findings suggest that rural residence and other social vulnerabilities are associated with decreased perception of need, which may bias subjective measurements of unmet need for these populations.

Current views and advances on Paediatric Virology: An update for paediatric trainees

Paediatric Virology is a bold new scientific field, which combines Paediatrics with Virology, Epidemiology, Molecular Medicine, Evidence-based Medicine, Clinical Governance, Quality Improvement, Pharmacology and Immunology. The Workshop on Paediatric Virology, which took place on Saturday October 10, 2015 in Athens, Greece, provided an overview of recent views and advances on viral infections occurring in neonates and children. It was included in the official programme of the 20th World Congress on Advances in Oncology and the 18th International Symposium on Molecular Medicine, which attracted over 500 delegates from the five continents. During the Workshop, the topics covered included the challenges of vaccine implementation against human papillomaviruses in countries under financial crisis, strategies for eradicating poliomyelitis and its 60th vaccine anniversary, as well as the debate on the association between autism and vaccination against measles, mumps and rubella. Among the non-vaccine related topics, emphasis was given to viral infections in prematurely born infants and their long-term outcomes, new paediatric intensive care management options for bronchiolitis related to respiratory syncytial virus, the clinical implications of hepatitis B virus and cytomegalovirus genotyping, the Ebola virus threat and preparedness in Paediatric Emergency Departments, oral, oropharynx, laryngeal, nasal and ocular viral infections and Merkel cell polyomavirus as a novel emerging virus of infancy and childhood. In this review, we provide selected presentations and reports discussed at the Workshop.

Early Career Experiences of Pediatricians Pursuing or Not Pursuing Fellowship Training

BACKGROUND AND OBJECTIVES

Choosing career paths can be difficult decisions for residents contemplating fellowship training. This study compares the experiences of early career pediatricians who did and did not pursue fellowships.

METHODS

We analyzed national, weighted data from pediatricians 8 to 10 years after residency (n = 842). Work environment, work-life balance, and satisfaction were compared for pediatricians who had pursued fellowship training (fellowship trained) and those who did not pursue fellowship training (generalist trained). Logistic and linear regression examined the independent effects of fellowship training while controlling for demographic differences.

RESULTS

A total of 39% of the pediatricians (328/842) pursued fellowship training. The fellowship-trained group was less likely than the generalist-trained group to spend time in direct patient care and more likely to report learning opportunities in their work environment. This group was also more likely to report an income of ≥$150,000, although no difference was found when only full-time pediatricians were examined. Generalist-trained pediatricians were more likely to work <50 hours per week, have flexibility with their schedules, and be satisfied with time spent with their own children. Pediatricians in both the fellowship-trained and generalist-trained groups generally found their work to be rewarding and were satisfied with their lives.

CONCLUSIONS

Although residents need to consider important life and career differences when contemplating fellowship training and general care, pediatricians in both groups can achieve overall life and career satisfaction.

Current pediatric rheumatology fellowship training in the United States: what fellows actually do

BACKGROUND

Pediatric Rheumatology (PR) training in the US has existed since the 1970's. In the early 1990's, the training was formalized into a three year training program by the American College of Graduate Medical Education (ACGME) and American Board of Pediatrics (ABP). Programs have been evaluated every 5 years by the ACGME to remain credentialed and graduates had to pass a written exam to be certified. There has been no report yet that details not just what training fellows should receive in the 32 US PR training programs but what training the trainees are actually receiving.

METHODS

After a literature search, a survey was constructed by the authors, then reviewed and revised with the help members of the Executive Committee of the Rheumatology Section of the American Academy of Pediatrics (AAP) using the Delphi technique. IRB approval was obtained from the AAP and Nationwide Children's Hospital. The list of fellows was obtained from the ABP and the survey sent out to 81 current fellows or fellows just having finished. One repeat e-mail was sent out.

RESULTS

Forty-seven fellows returned the survey by e-mail (58%) with the majority being 3rd year fellows or fellows who had completed their training. The demographics were as expected with females > males and Caucasians> > non-Caucasians. Training appeared quite appropriate in the number of ½ day continuity clinics per week (1-2, 71%), number of patients per clinic (4-5, 60%), inpatient exposure (2-4 inpatients per week, 40%; 5 or greater, 33%), and weekday/weekend call. Fellows attended more didactic activities than required, had ample time for research (54% 21-60/hours per week), and had multiple teaching opportunities. Seventy-seven percent of the trainees presented abstracts at national meetings, 41% had publication. Disease exposure was excellent and joint injection experience sufficient.

CONCLUSIONS

Most US PR training programs as a whole provide an appropriate training by current ACGME, American College of Rheumatology (ACR), and ABP standards in: 1) number of continuity clinics; 2) sufficient on-call activities for weekday nights and weekends; 3) joint interdisciplinary conferences; 4) electives 5) didactic activities; 6) scholarly activities; and 7) exposure to diverse rheumatology diseases. Areas of concern were uniformity & standardization of training, need for a customized PR training curriculum, more mentorship, free electives, training in musculoskeletal ultrasound, need for a hands-on OSCE certification exam and more exposure to ACGME competencies.

Perceived benefits and barriers to a career in pediatric neurosurgery: a survey of neurosurgical residents

OBJECT

Research suggests that there may be a growing disparity between the supply of and demand for both pediatric specialists and neurosurgeons. Whether pediatric neurosurgeons are facing such a disparity is disputable, but interest in pediatric neurosurgery (PNS) has waxed and waned as evidenced by the number of applicants for PNS fellowships. The authors undertook a survey to analyze current neurosurgical residents' perceptions of both benefits and deterrents to a pediatric neurosurgical career.

METHODS

All residents and PNS fellows in the United States and Canada during the academic year 2008-2009 were invited to complete a Web-based survey that assessed 1) demographic and educational information about residents and their residency training, particularly as it related to training in PNS; 2) residents' exposure to mentoring opportunities from pediatric neurosurgical faculty and their plans for the future; and 3) residents' perceptions about how likely 40 various factors were to influence their decision about whether to pursue a PNS career.

RESULTS

Four hundred ninety-six responses were obtained: 89% of the respondents were male, 63% were married, 75% were in at least their 3rd year of postgraduate training, 61% trained in a children's hospital and 29% in a children's "hospital within a hospital," and 72% were in programs having one or more dedicated PNS faculty members. The residencies of 56% of respondents offered 6-11 months of PNS training and nearly three-quarters of respondents had completed 2 months of PNS training. During medical school, 92% had been exposed to neurosurgery and 45% to PNS during a clinical rotation, but only 7% identified a PNS mentor. Nearly half (43%) are considering a PNS career, and of these, 61% are definitely or probably considering post-residency fellowship. On the other hand, 68% would prefer an enfolded fellowship during residency. Perceived strengths of PNS included working with children, developing lasting relationships, wider variety of operations, fast healing and lack of comorbidities, and altruism. Perceived significant deterrents included shunts, lower reimbursement, cross-coverage issues, higher malpractice premiums and greater legal exposure, and working with parents and pediatric health professionals. The intrinsic nature of PNS was listed as the most significant deterrent (46%) followed by financial concerns (25%), additional training (12%), longer work hours (12%), and medicolegal issues (4%). The majority felt that fellowship training and PNS certification should be recommended for surgeons treating of all but traumatic brain injuries and Chiari I malformations and performing simple shunt-related procedures, although they felt that these credentials should be required only for treating complex craniosynostosis.

CONCLUSIONS

The nature of PNS is the most significant barrier to attracting residents, although reimbursement, cross-coverage, and legal issues are also important to residents. The authors provide several recommendations that might enhance resident perceptions of PNS and attract trainees to the specialty.

Impact of critical care telemedicine consultations on children in rural emergency departments

OBJECTIVES

To compare the quality of care delivered to critically ill and injured children receiving telemedicine, telephone, or no consultation in rural emergency departments.

DESIGN

Retrospective chart review with concurrent surveys.

SETTING AND PARTICIPANTS

Three hundred twenty patients presenting in the highest triage category to five rural emergency departments with access to pediatric critical care consultations from an academic children's hospital.

MEASUREMENTS AND MAIN RESULTS

Quality of care was independently rated by two pediatric emergency medicine physicians applying a previously validated 7-point implicit quality review tool to the medical records. Quality was compared using multivariable linear regression adjusting for age, severity of illness, and temporal trend. Referring physicians were surveyed to evaluate consultation-related changes in their care. Parents were also surveyed to evaluate their satisfaction and perceived quality of care. In the multivariable analysis, with the no-consultation cohort as the reference, overall quality was highest among patients who received telemedicine consultations (n=58; β=0.50 [95% CI, 0.17-0.84]), intermediate among patients receiving telephone consultation (n=63; β=0.12 [95% CI, -0.14 to 0.39]), and lowest among patients receiving no consultation (n=199). Referring emergency department physicians reported changing their diagnosis (47.8% vs 13.3%; p<0.01) and therapeutic interventions (55.2% vs 7.1%; p<0.01) more frequently when consultations were provided using telemedicine than telephone. Parent satisfaction and perceived quality were significantly higher when telemedicine was used, compared with telephone, for six of the seven measures.

CONCLUSIONS

Physician-rated quality of care was higher for patients who received consultations with telemedicine than for patients who received either telephone or no consultation. Telemedicine consultations were associated with more frequent changes in diagnostic and therapeutic interventions, and higher parent satisfaction, than telephone consultations.

Characteristics and direct costs of academic pediatric subspecialty outpatient no-show events

BACKGROUND

Clinic no shows (NS) create a lost opportunity for provider-patient interaction and impose a financial burden to the healthcare system and on society. We aimed to: (1) to determine the clinical and demographic factors associated with increased NS rates at a children's hospital's subsubspecialty clinics and (2) to estimate the direct institutional financial costs associated with NS events.

METHODS

A comprehensive database was generated from all clinic encounters for 15 subspecialty outpatient clinics (five surgical and 10 medical) between September 12, 2005 and December 30, 2010. Multivariate logistic regressions were performed to identify the variables associated with NS events. Direct costs of NS events were estimated using annual revenue for each clinic.

RESULTS

A total of 284,275 encounters and 17,024 NS events were available for analysis. Public insurance coverage (Medicaid and Title V), compared to private insurance or self-pay status, was associated with an increased likelihood NS (OR 2.19, 95% CI 2.10-2.28, p < 0.0005 for Medicaid; OR 1.56, 95% CI 1.50-1.62, p < 0.0005 for Title V). Compared to patients 21-30 years of age, patients <12 years (OR 2.08, 95% CI 1.77-2.45, p < 0.0005) had increased likelihood of NS. Scheduled visits with medical subspecialists were more likely than surgical subspecialty visits to result in a NS (OR 1.69, 95% CI 1.63-1.75, p < 0.0005). The predicted annualized lost revenue associated with NS visits was estimated at $730,000 from the 15 clinics analyzed, approximately $210 per NS event.

CONCLUSION

Pediatric subspecialty NS events are common, costly, and potentially preventable.

Pediatric resident debt and career intentions

OBJECTIVE

To examine current levels of educational debt among pediatric residents and the relationship between educational debt and career intentions.

METHODS

Annual national random samples of 1000 graduating pediatric residents from 2006 through 2010 were surveyed. Responses were combined. We used t tests and 1-way analysis of variance to compare debt, linear regression to examine factors associated with educational debt, and logistic regression to assess the influence of debt on clinical practice goal. Response rate was 61%.

RESULTS

Three in 4 residents reported having educational debt. The mean debt (in 2010 dollars) among all residents, which included spouse's debt if married, increased 34% from $104 000 in 2006 to $139 000 in 2010. Among the subgroup who reported having any debt, the mean debt increased 24% from $146 000 in 2006 to $181 000 in 2010. Residents had varied clinical practice goals; 43% had goals that required fellowship training (subspecialty and combined primary-subspecialty) and 57% had goals not typically requiring fellowship training (primary care and hospitalist). In multivariate analyses, debt level (low, medium, high) remained an independent predictor of practice goal. Residents with medium debt (adjusted odds ratio: 1.46, 95% confidence interval: 1.16-1.84) and high debt (adjusted odds ratio: 1.51; 95% confidence interval: 1.20-1.90) had higher odds than residents with low debt of having a practice goal that does not typically require fellowship training. Other factors also had an independent association with career choice.

CONCLUSIONS

Multiple factors shape decisions about careers. Higher educational debt is one factor that may push residents toward primary care or hospitalist practice, rather than pursuing fellowship training.

Effect of communication style and physician-family relationships on satisfaction with pediatric chronic disease care

Over 8% of children have a chronic disease and many are unable to adhere to treatment. Satisfaction with chronic disease care can impact adherence. We examine how visit satisfaction is associated with physician communication style and ongoing physician-family relationships. We collected surveys and visit videos for 75 children ages 9-16 years visiting for asthma, diabetes, or sickle cell disease management. Raters assessed physician communication style (friendliness, interest, responsiveness, and dominance) from visit videos. Quality of the ongoing relationship was measured with four survey items (parent-physician relationship, child-physician relationship, comfort asking questions, and trust in the physician), while a single item assessed satisfaction. Correlations and chi square were used to assess association of satisfaction with communication style or quality of the ongoing relationship. Satisfaction was positively associated with physician to parent (p < 0.05) friendliness. Satisfaction was also associated with the quality of the ongoing parent-physician (p < 0.001) and child-physician relationships (p < 0.05), comfort asking questions (p < 0.001), and trust (p < 0.01). This shows that both the communication style and the quality of the ongoing relationship contribute to pediatric chronic disease visit satisfaction.

Private practice rates among pediatric subspecialists

OBJECTIVE

Historically, most pediatric subspecialists have conducted their clinical work in academic health centers. However, increases in the absolute numbers of pediatric subspecialists in past decades, combined with greater concentrations of children in urban and suburban settings, might result in more opportunities for pediatric subspecialists to enter private practice. Our goal was to assess the proportions of subspecialists in private practice.

METHODS

We surveyed a stratified, random, national sample of 1696 subspecialists from 5 subspecialties and assessed the ownership of their current clinical practice settings.

RESULTS

The response rate was 77%. Two-thirds of respondents (65% [n = 705]) reported that they work in academic hospitals or outpatient clinics. Compared with other subspecialists, greater proportions of neonatologists (38% [n = 92]) and critical care physicians (19% [n = 44]) reported that they work in community hospitals. Larger proportions of cardiologists (27% [n = 58]) and gastroenterologists (24% [n = 47]) reported that they work in private outpatient practices.

CONCLUSIONS

There were significant proportions of pediatric subspecialists in private practice in most of the 5 subspecialties studied. Ensuring children's access to pediatric subspecialists likely will require a robust workforce in both academic and private clinical settings. Ongoing studies of the career trajectories of pediatric subspecialists with respect to their venues of practice will be essential for future workforce planning.

Primary care pediatricians' satisfaction with subspecialty care, perceived supply, and barriers to care

OBJECTIVES

To compare satisfaction with specialty care by primary care pediatricians (PCPs), perceived barriers to care, and adequacy of specialist supply.

STUDY DESIGN

A survey of U.S. pediatricians was conducted in 2007. PCPs were asked about satisfaction with specialty care for their patients, as well as supply of specific pediatric subspecialists. Responses of rural and nonrural PCPs were compared regarding 10 potential barriers to care.

RESULTS

Most PCPs are satisfied with the quality of subspecialty care. However, they were not satisfied with wait times for appointments, and the availability of many pediatric medical subspecialties and several pediatric surgical specialties. Rural PCPs were significantly more likely to report these shortages compared with nonrural pediatricians; these included 9 of the 18 medical and 5 of the 7 surgical specialties. In addition to wait times for appointments, PCPs reported that subspecialists' nonparticipation in health insurance plans and lack of acceptance of uninsured patients were also barriers to obtaining subspecialty care for their patients.

CONCLUSIONS

PCPs provide valuable insight into access to the pediatric subspecialty workforce. This survey of PCPs raises significant concerns about the adequacy of children's access to pediatric subspecialists, especially in rural communities.

Pediatric critical care telemedicine in rural underserved emergency departments

OBJECTIVE

A disparity in access to health care exists between rural and urban areas. Although 21% of children in the United States live in rural areas, only 3% of pediatric intensivists practice in rural areas. In an attempt to address this issue, we implemented a program of pediatric critical care telemedicine consultations in rural emergency departments (EDs) and report our results.

PATIENTS AND METHODS

A prospective evaluation of pediatric critical care consultations in rural EDs was undertaken March 2006 through March 2008. A referral area with a population of 1,000,000 in 19 rural counties in Vermont and upstate New York comprised the study area.

MEASUREMENTS AND MAIN RESULTS

Sixty-three telemedicine consultations were performed in 10 rural EDs. The average number of consultations was 6.3 per site (range 2-17). Minor technical issues were identified in 18 consultations (29%). There were 12 primary diagnoses. Telemedicine was used to supervise the critical care transport team on 25 occasions (40%). Consulting intensivists made 236 specific recommendations. Consulting intensivists thought that telemedicine consultations improved patient care 89% of the time, were superior to telephone consultations 91% of the time, and provided good to very good provider-to-provider communications 98% of the time. Referring providers reported that telemedicine consultations improved patient care 88% of the time, were superior to telephone consultations 55% of the time, and provided good to very good communications 94% of the time.

CONCLUSIONS

With telemedicine, it is feasible to provide urgent subspecialty critical care for children in underserved rural EDs, improve patient care, and provide a high degree of provider satisfaction. Pediatric critical care telemedicine may help to address the disparities in the access to and the outcome of medical care between rural and urban areas.

The residency experience in pediatric otolaryngology

OBJECTIVES

To assess the residency experience in pediatric otolaryngology, determine the impact of pediatric fellowship programs on residency training, and evaluate the need for fellowship training in pediatric otolaryngology.

DESIGN

An anonymous, web-based survey of chief residents in otolaryngology.

METHODS

Respondents described their experience in pediatric otolaryngology using a 5-point Likert scale and reported their comfort levels (yes/no) with various medical and surgical issues in pediatric otolaryngology.

RESULTS

The survey was successfully completed by 70 respondents, representing a response rate of 26%. The majority of the respondents reported positive experiences with regard to the following aspects of pediatric otolaryngology training: didactics (81%), clinical research opportunities (78%), positive faculty role models (87%), career mentorship (74%), independent medical (84%) and surgical (81%) decision-making, and overall comprehensive residency experience (87%). Basic science research opportunities (50%) were reported as less available than clinical research opportunities (78%) (P = .002). Compared with other surveyed issues, a lower comfort level was reported for management of craniofacial anomalies (P < .001), excision of large lymphatic malformations (P < .001), cochlear implantation (P < .001), laryngotracheal reconstruction (P < .001), and surgical correction of velopharyngeal insufficiency (P < .001). No statistically significant difference was noted in responses based on the presence of a fellowship program at the institution.

CONCLUSIONS

The residency experience in pediatric otolaryngology is perceived as comprehensive by graduating chief residents participating in this survey. The presence of a fellowship program does not appear to negatively impact the residency experience. Based on the reported comfort levels, the management of complex issues in pediatric otolaryngology may require additional training.

A 15-year review of pediatric neurosurgical fellowships: implications for the pediatric neurosurgical workforce

OBJECT

The Accreditation Council for Pediatric Neurosurgical Fellowships (ACPNF) was established in 1992 to oversee fellowship training in pediatric neurological surgery. The present study is a review of all graduates from 1992 through 2006 to identify predictors of American Board of Pediatric Neurological Surgery (ABPNS) certification.

METHODS

Basic demographic information including sex, year of graduation from residency, residency training program, year of fellowship training, and fellowship program was collected on each graduate from each of the 22 ACPNF programs. Individuals who did not meet ACPNF requirements (39 trainees) and those currently practicing in Canada (11 individuals) were excluded. Univariate and multivariate analysis were used to identify predictors of ABPNS certification.

RESULTS

Of the 193 ACPNF graduates, 143 individuals met the criteria for analysis. Currently, 70 (49%) are ABPNS certified. There is a mean period of 5.1 +/- 2.4 years (range 2-13 years) between finishing fellowship and ABPNS certification. If those who are not expected to be sitting for the boards yet (2002-2006 graduates, 57 individuals) are removed, the rate of ABPNS certification is 66.3%. On average, 9.5 +/-3.0 (range 4-16) fellows are trained per year. There is no statistically significant relationship between fellowship or residency training program and ABPNS certification.

CONCLUSIONS

Although the present training infrastructure has the theoretical capacity to train > 20 pediatric neurosurgeons each year, this analysis suggests that current levels will provide approximately 6 ABPNS-certified pediatric neurosurgeons annually. This raises the question of the sufficiency of the future pediatric neurosurgical workforce.

Differences in characteristics among new pediatric neurology patients: the effect of a newly established private pediatric neurology practice

OBJECTIVE

To investigate changes in volume and characteristics of new patients referred when a private pediatric neurology practice (PP) opened in 2004 in an area served primarily by an academic medical center's (AMC) pediatric neurology practice.

METHODS

Retrospective analysis of medical and billing records to examine changes in volume, diagnosis, and sociodemographic factors of new patients at the AMC from July 2004 to June 2005; the PP during the same period; and the AMC during the year before.

RESULTS

One year after the PP opened, 40% more new pediatric neurology patients were seen in this area than the year before. Compared with the AMC, PP saw a greater proportion of seizures (34% vs 26%, P < .05) and headaches (32% vs 17%, P < .001), and a lesser proportion of developmental delay/musculoskeletal disorders (12% vs 19%, P < .001) and congenital/metabolic disorders (<1% vs 2%, P < .001). Fewer PP patients lived >20 miles from the practice (32% vs 64%, P < .001), and fewer had public insurance (4% vs 33%, P < .001).

CONCLUSIONS

The establishment of the PP dramatically increased the volume of new pediatric neurology patients in this area. After the PP opened, the AMC continued to care for most patients with rare diseases and fewer financial resources. Future research should examine whether the increase in volume reflects relief of pent-up demand or increased referral rates due to eased access, and should elucidate how differences in patient populations at academic and private subspecialty practices relate to access to subspecialty care and financial well-being of academic practices.

Geographic distribution of childhood diabetes and obesity relative to the supply of pediatric endocrinologists in the United States

OBJECTIVE

To determine the geographic distribution of childhood diabetes and obesity relative to the supply of US pediatric endocrinologists.

STUDY DESIGN

Estimation of observed and "index" ratios of children with diabetes (by region and division) and obesity (body mass index >/=95th % for age and sex) (by region and state) to board-certified pediatric endocrinologists.

RESULTS

At the national level, the ratio of children with diabetes to pediatric endocrinologists is 290:1, and the ratio of obese children to pediatric endocrinologists is 17,741:1. Ratios of children with diabetes to pediatric endocrinologists in the Midwest (370:1), South (335:1), and West (367:1) are twice as high as in the Northeast (144:1). Across states, there is up to a 19-fold difference in the observed ratios of obese children to pediatric endocrinologists. Under conditions of equitably distributed endocrinologist supply, variation across states would be mitigated considerably.

CONCLUSIONS

The distribution of children with diabetes and obesity does not parallel the distribution of pediatric endocrinologists in the United States, due largely to geographic disparities in endocrinologist supply. Given the large burden of obese children to endocrinologists, multidisciplinary models of care delivery are essential for the US health care system to address the needs of children with diabetes and obesity.

Effects of insurance status on children's access to specialty care: a systematic review of the literature

Background

The current climate of rising health care costs has led many health insurance programs to limit benefits, which may be problematic for children needing specialty care. Findings from pediatric primary care may not transfer to pediatric specialty care because pediatric specialists are often located in academic medical centers where institutional rules determine accepted insurance. Furthermore, coverage for pediatric specialty care may vary more widely due to systematic differences in inclusion on preferred provider lists, lack of availability in staff model HMOs, and requirements for referral. Our objective was to review the literature on the effects of insurance status on children's access to specialty care.

Methods

We conducted a systematic review of original research published between January 1, 1992 and July 31, 2006. Searches were performed using Pubmed.

Results

Of 30 articles identified, the majority use number of specialty visits or referrals to measure access. Uninsured children have poorer access to specialty care than insured children. Children with public coverage have better access to specialty care than uninsured children, but poorer access compared to privately insured children. Findings on the effects of managed care are mixed.

Conclusion

Insurance coverage is clearly an important factor in children's access to specialty care. However, we cannot determine the structure of insurance that leads to the best use of appropriate, quality care by children. Research about specific characteristics of health plans and effects on health outcomes is needed to determine a structure of insurance coverage that provides optimal access to specialty care for children.

The effect of dual training in internal medicine and pediatrics on the career path and job search experience of pediatric graduates

OBJECTIVE

To compare the job search experience and career plans of medicine-pediatrics (med-peds) and pediatric residents.

STUDY DESIGN

Annual surveys of graduating med-peds and pediatric residents were compared from 2003 and 2004.

RESULTS

The survey response rates were 58% for med-peds residents (n = 427) and 61% for pediatric residents (n = 611). Pediatric residents were more likely to be female or an International Medical Graduate. The groups were equally satisfied with their career choice and had equivalent debt. Med-peds residents were more likely to seek and accept generalist and hospitalist positions. Pediatric residents were more likely to seek subspecialty careers and research opportunities. More than 94% of med-peds residents expected to care for pediatric patients. Among residents seeking generalist positions, med-peds residents sent half as many applications to get the same number of interviews and offers as pediatric residents, were more likely to be offered their most desired position, and were more likely to accept a position in a rural area/small town. Med-peds residents had substantially greater starting salaries as hospitalists or generalists compared with pediatric residents.

CONCLUSION

Med-peds and pediatric trainees differ in their career plans, although primary care is their most popular choice. Med-peds- trained physicians have an easier job search experience and greater market valuation.

Canadian pediatric gastroenterology workforce: current status, concerns and future projections

BACKGROUND

There is concern that the Canadian pediatric gastroenterology workforce is inadequate to meet health care demands of the pediatric population. The Canadian Association of Gastroenterology Pediatric Committee performed a survey to determine characteristics and future plans of the Canadian pediatric gastroenterology workforce and trainees.

METHODS

Estimates of total and pediatric populations were obtained from the 2001 Census of Population, Statistics Canada (with estimates to July 1, 2005). Data on Canadian pediatric gastroenterologists, including clinical full-time equivalents, sex, work interests, opinions on workforce adequacy, retirement plans, fellowship training programs and future employment plans of fellows, were gathered through e-mail surveys and telephone correspondence in 2005 and 2006.

RESULTS

Canada had an estimated population of 32,270,507 in 2005 (6,967,853 people aged zero to 17 years). The pediatric gastroenterology workforce was estimated at 9.2 specialists per million children. Women accounted for 50% of the workforce. Physician to pediatric population ratios varied, with Alberta demonstrating the highest and Saskatchewan the lowest ratios (1:69,404 versus 1:240,950, respectively). Between 1998 and 2005, Canadian pediatric gastroenterology fellowship programs trained 65 fellows (65% international trainees). Twenty-two fellows (34%) entered the Canadian workforce.

CONCLUSIONS

The survey highlights the variable and overall low numbers of pediatric gastroenterologists across Canada, an increasingly female workforce, a greater percentage of part-time physicians and a small cohort of Canadian trainees. In conjunction with high projected retirement rates, greater demands on the workforce and desires to partake in nonclinical activities, there is concern for an increasing shortage of pediatric gastroenterologists in Canada in future years.

Job market survey of recent pediatric emergency medicine fellowship graduates

OBJECTIVES

The American Academy of Pediatrics Section of Emergency Medicine's Subcommittee on Administration developed a survey tool targeting recent pediatric emergency medicine (PEM) fellowship graduates to assess the current PEM job market in a variety of areas including (1) the new positions accepted, (2) perspectives of fellowship training, and (3) the relationship between PEM and general emergency medicine practice.

METHODS

The 40-question internet-based survey was developed through www.surveymonkey.com. Solicitations to PEM fellowship graduates who completed training between the years 2000 and 2005 were sent via the Section of Emergency Medicine member e-mail list as well as the PEM LISTSERV. Data collection occurred from April to May 2005.

RESULTS

Of 125 survey respondents, 89% completed a 3-year pediatrics residency plus a 3-year PEM fellowship. Offers to graduates of positions with research expectations outnumbered clinical positions, 3:2, with an average of 5 total positions offered per respondent. Thirty-four percent remained at the institution of fellowship graduation, and 71% accepted faculty appointments with medical school affiliation. Seventy percent of work time was spent on clinical duties and 10% on research. Most felt better prepared in the areas of clinical training and teaching than in the areas of research and administration. Additional general emergency medicine exposure was not desired. Half of the respondents felt that a 2-year fellowship program would have met their career goals.

CONCLUSIONS

Recent PEM fellowship graduates felt that job availability was good and were satisfied with their new positions. Respondents perceived better fellowship training in clinical and teaching aspects than in research and administration. New positions were heavily clinical and matched career goals.

Are we there yet? Distance to care and relative supply among pediatric medical subspecialties

OBJECTIVE

The objective of this study was to describe geographic proximity, quantify variation in supply, and estimate pediatric population increments that are needed to support providers across pediatric subspecialties.

METHODS

Data from the American Board of Pediatrics and the Claritas Pop-Facts Database were used to calculate subspecialty-specific straight-line distances between each zip code and the nearest board-certified subspecialist. These data sources also were used to estimate the percentage of hospital referral regions with providers and calculate physician-to-population ratios for each of 16 pediatric medical subspecialties. Coefficients of variation for the ratios were used to assess intraspecialty variation in supply across markets. Estimates of the pediatric population that is needed to support an initial or additional physician in a market were generated using subspecialty-specific ordered logit analyses.

RESULTS

The population-weighted average distance to a subspecialist ranged from 15 miles for neonatology to 78 miles for pediatric sports medicine. For most pediatric subspecialties, more than two thirds of children live within 40 miles of a certified physician. For 7 of 16 of pediatric subspecialties, fewer than one half of hospital referral regions have a provider. Coefficients of variation vary across subspecialties and are lowest for neonatology at 76% and greatest for pediatric sports medicine at 287%. Pediatric population thresholds likewise vary with a tendency toward lower thresholds for procedural specialties, such as cardiology and critical care medicine.

CONCLUSIONS

The practice locations of pediatric subspecialists parallel the geographic distribution of children in the United States, yet many hospital referral regions lack pediatric subspecialists and coefficients of variation vary widely across subspecialties. These findings suggest that either the supply of pediatric subspecialists is inadequate, pediatric subspecialists are distributed inequitably, or the market for pediatric subspecialists is larger than the hospital referral regions. Furthermore, population thresholds for many cognitive pediatric subspecialties are high; the extent to which high thresholds reflect low disease prevalence versus other factors, such as inadequate reimbursement, is not established.