Final report of the FOPE II Financing of Pediatric Education Workgroup

Some of the challenges of financing pediatric medical education are shared with all medical education; others are specific to pediatrics. The general disadvantage that funding of graduate medical education (GME) is linked to reimbursement for clinical care has uniquely negative consequences for freestanding children's hospitals because they therefore receive little Medicare GME support. This represents both a competitive disadvantage for such hospitals and an aggregate federal underinvestment in children's health care that now amounts to billions of dollars. The need to subsidize medical student and subspecialty education with clinical practice revenue jeopardizes both activities in pediatric departments already burdened by inadequate reimbursement for children's health care and the extra costs of ambulatory care. The challenges of funding are complicated by rising costs as curriculum expands and clinical education moves to ambulatory settings. Controversies over prioritization of resources are inevitable. Solutions require specification of costs of education and a durable mechanism for building consensus within the pediatric community. Pediatrics 2000;106(suppl):1256-1269; medical student education, continuing medical education, medical subspecialties, children, pediatrics, health maintenance organizations, managed care, hospital finances, children's hospitals.

Rey-Osterrieth Complex Figure Test performance in acute, chronic, and remitted schizophrenia patients

To assess visual memory disturbance in different forms of schizophrenia, we compared Rey-Osterrieth Complex Figure Test (RCF) performance in acutely psychotic, chronically psychotic, and outpatient schizophrenia patients and in a control group of acutely psychotic patients with disorders other than schizophrenia. There were no group differences on the copy condition of the RCF. The chronic schizophrenia group utilized more abnormal copying strategies, however, than the outpatient or nonschizophrenia groups. Moreover, the chronic schizophrenia group demonstrated significantly poorer recall than the outpatient or nonschizophrenia groups, and a trend toward poorer performance than the acute schizophrenia group. Both groups of inpatient schizophrenia patients were characterized by a lack of relationship between copying strategies and recall accuracy. These data suggest that (a) chronic schizophrenia patients are characterized by more severe memory impairment than are nonchronic schizophrenia patients, and (b) visual memory disturbance in chronic schizophrenia is not solely a function of encoding difficulties.

Organizational responses to managed care: issues for academic health centers and implications for pediatric programs

The health care market dynamics that supported and directed the growth and development of Academic Health Centers (AHCs) have changed dramatically in the last 10 years. AHCs are struggling to adapt to new reimbursement mechanisms and to compete effectively for limited dollars, but are constrained by administrative and governance structures that are slow to evolve. Their multiple missions, including education, research, and care for complex patients and underserved populations, are at risk. Although most recognize the need for substantive reorganization, available resources and market specifics vary dramatically from one AHC to another. The current approaches to adaptation by four AHCs are described, along with some of the unique challenges confronted by academic pediatric programs.

Implementing community-based education: essential elements and recommendations

Two elements are essential for implementing community-based educational programs: a vision of how community experiences fit into the training of the health professionals of the future and a local environment that will support innovation, change, and growth. Change cannot occur unless very basic assumptions regarding medical education are challenged. What is "quality education"? Can programs oriented toward tertiary and specialty care adequately provide the training that should be the core of a 3-year general training program? Do schools and programs select and train physicians to function within the microcosm of the academic center, or do they prepare physicians to manage the country's health care needs? National consensus has had little influence over local environments. Each medical school, training program, and teaching facility must reexamine its values and its culture. Each must have a vision of the physicians of the future and a commitment to train them appropriately. The role of vision and culture in creating successful programs has been clearly described. Several key elements have been found to be consistent with success, the first being vision. Four basic principles will bring the vision to fruition: (1) preserving core values while still stimulating progress; (2) emphasizing the process by which programs are created, implemented, and changed rather than the product; (3) avoiding the "tyranny of the or," learning to be inclusive with a broad vision rather than limited to an "either-or" approach; and (4) aligning the process, management, and values in working toward envisioned progress for the future. Effective leadership is essential for a group or organization to accomplish its mission, as is an organizational structure that aligns responsibility, authority, resources, and accountability.

Stimulus configuration and context effects in perceptual organization in schizophrenia

Two studies assessed perceptual organization in schizophrenia to determine (a) whether inpatient and outpatient groups with poor premorbid schizophrenia have comparable levels of perceptual organization deficit; and (b) whether the deficit could be eliminated by task manipulations. In Study 1, inpatients demonstrated clear evidence of a perceptual organization deficit, whereas outpatients performed similarly to the control groups. In Study 2, a performance pattern that operationally defined a perceptual organization deficit was eliminated by a task manipulation thought to aid in context processing. The perceptual organization deficit is most pronounced in actively symptomatic patients with poor premorbid schizophrenia, and the deficit reflects, in part, deficient top-down influences to basic perceptual processes.

Stimulus configuration and context effects in perceptual organization in schizophrenia

Two studies assessed perceptual organization in schizophrenia to determine (a) whether inpatient and outpatient groups with poor premorbid schizophrenia have comparable levels of perceptual organization deficit; and (b) whether the deficit could be eliminated by task manipulations. In Study 1, inpatients demonstrated clear evidence of a perceptual organization deficit, whereas outpatients performed similarly to the control groups. In Study 2, a performance pattern that operationally defined a perceptual organization deficit was eliminated by a task manipulation thought to aid in context processing. The perceptual organization deficit is most pronounced in actively symptomatic patients with poor premorbid schizophrenia, and the deficit reflects, in part, deficient top-down influences to basic perceptual processes.

Family psychosocial screening: should we focus on high-risk settings?

The objective of this study was to address the question of whether or not psychosocial screening should be focused on "high-risk" populations. A cross-sectional survey of mothers of young children was conducted in various clinics: 758 in teaching clinics, 444 in private practices, and 202 at a military clinic. The self-administered questionnaire covered demographic factors, problems in mothers family of origin, maternal depression, and substance abuse. Mothers in the teaching clinics were younger and had less education and lower incomes than mothers in private practices, with intermediate levels in the military clinic. However, a substantial proportion of mothers seen in all sites reported psychosocial problems. Approximately 20% of mothers in all sites reported a family history of alcoholism. Positive screens for maternal depression ranged from about 15% to 35%. Binge drinking was reported by 10% to 20% at different sites. Psychosocial problems were common even among families seen in "low-risk" settings. Focusing screening only on high-risk clinics would miss many families with psychosocial problems.

The changing role of academic health care centers in generalist education and practice support

Academic medical centers have been more compatible with the training and support of specialist and subspecialist physicians than that of their generalist colleagues. To meet the increasing demand for well-prepared generalist physicians, academic centers must change the manner in which they discharge their traditional missions of patient care, education, and training. This will require alteration of their organizational structures, changes in the allocation of resources, and an evolution of the culture of academic medicine toward one that is supportive of generalist education and practice. This paper discusses 1) the present organizational, structural, and cultural elements of the academic health care center that are inadequate for that goal; 2) a model for reorganizing academic health care centers to best achieve that goal; and 3) educational programs and technologies that promise to address the continuing educational needs of generalists.

Immunization status and reasons for immunization delay among children using public health immunization clinics

OBJECTIVES

To determine whether children attending our local health department clinics were being immunized in a timely manner, and to investigate the reasons for children not being immunized on schedule.

DESIGN

Cross-sectional research design.

SETTING

Five Salt Lake City/County Health Department immunization clinics in Utah.

PARTICIPANTS

All patients presenting to the clinics for immunization from November 1990 to March 1991 when minor illness is prevalent.

INTERVENTIONS

Data were gathered through interview and questionnaire.

MEASUREMENTS/MAIN RESULTS

Children were mostly white; they came from two-parent households with reasonably high incomes and high parental education level. Only four children were denied vaccination, all for inappropriate timing. None were denied for illness. More than 75% had postponed bringing their children in for immunization. The most common reason given for delay was minor illness in the child.

CONCLUSION

Even in this "low-risk" population, parental misperception regarding immunizations is a significant, contributing factor to low immunization rates. Public educational programs directed at increasing parental knowledge must be developed.

Effects of time-in-clinic, clinic setting, and faculty supervision on the continuity clinic experience

STUDY OBJECTIVE

To evaluate the effects of setting, type of supervision, and time in clinic on the resident continuity clinic experience.

DESIGN

Prospective cohort with preintervention and postintervention measures.

SETTINGS

Pediatric residents selected one of three clinic settings for their continuity clinic experience. These included a traditional, university-based clinic, private practice offices, and publicly funded community-based clinics.

SUBJECTS

All pediatric residents at the University of Utah Health Sciences Center, July 1985 through June 1991.

INTERVENTIONS

Using varied clinic sites, matching residents one or two to one with preceptors for their continuity clinic, increasing continuity clinic from 1 to 2 half-days per week.

MEASUREMENTS AND MAIN RESULTS

Residents in private offices had the most varied experience, seeing more patients, more acute care, and a broader age range of patients than residents at other sites. They were more likely both to be observed by their preceptors during patient visits and to observe their preceptors delivering care. Because the number of patients seen per session rose, increasing continuity clinic time from one to two half-days per week more than doubled the number of patients seen per week. Increased time away from hospital did not affect scores on the Pediatric In-Training Examination. While test scores were similar for incoming residents, those in private offices scored higher on the final Behavioral Pediatrics Examination (P < .05).

CONCLUSIONS

Clinic setting, time in clinic, and faculty supervision affect the quality of the continuity clinic experience. Increased time in clinic resulted in a broader exposure to patients. Residents placed in private offices had a more varied patient mix, were more closely supervised, and seemed to gain primary care skills more rapidly than residents at other sites.

Group Health Supervision Visits More Effective Than Individual Visits in Delivering Health Care Information

Preventive health care consumes a substantial amount of pediatricians' time and has been promoted as one of the most important medical functions physicians perform.1-4 The American Academy of Pediatrics (AAP) has emphasized the need for preventive health care. To assist in the delivery of child health supervision, the AAP Committee on Psychosocial Aspects of Child and Family Health has recently published guidelines recommending specific topics to be covered at each of the routine health maintenance visits.5

Despite the acceptance of recommendations for preventive child health care, the efficacy of office-based prevention strategies has not yet been proven.6 However, assessment of the literature addressing the effectiveness and costs of strategies for promoting and maintaining child health has been noted to be "more remarkable for its limitations than its findings."6

Cough variant asthma: a review of the clinical literature

Cough variant asthma is an occult form of asthma of which the only sign or symptom is chronic cough. This review examines 15 clinically oriented research articles on cough variant asthma and summarizes what is known about its frequency of occurrence, clinical presentation, diagnosis, treatment, and natural history. Cough variant asthma is a common problem among all ages that frequently goes unrecognized. Pulmonary function, as measured by spirometry, is often within normal limits. Any patient with a nonproductive, nocturnal cough lasting more than two weeks, should receive an empiric trial of bronchodilators. The natural history of cough variant asthma is variable. A significant proportion of patients followed over time develop the classic signs and symptoms of asthma, whereas for many patients, cough resolves without need for further treatment.

Resident training in community pediatricians' offices. Not a financial drain

There are numerous disadvantages to teaching ambulatory pediatrics in hospital-based clinics. The present study evaluated the economic impact on community pediatricians' practices that served as continuity experience sites for pediatric residents by using an apprenticeship model. The number of patients seen and the dollars billed by the presence of a resident, even though these preceptors provided significantly more supervision to residents than that received by residents in hospital-based clinics. Furthermore, residents billed substantial revenues for preceptor practices. This approach to teaching general pediatrics is economically viable, providing resident stipends are not dependent on fees generated by patient visits.

Implications of pregnancy for residents and their training programs

This study investigated the implications of pregnancy on residents and their training programs and how programs have planned for pregnancy disruptions compared to other employers. We received questionnaires from 236 male and female residents and their families who had experienced at least one pregnancy during their training. Results for female residents were compared with working spouses of male residents. Approximately half of the female residents reported that their programs had formal leave policies compared to 70% of the working spouses. The average amount of leave taken by residents was considerably less than that taken by the spouse group. For both groups, 35% of all pregnancies were unplanned; 19% of these without benefit of birth control. Approximately 30% of both groups said they should have timed their pregnancies differently. Female residents were more likely to perceive their pregnancies as a stressful time. Despite this greater stress, female residents were equally as unlikely as spouses of male residents to miss work for pregnancy-related causes. This study supports the need for better planning for pregnancy during residency training.

Group well-child care offers unique opportunities for patient education

By using a group process, health educators can greatly increase the cost effectiveness of well-child care. Benefits of group care, compared with traditional well-child care, include increased time for patient education, prolonged observation of parent-child interactions, the ability to observe children with their peers, and the opportunity to employ a broad variety of teaching techniques, such as role-modeling. This paper describes the author's 15 years of experience using this model, illustrating with examples the advantages of group well-child care.

Preventive health care utilization. Prenatal and the first 3 years in a Utah population

The utilization of preventive health care services prenatally and for children up to 3 years old was determined by mailed questionnaire. The parents surveyed were randomly chosen from birth records provided by the Utah Bureau of Vital Records. "Adequate use of preventive services" was defined as six prenatal visits for a full-term pregnancy and as seven well-child visits during the first 3 years of life. Responses, received from 219 (36.5%) parents, indicated only 1 percent did not utilize adequate prenatal care. Women made an average of 11.3 visits during their pregnancies; 83 percent saw their prenatal health care provider at least 10 times. Well-child visits were less adequately utilized, an average of 6.3 visits per child. Fifty-six percent made fewer than seven visits; only 23 percent made all of the nine visits recommended by the American Academy of Pediatrics. Patients who made seven or more well-child visits were more likely to have received their fourth diphtheria, pertussis, tetanus (DTP) immunization and to have health insurance policies that paid for preventive health care services. Results indicate that families use preventive services more consistently before the birth of their children than after. Use of preventive services is associated with adequate insurance coverage and results in more thorough immunization.

Influence of parental knowledge and opinions on 12-month diphtheria, tetanus, and pertussis vaccination rates

To assess the magnitude and cause of decreasing diphtheria, tetanus toxoids, and pertussis (DTP) immunization rates, a retrospective cohort study investigated the immunization status against pertussis among 1-year-old children in Utah. Questionnaires were sent to the parents of 2975 children born in June 1985. Parents were asked about each child's DTP immunization status, including the number, type, and dates of the vaccinations, reasons for or against vaccination, and their knowledge of whooping cough and the vaccine. Children were considered adequately immunized against pertussis when they had received three DTP vaccinations by their first birthday. In Utah, the lack of pertussis immunization among young children is a serious problem: greater than 30% of 1-year-old children were not adequately protected. Accurate parental knowledge about the relative risks of vaccination and illness was associated with a greater likelihood for immunization. Although some parents chose to forego the vaccination because they were concerned about its side effects, the most common reason for incomplete immunization was illness at the time the vaccination was to be given. If immunization rates are to improve, health care professionals must not only make an effort to educate the general population regarding the vaccine, but they must also ensure immediate follow-up for immunization when the procedure is delayed.

Management of neonatal jaundice

Jaundice is the most commonly encountered neonatal clinical problem; 80 percent of neonates become clinically jaundiced, while 5 percent develop serum bilirubin levels above currently recommended treatment standards. This article outlines theories about the pathophysiology of neonatal jaundice and presents a logical approach to its management. First, the health care provider must distinguish between physiologic, exaggerated and pathologic jaundice. The treatment modalities of exchange transfusion, phototherapy and cessation of nursing are discussed.

Group well-child care

Well-child care can be a positive influence on parent-child relationships when social, psychological, and emotional health are stressed. Because of its brevity, the traditional well-child visit does not offer adequate opportunities to address these issues. A group format, in which four to six parent-infant pairs meet, changes the character of the child health maintenance visit. Advantages of group visits include increased time for patient education, more active parental participation, greater time for the physician to observe parents and their children, and more reassurance for parents that they and their children are normal. Problems of group visits are those of space and scheduling. Few pediatric offices have ideal space for group visits, so many visits take place in cramped quarters. Siblings can be disruptive to the group and should be excluded. A dedicated receptionist and an efficient nurse are essential if the groups are to run smoothly. Because the visits last one to one-and-one-half hours, only one group visit can be scheduled during a half day. Although parents of varied socioeconomic and cultural backgrounds benefit from group visits, this format appears to be most acceptable to white, middle-class families. The content of group visits is somewhat dependent upon parental questions and concerns; however, the physician must be careful to include important issues that do not usually arise spontaneously. These topics usually include safety, disease prevention, and anticipatory guidance. Although group visits may not fit every practice, the format does offer to both obstetricians and pediatricians some exciting possibilities. The increased patient-provider contact and the increased patient participation help establish better rapport, better educate families about health, and hopefully, will produce better babies.

Phototherapy in full-term infants with hemolytic disease secondary to ABO incompatibility

Current guidelines for treatment of hemolytic disease of the newborn make no differentiation between ABO and Rh incompatibility. A protocol that prolonged the observation period in full-term, ABO-incompatible infants with positive Coombs' tests who were otherwise healthy was tested. Postponement of treatment made it possible to determine more accurately which infants needed phototherapy. This dramatically decreased the number of infants treated without increasing their risk of requiring exchange transfusion.

Jaundice in the full-term neonate

Hyperbilirubinemia is the most common problem experienced by the full-term infant in the immediate neonatal period. The development of jaundice was prospectively investigated in 866 newborns. Significant correlations were found between the serum bilirubin level and the method of birth, perinatal complications, blood group incompatibilities, birth weight, and method of feeding. Breast-feeding was highly related to the development of exaggerated jaundice. The most common occurrence of jaundice requiring phototherapy was in breast-feeding infants in whom no cause for the jaundice could be determined. Study findings were most compatible with a theory of relative caloric deprivation as an explanation of the increased incidence of hyperbilirubinemia found in breast-fed newborns.

Circumcision. A study of current practices

The purpose of this study was to investigate the current incidence of circumcision, the reasons governing parental decisions regarding circumcision, the immediate and later complications from the procedure, as well as genital problems occurring in uncircumcised boys. The incidence of circumcision was found not to have changed over the past five years despite the recommendations of the American Academy of Pediatrics Task Force on Circumcision. The reasons given for circumcision reflected mostly the strength of tradition, rather than a medical approach. Four per cent of newborns experienced early complications from the procedure, whereas 13 per cent experienced later, minor complications. Problems reported in uncircumcised infants were probably variants of normal. While the results of this study and evidence for discontinuing neonatal circumcision, we strongly recommend that, if physicians dissuade parents from having their infants circumcised, they must give adequate information concerning hygiene and the slow, natural separation of the foreskin from the glans.

Teaching well child care

Despite recommendations that the emphasis of the well child visit be on behavior and development, some studies indicate that pediatricians continue to spend a relatively small percentage of each well baby visit on these subjects. One factor contributing to the discrepancy between current recommendations and practice may be the way we teach residents to perform this task. In this study, we investigated and evaluated current methods for teaching well child care. Our data indicate that the content of well child care is being taught, but that problems with teaching setting, methods and frequency of supervision, and lack of formal evaluation may be among the factors which contribute to our continued inability to change the focus of well child visits.

The Winnecott "set situation". A useful tool for the pediatrician

D.W. Winnecott devised a short, simple test which he used to evaluate normal infants. In this study, we compared 9-month-old infants' behaviors elicited during the Winnecott Test (WSS), both with historical data and with their behavior during a structured separation from their mothers. We found significant correlations between the WSS, the structured separation, and historical data. This simple test can provide the practitioner with invaluable information regarding the infant, his temperamental style, and his relationship with others.

Clinical estimation of liver size in newborn infants

Liver size was measured in 100 healthy newborn infants of gestational ages 35 to 44 weeks. A mean liver span of 5.9 +/- 0.8 cm was determined in these infants by measuring the distance between the percussed upper and palpated lower liver borders along the midclavicular line. This value correlated well with measurements derived from percussing both borders (r = .8) and correlated poorly with measurements of liver projection below the costal margin (r = .55). The practice of reporting liver projection below the costal margin as a single indicator of liver size should be discouraged.

Use of Groups in Well Child Care

A controlled study was conducted to examine the use of groups for well child care in the office setting. Group visits were compared to traditional visits by assessing the efficiency, efficacy, content, and process of visits as well as patient satisfaction. The group method was efficient and required no more provider time per pair than individual visits. The group method effectively changed the process and content of the well child visits and was acceptable to the sample population. Few changes in health care utilization were found, but mothers in the experimental group completed more well child visits and sought less advice between visits than mothers in the control group. The group method offers an alternative method of care that is worthy of further investigation and implementation.

Hygienic care in uncircumcised infants

A written questionnaire was used to determine the advice pediatricians give concerning hygienic care of uncircumcised infants. A telephone survey was conducted in which new mothers were asked what they had been told about genital hygiene and how they were caring for their infants. Pediatricians' advice concerning hygiene in uncircumcised infants varied greatly. Most counseled mothers to retract the foreskin and clean the child, but few (22%) knew when this could be readily accomplished. None of the mothers of uncircumcised children had been told when the foreskin could be expected to retract, and only half had been given any advice concerning hygiene. Mothers of infants whose foreskins had been manipulated by physicians felt this practice was traumatic. Both this and the stress of caring for their infants without adequate instruction caused 40% of the mothers to state they would choose to have the next child circumcised. Recommendations for hygienic care of uncircumcised infants are given.