The FOPE II Commentary

Abstract

To the Editor—In a recent issue of Pediatrics, a subspecialty task force of the AAP offered a commentary about the Future of Pediatric Education II (FOPE II) document with regard to pediatric subspecialists. We concur with this committee that organized pediatrics should be concerned with the appropriate training of subspecialty educators, clinicians, and researchers. As recommended in the FOPE II report, there should be an ongoing process for assessing the manner in which subspecialty fellows are trained. We also strongly believe that innovative approaches are necessary for the appropriate methods to train these fellows so that they can achieve clinical skills, teaching techniques, and research training leading to subboard certification. It is noteworthy that 2 members of the FOPE II Task Force have given major addresses at annual Pediatric Academic Society meetings concerning the need for innovation in this process. Both Dr James Stockman, in his 1999 St Geme Award Address, and Dr Thomas Boat, in his 2001 American Pediatric Society Presidential Address, vigorously emphasized the need for flexibility in the education of subspecialists with differing pathways dependent on the ultimate goal of training.It should be recognized that a process is being developed to follow up the FOPE II recommendations. At least 3 specific efforts have already been accomplished. First, a new committee, the Pediatric Education Steering Committee (PESC), has been charged with carrying on the work of FOPE II and its recommendations. This committee, comprised of a representative from each of the 7 organizations that form the Federation of Pediatric Organizations, is choosing a chair. Second, the implementation of the Task Force’s recommendations regarding pediatric subspecialists was undertaken with a meeting of major subspecialty groups in March 2001 in San Diego sponsored by the Federation of Pediatric Organizations and the Association of Medical School Pediatric Department Chairs. This was an exciting meeting, and leaders of many of the pediatric subspecialty groups found areas of common interest. Third, the American Board of Pediatrics has formed a group that is reexamining the training pathways leading to eligibility for subspecialty certification to determine if changes are needed. It is unlikely, however, that certification in general pediatrics and a subspecialty can be accomplished within a 4-year period, as the Pediatrics commentary proposes. The competencies required are too extensive.Many of the issues raised by the AAP subspecialty committee were thoroughly discussed by the FOPE II Task Force and the Future of Pediatric Subspecialists Workgroup and are included in the Final Subspecialty Workgroup Report published in the November 2000 issue of Pediatrics.1 It is noteworthy that the Task Force did not detect the bias against pediatric subspecialists mentioned in the commentary. Moreover, the Task Force agreed that children with complex subspecialty problems should be taken care of by pediatric subspecialists, but until there is an adequate supply, other alternatives had to be considered.Regarding the adequacy of the pediatric subspecialty workforce, the Pediatrics commentary indicates that there are declining numbers of subspecialty trainees. It should be noted, however, that while the percentage of those who have exited residency training who went on to subspecialty fellowship training declined in the mid- to late-1990s, a reversal of this trend has recently been seen. The actual numbers of starting fellows never significantly declined throughout this period and is, in fact, higher now than 10 years ago. Nonetheless, there does appear to be a true shortage of pediatric subspecialists in the workforce, a shortage largely driven by an increase in the demand for clinical care provided by the subspecialist.The Task Force also fully realizes that the needs of other pediatric subspecialty groups, including pediatric subspecialties in other disciplines such as surgery, radiology and psychiatry, must be fully supported to provide appropriate care to chronically and severely ill children and adolescents. Encouraging greater teamwork between subspecialties and generalists does not diminish the support of the subspecialist but, by developing improved systems of care, makes best use of available pediatric subspecialists. It is important to recognize, however, that the need for more pediatric subspecialists to advance medical science and teach should not be put in a zero sum game relationship with the role of generalists and other health care providers. Collaboration among all the stakeholders in the pediatric community is the best way to understand and advocate for the needs of the subspecialty community and the patients they serve. That is the concept behind the formation of the Pediatric Subspecialty Education Committee, which answers to the Federation of Pediatric Organizations. Through this mechanism, all invested parties, such as the Pediatric Subspecialty Committee of the AAP, will have an effective voice.