Toward a Quality Workforce: Setting the Record Straight

Abstract

Assuring quality health care to all children is a challenge to the entire medical community. Working collaboratively in teams is a time-tested approach that brings together the expertise of diverse individuals. Intrinsic in the team concept is that health care is not reduced to an either-or-approach, but is all-inclusive, taking into account the physical, emotional, developmental, cultural, and psychosocial needs of the child and the family.The policy statement, “Scope of Practice Issues in the Delivery of Pediatric Health Care,”1 was developed to serve as an advocacy tool to assist when legislators, policy makers, and other stakeholders deliberate issues of nonphysician scope of practice. Although it is understandable that some would take issue with components of the statement, it is mandatory that such disagreement be founded on a truthful representation of the contents of the statement and on the facts related to education and training of physicians.Mundinger,2 in her commentary, “Toward a Quality Workforce,” mistakenly identifies the health care provided by pediatricians as solely disease-focused, and implies that pediatricians are inadequately educated about health promotion, school-related issues, home care, office-based care, and care in long-term settings. She inaccurately describes residency education as exclusively hospital-based with a focus on acutely and seriously ill children. Obviously, Dr Mundinger would readily acknowledge that pediatricians are the best trained to care for the sickest of children. What she has failed to acknowledge (or to be aware of) is that 50% of the 3 years of pediatric residency training occurs in the ambulatory setting. Residents are required to spend time in community sites, including schools, day care centers, private offices, and public health clinics. Experience in these arenas is not just the purview of nurse practitioners. Even as a resident over 30 years ago, I trained in the community, working in the welfare hotels in New York City as well as the settlement houses.Mundinger also misrepresents the information regarding malpractice suits and suggests that malpractice insurance premiums, which are higher for physicians, are a valid indicator of the potential harm that can accrue to patients from health care practitioners. I hope that Dr Mundinger will acknowledge that physicians care for children with significantly more complex problems, problems that intrinsically put both the physician and patient at greater risk for an adverse outcome.Mundinger also decries the role of telemedicine as a “supervisory method.” Telemedicine is a valuable resource that allows for consultation and advice when health care providers are not in geographic proximity. This tool has been used for years to augment one’s expertise. I would hope that Dr Mundinger would be open to the newer technologies that facilitate collaboration.Education and experience both contribute to the skill set of any clinician. There is no doubt that a pediatric nurse practitioner with 10 years of experience may be better prepared to care for some pediatric patients than a third-year medical student starting a pediatric clerkship.Nurse practitioners are a valuable resource to the entire health care community. Their work and patient care responsibilities should be determined by their skill sets, and institutions should review their credentials as they do the credentials of all practitioners. Nurses who choose to take advanced training including a clinical doctorate degree would expect that their scope of practice be different from those of their nurse practitioner colleagues without such a degree.Collaboration and dialogue will promote quality health care for all children. Let us not be trapped by the tyranny of the “or.” Teamwork, advice, and collaboration work better than fragmentation and factionalization.