Ambulatory Pediatric Association Research Articles

Pediatric Injury Control in 1999: Where Do We Go From Here?

The problem of injuries to children and adolescents is not a new one. In recent years, however, interest in trauma has increased dramatically for a number of reasons. Advances in the treatment and prevention of a wide variety of acute and chronic diseases have highlighted the importance of trauma as a cause of mortality, morbidity, and disability.1 An increasingly scientific approach to injury causation over the last 2 decades has led to progressively more effective prevention programs.2 The interest of government agencies at the national level such as the Centers for Disease Control and Prevention has been accompanied by an infusion of money for both research and prevention. As a result, the scientific and academic communities have taken a greater interest in this problem, and in the last decade, a large number of important contributions have appeared.3,,4 This article addresses where we have come and where we must go to reduce further the impact of unintentional injuries on children and adolescents in our society. Self-inflicted injuries and injuries attributable to interpersonal violence are not discussed. The publication of this article in the new Journal of the Ambulatory Pediatric Association is appropriate, because additional advances primarily will come from investigators in academic centers using basic and applied science and collaborating with clinicians to address the injury problem from the point of primary, secondary, and tertiary prevention. There have been some remarkable gains in injury control over the last 2 decades. Data are limited on the true incidence of injuries as well as its consequences; we must rely primarily on mortality data to track trends over time. In the pediatric age group, unintentional injury mortality has fallen by 45.3% between 1979 and 1996 (Table 1). The largest decreases have been among those 5 to 9 years of …

Pediatric Residency Training in An Era of Managed Care: An Introduction to Proceedings of a National Conference

On May 4, 1996, a conference sponsored jointly by the Division of Medicine of the Health Resources and Services Administration and the Ambulatory Pediatric Association brought together pediatric educators from academic medical centers and managed care organizations to address the challenges and opportunities for pediatric residency training, given current trends toward increasing managed care for children. This supplement is designed to bring the issues discussed there to a broader audience of pediatricians and educators. The contributions are written by the participants of that conference, with invited commentaries to add additional perspectives on each topic. The papers were reviewed by an editorial board of leaders in pediatric education with experience in relevant areas. This introduction describes the impetus for the conference and highlights a number of critical issues facing pediatric postgraduate training that are presented in greater depth in the contributions that follow. Finally, this paper summarizes the recommendations of the conference for meeting the challenges of training pediatricians in these areas.

The pure pleasure of the process: reflections of a general pediatric researcher.

Thank you, members of the Ambulatory Pediatric Association, for bestowing this honor upon me. I cannot begin to acknowledge all of those who have contributed to this award and own a claim to a piece of it, but I also cannot avoid thanking those who have been most important to the work that led to it. First and foremost are my wife and our children. For most generalists involved in research, who do not have large blocks of time protected from clinical or educational responsibilities, much of their writing, and much of writing is rewriting and rewriting and becoming immersed in the process, often to the exclusion of other stimuli, much of this writing occurs evenings and weekends, and our families must tolerate and accommodate to this. I can not thank my family enough. Next are my mentors, without whom my career would have gone in a very different direction. The importance of mentors has been recognized since antiquity. Mentor is the name of Odysseus' best friend, in whose care he leaves his only son for 20 years when he goes off to fight in the Trojan War and struggles to get home again. This, from Homer's Odyssey, 1 the second oldest book in western civilization. At a time when diminishing numbers of trainees are choosing academic careers, the importance of mentors to academic medicine can not be overstated. I have been privileged to have a significant number of role models and mentors both early in and throughout my career. Three stand out among the many for me—Frank Oski, who picked me out as an intern, offered me inspiration and opportunity, and changed my life forever; Bob Haggerty, who introduced me as a fellow of his to the boundary world of pediatrics, public health, and the behavioral sciences—a place I …

Children at risk: we shall overcome.

Distinguished members of the Ambulatory Pediatric Association (APA) and guests, it is indeed a distinct and unique honor for me to be standing here before you accepting this most distinguished award. The almost 40 years of Armstrong lectureships have spanned a remarkable group of individuals and topic areas, which together form a history of some of the most important issues facing our children and our society over the decades. In many ways, they reflect the mission and vision of George L. Armstrong, the pediatrician whose name we use for this esteemed lectureship. Armstrong represents for us a beacon of dedication and determination toward bringing a healthier world for children in our society, to quote my introduction to the volume of collected lectureships I edited for our organization's 30th anniversary celebration. On the founding, in 1769, of the first dispensary for children in Red Lion Square in London, England, Dr Armstrong's

Comments From the Co-Editors

"It takes about 6 to 12 months to learn how to practice in an office after completing a residency in pediatrics." This common assertion has been heard so frequently as to have become almost axiomatic. It reflects what has been termed the "residency-practice training mismatch," a problem more extreme in pediatrics than in any other specialty. The effort to combat the mismatch by providing pediatrics residents "real world" experience in community settings is not new, but the movement has taken on new momentum. The Residency Review Committee Program Requirements now mandate "structured educational experiences that prepare residents for the role of advocate for the health of children within the community." Several programs nationally have led the way in developing, implementing, and evaluating models in practices, schools, and various community agencies. The conference, of which this supplement is a summary, provided a "State of the Art" review of basic and applied educational principles for residency education in community settings. The forerunner of the conference was an invitational symposium in Worcester, MA, on June 13 and 14, 1992, supported by the Maternal and Child Health Bureau. The 1992 conference brought together experienced, knowledgeable individuals from programs with education activities in their communities and served as the basis for the development of Pediatric Education in Community Settings. A Manual. The manual was supported by the Maternal and Child Health Bureau, the American Academy of Pediatrics, and the Ambulatory Pediatric Association. The 1996 national conference was designed to take place shortly after the printing of the manual, to reinforce basic elements of education—with special reference to education outside the hospital setting—and to promote active discussion and networking.

Pediatric Education in Community Settings: Where Do We Go From Here?

Pediatric education in community settings is an idea whose time has come. The board of the Johnson & Johnson Pediatric Institute recognized this reality, and they deserve great credit for bringing together this impressive group of people for what I believe to be a watershed event. The conference includes, for the first time in my experience, participants from community practice and academic societies such as the Ambulatory Pediatric Association (APA), the American Board of Pediatrics, the Association of Pediatric Program Directors (APPD), and the American Academy of Pediatrics (AAP), including members of its resident section. At least half of residency program directors are here, as are many chairs of pediatric departments in university and community hospitals. Representatives of funding agencies—the Maternal and Child Health Bureau and the Health Resources and Services Administration—are here as well; one of our speakers heads the Center for the Future of Children of the David and Lucile Packard Foundation. This conference is a pivotal event in medical education. Like those who remember another pivotal event, Woodstock '69, we will look back with nostalgia and pride and say that we were here. I consider a meeting successful if I leave with one good new idea. At this conference, we have heard many creative and provocative ideas about community-based education, and we will be thinking about them on our way home and during the next several months. One of my favorite quotations, however, is from Alfred North Whitehead: "Ideas won't keep. Something must be done about them.

Introduction

One of the ongoing objectives of the Johnson & Johnson Pediatric Institute is to provide pediatricians with practical information on issues that will improve the health of children. Each year the Board of Trustees selects a topic whose importance is just becoming clear, a topic that is not being addressed adequately in other forums or in the usual pediatric reference sources. Recent topics have included what the pediatrician can contribute toward violence prevention and how the pediatrician can thrive in the changing health care system. The Board of Trustees chose community-based education for the pediatric resident as the 1996 topic. A variety of factors, including the dramatic increase in managed care during the past few years, has led to an increasing proportion of children's care being shifted from inpatient to outpatient settings and has augmented the need for pediatrician involvement in public health and community issues. Some necessary major changes in resident education are reflected in the new Pediatric Residency Review Committee requirements and in the Pediatric Education in Community Settings. A Manual, whose sponsors or supporters included the Ambulatory Pediatric Association, the American Academy of Pediatrics, and the Health Resources and Services Administration. After the Board selected this topic for the 1996 conference, a planning committee—Errol Alden, Carol Berkowitz, Tom DeWitt, Lewis First, Alan Kohrt, and Ken Roberts—determined the structure, content, target audience, and possible faculty. Tom DeWitt and Ken Roberts, chosen as co-chairs, assumed the crucial and laborious tasks of developing the specifics of the program and of identifying the conference faculty and the invitees.

Improving participation and interrater agreement in scoring Ambulatory Pediatric Association abstracts. How well have we succeeded?

To determine whether increasing the number and types of raters affected interrater agreement in scoring abstracts submitted to the Ambulatory Pediatric Association. In 1990, all abstracts were rated by each of the 11 members of the board of directors of the Ambulatory Pediatric Association. In 1995, abstracts were reviewed by four to five raters, including eight members of the board of directors, two chairpersons of special interest groups, and 10 regional chairpersons, for a total of 20 potential reviewers. Submissions were divided into the following three categories for review: emergency medicine, behavioral pediatrics, and general pediatrics. Weighted percentage agreement and weighted kappa scores were computed for 1990 and 1995 abstract scores. Between 1990 and 1995, the number of abstracts submitted to the Ambulatory Pediatric Association increased from 246 to 407, the number of reviewers increased from 11 to 20, the weighted percentage agreement between raters remained approximately 79%, and weighted kappa scores remained less than 0.25. Agreement was not significantly better for the emergency medicine and behavioral pediatrics abstracts than for general pediatrics, nor was it better for the raters who reviewed fewer abstracts than those who reviewed many. The number and expertise of those rating abstracts increased from 1990 to 1995. However, interrater agreement did not change and remained low. Further efforts are needed to improve the interrater agreement.

1995 Annual Meeting of the Ambulatory Pediatric Association

1995 Annual Meeting of the Ambulatory Pediatric Association

1995 Annual Meeting of the Ambulatory Pediatric Association

1995 Annual Meeting of the Ambulatory Pediatric Association

Resolved: the proliferation of subspecialties is not in the best interests of general pediatrics. Ambulatory Pediatric Association debate.

Dr Nelson: The topic for the annual Ambulatory Pediatric Association debate is resolved: that the proliferation of new subspecialties is not in the best interests of general pediatrics. Dr Chesney: Let me review a few historical perspectives about pediatrics. For many years, about 9% of graduates of medical schools have gone into pediatrics and have done a variety of things as pediatricians. It turns out that about 10 schools, or 7% of our schools, have produced more than 350 pediatricians over those years, and not surprisingly, these are the largest schools, such as the University of Illinois, the University of Indiana, and the oldest schools, such as Harvard. These schools have tended to produce a larger number of pediatricians than other schools. The residents of our pediatric programs tend to settle in the state in which they took their residency or in a contiguous state in more than 65% of the cases. We come from a tradition of a relatively small number of schools producing a large number of pediatricians and a tradition of pediatricians remaining near home. The supply of pediatricians has been relatively stable for the past 12 years, at roughly 1350, plus or minus 50, residents per year, and of those 1350 American graduates, 47% immediately go into general pediatric practice, another third go into fellowships, and the remainder do other things, including chief residencies. Many of those trainees subsequently go into general pediatrics. Of the 33% of trainees who do fellowships, fully 50% go into neonatology, which is a very well-established subspecialty. One of the important things to recognize is that there is an established need for hospital-based services, which is,

From the Bedside to the Public Policy Arena: The Role of General Pediatric Research

The Ambulatory Pediatric Association is an organization dedicated to improving teaching, patient care, and research in general pediatrics. This paper addresses the task of conducting successful research in general pediatrics, often a challenging task for fellows and junior faculty beginning their careers. However, I believe general academic pediatrics has almost a unique opportunity to translate what is seen at the bedside into a research question and from there to try to use the results to affect the health of children. There are three steps in this process: finding a good idea, conducting rigorous research, and doing something with the results. PATIENT CARE AS A SOURCE OF RESEARCH IDEAS How does one come up with the "right" research idea? Fellows and graduate students find this a difficult process. I believe the best way to select a research topic is from one's patient care experience. By listening to and learning from our patients, the most important research questions become obvious. Nearly all of us started our careers as pediatricians and most of us remain practicing physicians. This means seeing patients each week, listening to the concerns of their parents, dealing with the thorny issues that arise, and scratching our heads about the unknowns and the uncertainties we face as clinicians. From this constant experience, we learn what is important. We learn which are the problems most in need of prevention, which problems need further study of their etiology and which problems are the most vexing to manage because of our inadequate knowledge.

The role of general pediatrics in an academic department.

In 1961, on completion of a chief residency in pediatrics, becoming the assistant director of the Outpatient Department at St Christopher's Hospital, Temple University, Philadelphia, Pa, was not considered by most to be a prestigious academic position. A true academician would become a neurologist, cardiologist, or some other legitimate subspecialist, was a frequent reminder. Despite these jibes, one's commitment, and even devotion, to Dr Waldo Nelson made the decision to assume this faculty position, under the mentorship of Dr Richard Olmsted, very easy to accept. Even the salary of $11000 per year seemed excessive after the lean residency years. Primary care or even ambulatory care were not common jargon in those years and we OPD [outpatient department] pediatricians found ourselves apologizing and defending our positions. 1 The first meeting of the Ambulatory Pediatric Association (APA) in 1963 was held in Atlantic City, NJ, in conjunction with the American Pediatric Society

Annual Meeting of the Ambulatory Pediatric Association

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In Reply: `Ivory Tower' Fellowship Statement Challenged

I would like to respond to Dr Newhart's question about who authored the Statement on Pediatric Fellowship Training. It was written by the Federation of Pediatric Organizations and approved by the Executive Committees/ Boards of each of the organizations represented on the Federation. These include the Ambulatory Pediatric Association, the American Academy of Pediatrics, the American Board of Pediatrics, the American Pediatric Society, the Association of Medical School Pediatric Department Chairmen, the Association of Pediatric Program Directors, and the Society for Pediatric Research.

Serving the Underserved

Numerous obstacles stand in the way of universal access to health care. 1,2 Some of these barriers are political, and influencing them is more problematic, slow, and subject to the climate of the time. Other aspects may be addressed by increasing the pool of physicians aware of and involved in the issues of serving the underserved. The Ambulatory Pediatric Association (APA), under the leadership of Paul McCarthy, MD, began addressing the issue of serving the underserved in March 1990. A conference, cosponsored by the APA and the Bureau of Maternal and Child Health, was convened. Participants in the conference included nurses, social workers, and physicians, many of whom were chief residents in their respective training programs. These individuals were representative of different regions in our nation and cared for different populations within these regions. Participants were asked to address one aspect of the impact of underserved children on resident education.

Annual Meeting of the Ambulatory Pediatric Association

Annual Meeting of the Ambulatory Pediatric Association

Statement on Pediatric Fellowship Training

The following statement was adopted by the Federation of Pediatric Organizations in February, 1990. The Federation consists of the following pediatric organizations: Ambulatory Pediatric Association, American Academy of Pediatrics, American Board of Pediatrics, American Pediatric Society, Association of Medical School Pediatric Department Chairmen, Association of Pediatric Program Directors, Society for Pediatric Research. The Federation supports the concept that "the principal goal of fellowship training should be the development of future academic pediatricians." Graduates of pediatric fellowship programs usually work in academic centers with significant time set aside for research. Some fellowship-trained pediatricians, particularly neonatologists, allergists, and neurologists, may not work in hospitals or ambulatory settings that are associated closely with academic programs. Fellowship-trained pediatricians in all settings should be encouraged to continue their interest in research to add to the body of pediatric knowledge. To achieve the goal of training pediatric scientists, the following guidelines for fellowship education are recommended: 1. Upon completion of a pediatric fellowship, the trainee should be proficient in clinical care, teaching, and research. Fellowship training should prepare a pediatrician to care for children with complex illnesses within his/her area of special expertise and to serve as a consultant for the general pediatrician. In addition, the fellowship-trained pediatrician should be responsible for the education of pediatric residents and the continuing education of practicing pediatricians. For this reason, fellowship training should include interpersonal skills and pedagogical techniques. 2. Research training should begin as soon as possible; premedical students, medical students, and pediatric residents should be encouraged strongly to participate in meaningful research, and research activities should be carried out throughout fellowship training.

AMBULATORY PEDIATRIC ASSOCIATION

The Ambulatory Pediatric Association (APA) held its 34th annual meeting in Seattle, Washington from May 2 to 5, 1994.1 Registrants participated in 31 workshops and 18 special interest groups. The Association of Ambulatory Pediatric Services held its first meeting in Swampscott, Massachusetts on May 2, 1960.2 Thirty-two pediatricians attended, most of whom were directors of pediatric outpatient departments (OPDs). The first Association of Ambulatory Pediatric Services scientific meeting was held at the Traymore Hotel in Atlantic City, New Jersey on May 3, 1961. Five of ten papers submitted were presented in one evening session. This essay describes the remarkable story of four decades of the APA and how this organization of over 1500 members became the recognized voice of ambulatory academic pediatrics.

Annual Meeting of the Ambulatory Pediatric Association

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