More than a decade has passed since the American Academy of Pediatrics (AAP) Task Force on Pediatric Education labeled the training provided by many residency programs in the biosocial and developmental aspects of pediatrics as 'inadequate.' [1] Past deficiencies of residency training specifically in school-related problems have been well-documented . [2] Evidence that training programs have increased emphasis in development pediatrics and school health since the Task Force report has been mixed. [3,4]
Nevertheless, regional data indicate a high proportion of pediatricians engage in some form of school health activity. Involvement with schools is a logical response to patients' demands for service and the 'new morbidity' that effects learning and behavior of children. [5] Special education legislation, categorical and comprehensive school health education, and school-based primary health care are among issues that recently have increased physician interest in school health. Creation of an AAP Section on School Health reflects this interest.
SURVEY IMPLEMENTATION
This survey measured the self-reported school health training and practice activities, and continuing education preferences of a national sample of pediatricians. Survey questions addressed are: 1) What proportion of a national sample of pediatricians report doing school health, 2) what school health activities are most commonly engaged in by pediatricians, 3) does training/education during pediatric residency influence doing school health later, and 4) what is the extent of residency education in school health according to reports of graduates of residency programs?
A questionnaire, available from the authors on request, was mailed to 2,245 pediatricians who comprised a nationwide 10% random sample of the AAP membership. A second mailing was sent to those not responding to the first questionnaire. Eight questionaires were not deliverable. Responses were analyzed used SPSS-X. Frequency distributions and cross-tabulations were used. Chi-square analyses were used to test significance of proportional differences between groups.
SURVEY RESULTS
The survey was received by 2,237 pediatricians and returned by 1,068 (48%). The following tables describing survey results indicate varying Ns, depending on response to specific questions. The data in Tables 1 and 2 show the distribution of respondents by year of completion of residency and subspecialty. Seventy-eight percent report primary involvement with direct patient care. Approximately two-thirds finished residency training before 1978. Most were general pediatricians who practiced in urban settings (urban 55%, suburban 35%, rural 11%).
School Health Activities
Most (77%) of all graduate pediatricians reported some involvement with school health. Seventy-five percent participated in some form of clinical school health activity and 21% have served on professional organization school health committees, advisory committees to schools, or have been elected school board members.
Performance of school-based, preathletic examinations was the most common school health activity after completion of residency (Table 3). Pediatricians surveyed usually were not paid for their school health services. General pediatricians were more likely to be paid than subspecialists. Twenty percent of respondents reported payment for sports-related activities and 25% were paid for activities unrelated to athletics. Neither lectures nor clinical experiences in school health training
Table 1
Year of Residency Completion
N %1967 and earlier 270 28.71968 - 1977 345 28.71978 and later 327 34.7 942 100
Table 2
Subspecialty Area
N %General pediatrics 615 60Adolescent medicine 20 2Allergy 47 5Cardiology 21 2Developmental-behavioral 53 5Hematology-oncology 15 1Perinatology-neonatology 73 7Surgey 19 2Other 167 16 1,030 100
Table 3
Reported School Health Activities in Pediatric Practice
N = 971
N %1. School-based preparticipation exams for student athletes 539 562. Game/event physician 221 233. Consultant to physical education programs 99 104. Reviewed student health curriculum for content/accuracy 130 135. Conducted student health instruction 209 226. Consultant to special education placement for students 248 267. School-based evaluation of children for special education 104 118. Consultant to school district employeehealth services 54 69. Consultant to school site health promotion program 76 810. Conducted faculty inservice 196 2011. Provider of school-based primary care (school-based clinic) 76 812. Member of local/state advisory committee in school health/health education 117 1213. Member of American Academy of Pediatrics or medical society school health committee 97 1014. School board member 40 415. Other 81 8
influenced receipt of payment for school health activities.
Pediatricians from rural areas are more likely to report school health activities (p < .02) than those practicing in suburban or urban areas. Rural pediatricians are more involved with schools in consultation and service areas, but do not serve more frequently as members of school health committees or boards. Their higher level of participation was statistically significant (p < .05) with activities that involve special education and sports medicine.
Pediatricians with developmental/behavioral and adolescent medicine subspecialties and those in general practice were most often involved in school health activities.
Resident Education is School Health
Nineteen percent reported their residency training programs offered clinical or didactic education in school health. This result is consistent with the 21% who indicated participation in school health residency training by listing both lectures and practical experience that were included under the rubric of school health. When school health residency training was offered, it was required 51% of the time. School health training was more commonly presented during a block rotation (57%), than as a longitudinally, weekly experience over several months (43%). Training in school health was offered more frequently during the PL-2/PL-3 years (59%/56%) than during the PL-1 year (31%).
Types of school health residency training experiences of all respondents are listed in Table 4. Learning and attention deficit disorders were topics covered most frequently in lectures. Performance of preathletic participation examinations were the most common clinical experiences in school health during residency. When responses were analyzed according to the training of individual pediatricians, 34% reported receiving lectures and 28% acknowledged clinical school health experience.
Pediatricians who have completed residency since 1978 are more likely to report residency training in school health (Table 5). This number still represents a small percentage (25%) of recent graduates.
Resident Education and Participation in School Health
Involvement in school health activities in the course of pediatric practice was correlated with self-reported residency training in school health (p < .005). Year of graduation from residency did not influence later participation in school health activities, except that earlier graduates were more involved in professional and advisory committees (p < .004). Greater participation of earlier graduates on school health committees was not reported by general pediatricians. Later participation in school health activities was not influenced by whether the residency training curriculum in school health was required or elective, or was provided as a month block or weekly longitudinal experience.
Continuing Education Preferences
A relatively small proportion of pediatricians expressed interest in continuing education about school health. Respondents indicated the most interest (43%) in additional training or education in the interpretation of psychoeducational tests. Interest exceeded 30% in only one other area, instruction about the role of school consultant (Table 6).
Active participation in school health had little effect on specific continuing education interests. The difference between those involved with school health and those not involved achived statistical significance only for systems factors and group dynamics. Twenty-two percent of those involved stated interest compared with 14% of those uninvolved. A trend emerged for those involved with school health to have a greater interest in learning more about the interpretation of psychoeducational tests (p < .06).
DISCUSSION
Physicians' roles and activities in school health have changed as management of development problems and reduction of high-rish health behaviors assumed increased importance in child health. In earlier years, school physicians spent most of their time with the control of infections disease and provision of direct medical services such as physical examination and care in emergencies. More recently, physicians involved with schools have shifted their focus to disease prevention, health promotion, and minimizing complications of health problems. [6] They have participated in health education programs and have recommended educational strategies for children with handicaps.
The traditional emphasis of residency training on hospital-based treatment of physical disease is not sufficient preparation for these new roles of physicians with schools. If pediatric residency curricula and experiences have been restructured, widespread alterations have occurred only in the past few years.
With results similar to these, Chilton [7] found that only 22% of pediatricians living in the southwest who graduated from medical school between 1962-1972 were exposed to school health during their residencies. Graham and Collins [8] found residency training directors generally agreed residents should be taught school consultation and management of learning disorders but often lacked resources to fully implement this component of the curriculum. A survey of pediatric residency training programs five years after the AAP Taks Force on Pediatric Education failed to demonstrate any trend indicating increased emphasis on training experiences in the new morbidity. [3]
This survey demonstrated that few pediatricians (about 20%) report residency training in school health, yet most (more than 70%) engage in school health activities. The high level of participation could be affected by sampling bias due to a response rate of slightly less than 50% of the sample. Similar to prior studies, those who had school health training during residency were more likely to be providing school health services. [7,9] The willingness of practitioners to assume a greater role in school health may be the result of training that arouses interest or influences self-confidence. Results also could be attributed to residency candidates with an interest in school health selecting programs that provide training in this area. If training does determine practice, having faculty expertise and a core curriculum available is probably more important than the logistics of training such as required/elective, block/longitudinal, or during PL-1/PL-2/PL-3 years.
Residency training in school health would be useful for pediatricians in almost any subspecialty. While general pediatricians and those practicing adolescent medicine and developmental pediatrics had the highest level of involvement with schools, other subspecialty groups also actively participate in school health. When a child has a handicapping condition that requires special education services, Palfrey et al [10] found it more likely the pediatric subspecialist will have been in communication with the school than the primary care physician.
This survey did not attempt to identify reasons given by practitioners for serving as school consultants. Becoming familiar with schools and community resources, getting known by a source of referrals, changing pace from the office routine, and learning about problems of school function are among the benefits to pediatricians that have been previously cited. [11] The low rate of reimbursement suggests that direct financial reward was an infrequent motivating factor.
Table 4
Residency Training in School Health
N = 970
Didactic N %Principles of consultation 93 10Physician's role in health education 141 15Learning and attention deficit disorders 311 32Sports medicine 115 12Other 23 2Clinical 107 11Served as a school consultant 107 11Taught a health education class 43 4Attended an Individual Education Plan meeting 72 7Did preathletic participation exams 221 23Other 43 4
Table 5
Training in School Health by Year of Residency Completion
N = 933
% with School HealthYear of Residency Completion N Residency TrainingPrior to 1967 39/267 151967 - 1977 55/342 161978 and later 80/324 25p <.002
[TABULAR DATA OMITTED]
Pediatricians practicing in rural areas may have greater school involvement because of more limited school system and community health professional resources. They may be less involved on school boards due to busier work schedules or because meetings of school health committees are held in metropolitan locations.
No single topic for continuing education was selected by most respondents. Because of their high level of school involvement, they may have previously achieved competency by self-study in the areas listed.
IMPLICATIONS
The striking discrepancy between the high proportion of pediatricians involved in school health activities and relative lack of training in school health during residency has important implications for pediatric education. If these results and the results of Zebal and Friedman [4] are accurate, many residency programs have recently changed their content. Still, this situation leaves many recent graduates with substantial continuing education needs.
It is now more important than ever that pediatricians understand and know how to collaborate with school systems and school health programs. Health education in school has assumed a major role in efforts to control the modern scourges of substance abuse and HIV infection. Many leading causes of morbidity in the U.S. today can be viewed primarily as educational problems: heart disease, motor vehicle accidents, tobacco-related illness, and cancer. [12] And AAP has included promotion of comprehensive health education in schools among its long-range goals. Comprehensive health services provided by school-based clinics linked to existing systems of care have been seen as one solution to financial and nonfinancial barriers to health care for children and youth. [13]
Coordination of educational and health services for children with handicaps should be learned during residency, yet only 7% of respondents attended an individual education program (IEP) meeting during their training. With passage of Public Laws 94-142 and 99-457, public schools have become a major source of medical services for children with handicaps. The AAP Committee on Children with Disabilities has called for a more comprehensive role for physicians in the supervision of medical care and related services in schools. [14] The increasing number of children in school who are dependent on medical technology should further increase the role of the pediatrician in the school setting. It is discouraging that most physicians interviewed by Palfrey et al [15] had no knowledge of their patients' special education program.
It is unlikely major changes will occur in pediatric residency training without alternative funding sources free from hospital-based service requirements. Programs funded by Title VII grants, which support residency instruction in primary care, have increased use of schools as sites for training. However, this federal support was sought by a minority of pediatric programs because of a reluctance to have resident and staff salaries financed by outside grants. [16]
Funding also is an issue for the physician in practice ecause, as this survey demonstrates, school health activities usually do not generate income. The scope and extent of physician participation would be expected to change if payment was more readily available for such services as contributing to the educational planning process for children with disabilities. Complicating physician reimbursement in this area is the anticipation that educational funding priorities are likely to shift from special education to more traditional and 'basic' academic programs. Additional expenditures could become available if comprehensive school health programs, including school-based health services, were viewed as valuable and proven to be a cost-effective method of achieving the nation's health goals for children. [17]
References
[1] Task Force on Pediatric Education. The Future of Pediatric Education. Evanston, Ill: American Academy of Pediatrics; 1978.
[2] Becker LD. Training pediatricians to serve learning disabled children and their families. Clin Pediatr. 1978;17:355-358.
[3] Weinberger HL, Oski FA. A survey of pediatric residency training programs 5 years after the Task Force report. Pediatrics. 1984;74:523-526.
[4] Zebal BH, Friedman SB. A nationwide survey of behavioral pediatric residency. J Dev Behav Pediatr. 1984;5:331-335.
[5] Burnett RD, Bell LS. Projecting pediatric practice patterns. Pediatrics. 1978;62(Suppl):625-680.
[6] Nader PR. A pediatrician's primer for school health activities. Pediatr Rev. 1982;4:82-92.
[7] Chilton LA. School health experience before and after completion of pediatric training. Pediatrics. 1979;63:565-568.
[8] Collins TR, Graham D. School health education in family medicine and pediatrics. J Fam Med. 1980;11:583-588.
[9] Novask SF, Rockowitz RJ, Zastowny T. Evaluation of training in school health for pediatricians. J Med Educ. 1978;53:837-840.
[10] Palfrey JS, Singer JD, Walker DK, Butler JA. Health and special education: A study of new developments for handicapped children in five metropolitan communities. Public Health Rep. 1986;101:379-388.
[11] Wright GF, Vanderpool N. School and pediatricians. Pediatr Clin North Am. 1981;28:643-662.
[12] Nader PR. The school health service: Making primary care effective. Pediatr Clin North Am. 1974;21:57-73.
[13] Haggerty RJ. New initiatives for children's services. Presented at New York Academy of Medicine annual health conference; New York, NY; 1989.
[14] Report of the AAP Committee on Children with Disabilities: Provision of related reviews for children with chronic disabilities. Pediatrics. 1985;75:796-797.
[15] Palfrey JS, Sarro LF, Singer JD, Wenger M. Physician familiarity with the educational programs of the special needs patients. J Dev Behav Pediatr. 1987;8:198-202.
[16] Mathieu OR, Alpert JJ. Residency training in general pediatrics. The role of federal funding. Am J Dis Child. 1987;141:754-757.
[17] Nader PR. The concept of 'comprehensiveness' in the design and implementation of school health programs. J Sch Health. 1990;60:133-138.
Jeffrey L. Black, MD, FASHA, Clinical Assistant Professor of Pediatrics, University of Texas Southwestern Medical School at Dallas, and Medical Director, Child Development Division, Texas Scottish Rite Hospital, Dallas, TX 75219; and Philip R. Nader, MD, FASHA, Professor of Pediatrics and Director; Shelia L. Broyles, PhD, Assistant Research Psychologist; and Julie A. Nelson, BS, Programmer Analyst, Child and Family Health Studies, Dept. of Pediatrics, 0927, University of California, San Diego, LaJolla, CA 92093. This article was submitted March 4, 1991, and accepted for publication April 8, 1991. This study was supported by grants from the American Academy of Pediatrics and the American School Health Association.
