Speaker Outlines Role of Family Medicine in Care of Children

Family physicians play an essential role in providing health care to children, and in many parts of the country, they often serve as a child's only health care provider, said a pediatric researcher during a forum here on March 29.

"Anyone who advocates for kids would be foolhardy not to think seriously about the real role family physicians play in serving the health care needs of children," said Scott Shipman, M.D., M.P.H., during a forum on the maldistribution of the child physician workforce sponsored by the AAFP's Robert Graham Center.

Unlike other specialties, family physicians are able to establish thriving practices in every part of the country, making them the most accessible specialty in the United States, said Shipman, an assistant professor of pediatrics at Dartmouth Medical School in Hanover, N.H., and a member of the American Academy of Pediatrics Committee on the Pediatric Workforce. "Family physicians tend to follow populations much more readily, and that makes sense because, in some communities, pediatrics cannot sustain a practice if there are not enough kids," he said.

There are an estimated 7.5 million children without access to pediatricians in their geographic service areas, and about 4.2 million children are more than a 30-minute drive from a pediatrician, prompting children and their parents to turn to "the more available family physician," for health care, said Shipman.

"That's why I am advocating that pediatricians and family physicians collaborate more," he said.

Shipman noted that the number of pediatricians more than doubled from 1981 to 2001, climbing from 20,000 to more than 40,000. According to some projections, the pediatric physician workforce will increase by another 60 percent during the next 20 years, far outpacing the expected child population growth rate and creating a "per capita expansion in the pediatric workforce that is very pronounced," said Shipman. By 2020, it is expected that there will be 18,000 more pediatricians than what is needed to serve the per capita workforce.

Nevertheless, rural areas -- parts of the country with fewer than 25,000 residents -- have registered few or no increases in the number of pediatricians since 1981.

"The pediatric workforce expansion over the last 20 years has not effectively eliminated inequities in regional distribution," Shipman said.

However, Shipman pointed out that family physicians are treating a declining number of children, both within their practices and as a proportion of all children. The reasons for this trend are not clear. "It could be an example of more pediatricians or family physicians seeing older adults," Shipman speculated.

He said that family physician residents also are probably treating fewer children, and thus, many are entering the medical field with little or no experience in child care. He was quick to point out, however, that "this is conjecture on my part. I don't have evidence to support that."

Interestingly, the number of pediatric resident positions offered through the National Resident Matching Program increased by 10 percent during the past decade compared to a 10-percent decline in the number of family physician resident positions offered in just the past five years. If this trend continues, the number of pediatric residents eventually will exceed those in family medicine residency programs, said Shipman.

"The data suggest there are dramatic shifts taking place in the training of the next generation of physicians," he explained. "This means we are going to have an increasingly difficult time finding physicians for underserved populations unless pediatricians change their scope of practice and their place of practice."

Shipman cited some facts about the health care coverage of children. For example, in 2004 about 21 million children ages 0-21 went without health insurance for at least part of the year. Nearly half (9 million) did not have any insurance for the entire year. In 2005, more than 12 million children were uninsured for the entire year, according to Shipman.

"We are going in the wrong direction," he asserted. The federal government spends a total of $49 billion on programs for children each year, not a large amount when you consider that the Medicare prescription drug benefit cost $40 billion during its first year, said Shipman. In the past 10 years, the State Children's Health Insurance Program, or SCHIP, cost $40 billion, according to Shipman.

"Our policy makers have the political will to add this entire new $40 billion entitlement to Medicare, but there is a lot of hand wringing about the dollars spent on SCHIP, even though that same amount covers a much broader scope of care (than the prescription drug benefit)," he said.