Medicine Pediatrics Career Paths:
Advocacy to Improve Transitions of Care
NMPRA
October 2015
Mary R. Ciccarelli, MD
Professor of Clinical Medicine-Pediatrics
tran·si·tion
(def.)
tranˈziSH(ə)n,tranˈsiSH(ə)n/
noun;
1. the process or a period of changing from
one state or condition to another, such as
from childhood to adult life.
2. in healthcare, the process which supports
patients to move safely and seamlessly from
one health setting or provider to another.
If you don't like something, change it.
If you can't change it, change your
attitude.
- Maya Angelou
Objectives
Attendees will:
 Review career paths of medicine pediatric
physicians in U.S.
 Recognize med-peds’ role and opportunities
in transition
 Consider the charge to be agents of change
to improve transition processes
AAMC Center for Workforce Studies
 Projected 2020
shortage
 12,500 to 31,100
PCPs
 28,200 to 63,700
non-primary care
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5,100 to 12,300
medical specialists
21,00 to 31,600
surgeons
2,400 to 20,200
other specialists
The Evolution in Medical Specialties
1920’s
Generalist Physician
1930’s
Pediatrics
Internal Medicine
1940’s
Subspecialties
Subspecialties
1970’s
1990’s
Med/Peds
Family Medicine
IM/FP
Onady G. WSU.
“It’s not the strongest species that
survive, or the most intelligent, but
the most responsive to change.”
- Charles Darwin
Medicine Pediatrics Careers:
Changes in the Clinical World
 Primary care
 Academic medicine
 Subspecialty care
 Adult, Pediatrics, Both
 Hospital medicine
 Adult, Pediatrics, Both
 Other
AMA Workforce - 2013 Masterfile
Med Peds Active Physicians –
AMA 2013 Masterfile
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N= 4,396
Least over age 55 –
5.4%
Female 3rd highest –
50.9%
Practice in state of GME 5th highest – 54.4%
Growth over last 5 years 6th highest – 29%
% U.S. allopathic grads 8th highest – 83.1%
Graduating Med-Peds residents
Survey - 2003-2007
 Females - 58% in 2007
 45% in 2003, p = .01
 URM 9% - stable
 Hispanic, Black, Native American
 AMG - 83% in 2007
 95% in 2003, p < .001
 997 residents (56% response)

Chamberlain JK. J Peds, 2012.
Career choices – 2003-07
Med-Peds fellowship, n=91
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ID
Allergy
Endocrine
Adult/Peds ICU
Cardiology
Pulmonary
Rheumatology
18.7%
11%
9.9%
9.9%
7.7%
6.6%
5.5%
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Nephrology
Gen academic
Adolescent
Emerg Med
Gastroenterology
Heme-Onc
Dev-Behav
NICU
Chamberlain JK. J Peds, 2007.
Med peds graduates in
Hospital medicine
 26.4% hospitalists (n=275)
 0% fellowship
 65% both adult and pediatric

O’Toole JK. Hosp Peds, 2015.
MP Career Transitions - Factors

64% of UNC graduates 1980–2007 (n=68) had transitioned jobs
 20 graduates interviewed (29.4% eligible)
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Transitioned less likely to see both adults and children
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40% transitioned vs. 60% of non-transitioned
 Reasons - personality, work environment, lifestyle,
family, finances
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Residency experiences insufficient to predict future job
satisfaction
Work post-training necessary to find career preferences
Perceived lack of control in the workplace
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Appreciated broad training regardless of career path
Sense of regret if not seeing both adult and children
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Burns H. No Carolina Med J,2011.
Who else is in the game?
Family
Medicine
Workforce
Med peds
4,396
Petterson SM. Ann Fam Med, 2012.
Pediatrics– Career choices
 First time ABP candidates – 2014
 N=3,252
 72.3% female, 77.4% AMG
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Chief residents
Fellowships
Hospitalists
Gen peds
Other
10%
37.9%
11%
33.6%
2014 ABP Pediatric Subspecialty
Fellow Tracking n=4,273
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Neonatal
Heme/Onc
EM
Crit care
Cardiology
GI
Endo
ID
Pulmonary
Nephrology
Dev behav
Adolescent
Rheum
Child abuse
819
527
517
511
465
297
259
196
186
134
110
86
85
38
(19.2%)
(12.3%)
(12.1%)
(12.0%)
(10.9%)
(7.0%)
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Med Peds ID
10
Med Peds Rheum
8
Med Peds Endo
5
Med Peds Neph
4
Med Peds Cardio
2
Med Peds Crit Care
1
Ped Pulm/Adult ICU/Pulm 1
Internal Medicine data
 2009-11 In-Training
Exam surveys
 45% female, 48.1% U.S.
med schools
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Gen med
Hospitalist
Fellowship
Other
21.5%
9.3%
64.2%
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Cardiology
Pulm/CCM
Heme/Onc
GI
Neph
ID
Geriatrics
Endo
Rheum
What does it take to care for
teens and young adults?
National Ambulatory Medical
Care Survey 2012
http://www.cdc.gov/nchs/data/ahcd/namcs_summary/
2012_namcs_web_tables.pdf
NAMCS Ages 15-24
 166 visits/100 person years
 Gender – female 211.5, male 121.8 visits
 Race – white 188.5, black 121.8
 27.6% preventive (decrease w/age across life)
 Preventive care in males – lowest at 19.5/ 100 person yrs
c/w injury 17.7/100 person yrs
 43.4% new problem
 18.0% chronic problem routine (increase w/age)
 5.7% chronic problem flare
 4.4% pre/post-op
Canadian Community Health
Survey (CCHS) 2005
 Ages 12-24
 Use vs. non-use – having regular MD, geography
 Non-user – underweight, poor mental health
 Non-predictive of use - income, young adults with
chronic condition
 High vs. low user – young adult females, living with
spouse/children, more chronic conditions
Ryan BL. BMC Family Practice, 2011.
National Ambulatory Medical Care
Survey - 2000 to 2006
Fortuna RJ, Acad Med, 2009.
Teens and Young Adults
Key Points
1. Adolescents and young adults share similar developmental and
health issues
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2.
The health of adolescents and young adults has not improved
over the last few decades to the same degree as in younger
children
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3.
Makes sense to place them together for medical care.
Patterns of risk behavior
Prevalence of mental health problems
Changing patterns of chronic illness
Develop and evaluate models of care that improve the health
of young people
Caring for teens with chronic
illness: risky business?
Subspecialty Workforce
 U.S. population
 28% of popln are children ages 0-19
 18% have SHCN
 11,000 pediatric subspecialists
 13 pediatric subspecialists/100,000 children
 Access issues
 i.e. GI and Pulm new appts ~2 mos
 72,000 medicine subspecialists
 36 internal medicine subspecialists/100,000 adults
 Adult subspecialists likely to care for children if
nearest peds subspec > 50 miles
Jewett EA. Pediatrics 116(5) 2005.
Adolescent Medicine
 500 ABP certified practitioners
 mean age 49.6 years
 State distribution – 0-2.7 per 100,000 child
 7% practice in rural settings
 170 ABIM/ABFM certified practitioners
 66 fellows in training 2005-06

Althouse LA. J Peds, 2007.
Med-peds physicians - 2003
 73% primary care, 27% subspecialty
 Primary care n=726
 Over ¾ care for all ages
 26% care for adults with disabilities of
childhood
 56% referrals from FM, 61% referrals from pediatrics
 20% academic, 88% full-time
 Part-time - 24% women, 7% men
 Subspecialists
 8% Peds, 38% MP, 54% IM
 74% care for adults with disabilities of
childhood
 60% academic
 Part-time – 10% women, 3% men
Freed GL. Acad Med, 2005.
What are possible roles in the
transition from pediatric to adult
care?
Leadership
Agent of Change – (def.) leader who helps
members of an organization adapt to or
create organizational change.
Leaders "walk the way they talk."
They have:
 the ability to translate intention into reality
and
 to sustain it with action and behavior

Leaders: The Strategies For Taking Charge
by Warren Benis and Burt Namus
Culture of medicine
 Characterize the profession
 Language, thought processes, styles
of communication, customs, beliefs
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White coat
Doctor talk
Conceptualization of health
Specialty-related concepts
Culture of Pediatric vs. Adult
Medicine
Pediatrics
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Adult Medicine
Family-centered
Developmentally oriented
Focus on wellness
Prescriptive
Nurturing
Interdisciplinary
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Autonomy
Disease oriented
Expect disease progress
Collaborative
Self-responsibility
Multidisciplinary
Eiser C. Diabet Med 10:285–259, 1993.
The Adolescent-Young Adult
Specialist
 Requires expertise in
 Developmental model of care
 Interface between physical & mental health &
health-related behaviors
 Family and environmental interventions
 Anxiety, depression, chronic fatigue, functional
& somatizing disorders
 Interactions with peers and education systems
 Substance use and other risk behaviors
 Therapy non-adherence
 Sexuality and reproductive health

Steinbeck K. J Paeds Child Health, 2014.
AYA specialist
 Expertise in 2 different medical cultures
 Quality research that supports the
practice of adolescent and young adult
medicine
 Education of other professionals
 WHO DOES THIS SOUND LIKE TO YOU?
“I alone cannot change the
world, but I can cast a stone
across the waters to create
many ripples.”
― Mother Teresa
Pediatrician’s Role
 Provide regular health care until transfer age (18-21
yo)
 Address transition issues early and regularly
 Promote health self-management, system navigation
 Create and implement transition plan
 Work with specialists, schools, other resources
 Identify adult health providers
 Handoff with effective “handshake” to adult provider
 Follow up with youth to verify connection to the
adult system
Promoting self-management
 Include youth in the discussion of their health
and related issues starting in early school years.
 Encourage children to participate actively in
health care visits and report their concerns and
accomplishments.
 By early adolescence, set some time during each
visit aside for private discussions with the child.
 Increase private time, until the teen has
essentially private office visits with the doctor.
 In early adolescence, discuss transition-related
issues
 Education about condition, treatments and
medications, general health issues, transition and
transfer to adult health care
Adult physician’s roles
 Introduce young adults into adult system
 Promote privacy and confidentiality
 Involve family and caregivers as appropriate
 Collaborate with other providers
 Assess resources to learn about conditions and
utilize other supports
 Expand skills in management of adherence and
health concerns unique to young adults
 Consider adaptations to usual methods, i.e.
alternate scheduling options and care
coordination supports
Adult physician’s concerns
 Family involvement
 Need for family in caring for adults with ID
 Patient maturity
 Youth readiness vs. need for parental help
 System issues
 Building new relationship while dealing with
disability or end of life
 Providers' medical competency
 Need for super-specialists – i.e. spina bifida
 Patient psychosocial needs & coordination of
transition process
 Clinical time expectations

Peter NG. Pediatrics, 2009.
Promoting adherence in teens &
young adults
 Predictors of non-adherence in pediatric transplant
recipients - meta-analysis
 Major factors
 Psychiatric comorbidities
 Child responsibility for medication
 General Factors
 Inadequate regimen knowledge, depression and anxiety,
poor health-related quality of life, low social support,
substance abuse, life stress, barriers to medication
access, poor physician–patient relationship
 Specific factors - Adolescent transplant recipients –
 Increased disease frustration, poor regimen adaptation,
cognitive issues, difficulty with ingestion (e.g., number of
medications, taste), lack of parental monitoring and
involvement
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Fredericks EM. Curr Opin Organ Transplant, 2010
Attending to the vulnerable
subpopulations
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Homeless
Incarcerated
Refugees and immigrants
Rural and remote youth
Adolescent-young adult mothers
Those with limited social competencies
The Five E’s
of Change Leadership
Experiment with new approaches
Educate others about what lies ahead
Exemplify openness yourself
Empower others to control what they
can control
 Engage everyone who is affected by
the change
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The Magnetic Boss: How to Become the Boss No
One Wants to Leave, by Linda D. Henman, PhD
Six core elements
Pediatric Care
Setting
Adult Care Setting
1. Transition policy
1. Young adult privacy & consent
policy
2. Registry
2. Registry
3. Transition preparation –
readiness assessments
3. Transition preparation
4. Transition planning – written 4. Transition planning
plan
5. Transition and transfer of
care – medical summary, plan
of care
5. Transition and transfer of care
6. Transition completion
6. Transition completion
Information
Motivation
Behavior - IMB model
1. Provide effective health info re: health
behavior, condition, population.
2. Increase personal motivation and social
support.
3. Skill-train to increase self-efficacy for
performing a health behavior.
 Low income urban women in HIV risk avoidance
program - 12-16% increase in condom use
 IMB intervention - condom info, social norms and
perceived risk training, practice of condom negotiation
and procurement skills

Anderson ES. Ann Behav Med. 2006
Collaboration
 The "medical neighborhood"
 A framework for structured, reciprocal relationships
that integrate specialty care and extend the principles
of the medical home to all practicing physicians.
 Collaborative care agreement
 Outline mutual expectations for primary care and
specialists as they care for patients together.
 Preconsultation exchange between referring physician
and consultant
 Consultation
 Subsequent comanagement of patients over time

Greenberg JO et al. JAMA Int Med 2014.
Teaching others in health system
Do you want to be an Agent of
Change?
 To move with the changing world?
 To make a difference in the world?
 Because you care about …fill in the
blank…health care, medicine-pediatrics,
transition?
The best thing you can do is the right thing;
the next best thing you can do is the wrong thing;
the worst thing you can do is nothing.
-Theodore Roosevelt
Thank you!
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