American Pediatric Society Presidential Address 1996: The APS and Academic Pediatrics

Members of the Society, you have bestowed upon me the honor of serving as President of the Society for the past year. To say that I was surprised and overwhelmed by your choice would be an understatement of mythical proportions. When I conveyed this selection to my wife and my qualms about the address I would be expected to give, she pointed out that I had probably never heard a presidential address which was not applauded, regardless of its content or quality of delivery. Far from reassuring me, this only increased my determination not to be a conspicuous first in that regard.

I have chosen to expand on the topics discussed in two previous Presidential addresses to the Society. Dr. Grumbach, in his address in 1990, discussed some of the opportunities and challenges facing academic pediatrics, particularly in the area of career development⁽¹⁾. Dr. Rudolph, in his 1994 address⁽²⁾, raised a number of educational and research issues facing academic pediatrics. I should like to address these issues from the viewpoint of the role the American Pediatric Society might have in the solution of some of the problems. The American Pediatric Society is the oldest and most distinguished of the societies in academic pediatrics. It is of concern to me that it may be losing some of its identity as our annual meeting becomes a consortium of many different societies and, of more concern, that the Society is in danger of forsaking its role within academics.

Recently I received a progress report of a clinical department in Hungary. A quotation from that report⁽³⁾ would appear to express the feelings of many of us in academics right now.

The year which is now over was an “average” one. This was because it was worse than the previous one but (supposedly still) better than the forthcoming one.

I am assuming that we share the conviction that it is worth preserving an academic environment in departments of pediatrics. The conundrum is that, although the presence or absence of an academic environment is easily recognized, its individual characteristics are difficult to define. Several authors have addressed this question from different perspectives⁽⁴⁾. I believe that it is useful to attempt the description of some of these characteristics, because we may find ways to preserve some of them despite the many profound changes inevitable in academic clinical departments. It is an environment which encourages us to learn from each other, through unstructured time for informal discussions among faculty members, an environment which permits some contemplative time to organize thoughts and ideas about our teaching and research. In the past, such discussion and exchange among specialties often occurred in a clinical setting, either on rounds or at a patient's bedside. Today, in homage to the god of efficiency, specialists make rounds without much contact with other faculty, and without the opportunity for residents and students to hear lively debate about clinical management. Teaching and learning are inherently inefficient. Some administrators have suggested that we teach those topics which can be taught efficiently in a managed care environment, topics such as managing your “business,” triage, and so forth. Such suggestions are disturbing enough, but it has even been suggested that such topics be taught instead of traditional subjects aimed at providing students with the knowledge base necessary to take care of the patient's needs, not their own interests nor the interests of other parties. There are nursery services where full-time faculty are asked to provide clinical service without the presence of students, residents, and postdoctoral fellows. I submit that by whatever circuitous reasoning we arrive at such situations, it is wrong to do so. It makes the assumption that the only thing faculty taught was practice in their area as it was at that moment. But that is not what clinical teaching was about. Faculty taught students and residents how to think and how to practice medicine safely by developing a respect for the limits of their and our knowledge. I repeat, teaching and learning are inherently inefficient, and thus, difficult to accommodate within a competitive managed care environment. Because physicians in the community teaching primary care to students and residents may be in HMOs which reward physicians for minimizing services to the patient, the main message given may be how to provide cheap medicine, not quality medicine based upon correct diagnosis and treatment.

What we feared might happen to pediatrics is what has already happened to internal medicine residencies, illustrated in Figure 1, taken from the data in Institute of Medicine report 2020 VISION⁽⁵⁾. In internal medicine there has been a steady decrease in the percent of residency positions filled by USMGs and a marked increase in the percent filled by FMGs. In pediatrics, however, this fear appears groundless. Figure 2 clearly illustrates that pediatrics has seen an increase in the percent of residency positions filled by USMGs, and in the last match results of 1996, almost 80% were filled by USMGs and 97% of positions filled⁽⁶⁾. In addition, there has been a definite shift toward primary care pediatrics and away from subspecialties. In large part, this is a reflection of practice positions available. This trend is presented in Figure 3 taken from the 1996 data of the American Board of Pediatrics⁽⁷⁾.

Figure 1

The cumulative percent change in foreign medical graduates (FMG) and United States graduates (USMG) within internal medicine residency programs is presented. The data are taken from Paul Griner's article in the 1996 Institute of Medicine (IOM) report entitled 2020 Vision⁽⁵⁾.

Figure 2

(Upper panel) Cumulative percent change in USMGs and FMGs filling pediatrie residency positions from 1993 to 1996. Pediatrics presents a completely different picture compared with internal medicine residencies. (Lower panel) percent of residency positions filled by the Matching program. The data are taken from the AAMC report in theAAMC Data Book: Statistical Information Related to Medical Education⁽⁶⁾.

Figure 3

The data from the American Board of Pediatrics(ABP) Annual Report 1996 were used to construct this figure. Note the large increase in total candidates for the general pediatric Board exam and the steadily decreasing percent of subspecialists applying.

Let's turn next to academic bureaucracy and to its demands upon academic citizenship. These demands were minimal in the past, but they now comprise an enormous and growing burden for the faculty. Consider the evolution of animal research committees, human research committees, committees to consider scientific misconduct, clinical practice plan committees, and so forth. All of these activities consume faculty time, and unfortunately, fewer faculty are willing to serve. As faculty get distracted by involvement with private companies or academic related businesses, they are less willing to serve, leaving the increasing committee work to fewer faculty. At the University of Colorado Health Sciences Center there are currently 72 standing committees and no one has any idea of the number of ad hoc committees. One giant step forward would be a university practice mandating that for every new committee set up, one is discontinued. Service on committees is voluntary, to say nothing of attendance at their meetings, so that those faculty concerned only with their self-interest refuse to serve. As a spreadsheet mentality pervades universities, it is time for a look at structural overhaul which would significantly reduce the need for so much time and effort directed at areas with so little return. Academic societies could work through a central organization such as the Institute of Medicine and the appropriate government agencies to curtail the expanding bureaucracy in areas such as institutional review of human and animal research protocols.

The expanding central administration has been funded, in part, from grant indirects. Few businesses would show a constant increase in the cost of doing business as the business grew. They would expect efficiencies to accompany their increased size. Yet, since 1984, NIH indirects have remained a constant fraction of total NIH support (Fig. 4), despite a large increase in total support⁽⁸⁾. The increase in support to universities has not resulted in significant improvements in the research environment. In fact, it has been coupled with more and more charges from central administration, which must be borne on direct costs. It would be interesting to know what is used to defend an increase in indirects at a time when charges are instituted for services previously provided. To my knowledge, no senior research society in any medical discipline has addressed this issue, although the AAMC has, not surprisingly, defended this form of university support. I have no question that universities need support from the federal government, and that this is one way of getting it, but it should not be coupled with raids on grant directs. It is not clear what a single society in one specialty can accomplish in this area, but we can try. For example, if a subset of members were charged with collecting information from other members at the more than one hundred medical schools represented in our membership, we could easily establish what was charged to indirects in the past 10 years and what new charges are being levied on grant directs. Once the Society takes a position, a statement expressing our concern should be sent to the appropriate NIH officials. Whether we go beyond that to the congressmen and senators most supportive of medical research should be discussed extensively.

Figure 4

The total grant dollars from 1984 to 1993 is presented along with the percent indirects charged which has been essentially constant.

I would like to turn now to what I have termed academic citizenship and to the precarious funding of departments of pediatrics, with its attendant effects on morale. I won't discuss the funding problems since Dr. Rudolph did so in his presidential address⁽²⁾, but a moment on these issues is worth-while, because funding does affect the quality of teaching and research. Figure 5 presents the changes in the proportion of faculty salaries funded on “soft” versus“hard” money in the pediatrics department at Colorado over the last 10 years. One certainly could debate the meaning of hard and soft money but even the proportion of tenure track professors' and associate professors' salaries funded by the state has dwindled to the point of irrelevance. This is not peculiar to Colorado. Figure 6 presents a summary of the funding base for U.S. departments of pediatrics⁽⁹⁾. Please note that, at most state medical schools, the School of Medicine money is “soft” money because it derives from taxation of clinical income. Only state money and endowment are reasonably secure, but the total of these is only 14% of faculty salaries.

Figure 5

The percent of faculty salaries derived from three different sources is presented for the Department of Pediatrics, University of Colorado. It is subdivided by faculty rank and by funding source. Data kindly provided by department administrator, Mr. Dick Argys.

Figure 6

The percent funding of pediatric faculty in all U.S. medical schools from various sources is presented for the academic year 1993-1994. Data derived from AAMC Report on Medical School Faculty Salaries 1995-96⁽⁹⁾. SOM = School of Medicine.

The APS and the member societies have taken steps to encourage clinical research. Far more clinical research is now incorporated into the program, and there is support for specific small new programs to fund aspects of clinical research. But these attempts, although worthy, are not going to cause any fundamental change in support for clinical research. This led me to examine NIH and its role in this area. I am well aware that committees have been set up to look at one or another aspect of this problem. I should like to discuss primarily one question in this area, namely, where is the funding for investigator-initiated clinical research? Most of us who have served on study sections have had similar experiences. On the Human Embryology study section in the last 8-10 years only ≈10% of approved grants were funded, and most of these were resubmissions. Very few, if any, of the funded grants involved clinical research. Figure 7 presents the percent of approved grants funded by NIH institutes with highlighting of the percent for the National Institute of Child Health and Development (NICHD)⁽¹⁰⁾. It is rather striking that NICHD is in the lower end of percent of grants funded year after year. Part of the solution rests with an increase in support for NIH which was successfully defended, at least in the current budget request. But another issue rests with the allocation within NIH institutes. Funding for the one institute charged with conducting research for women and children is inadequate compared to funding of other institutes. The solution is not for the government to mandate funding for women's health or children's health initiatives which bypass NIH, but to direct new funding into this area. Figure 8 is constructed from data contained in the NIH Handbook for 1996⁽¹¹⁾. It compares three NIH institutes with NICHD. National Heart Lung and Blood Institute (NHLBI) was selected as a large institute which funds a considerable amount of pediatric research. Its budget is ≈3 times that of NICHD. National Institute on Drug Abuse (NIDA) and National Institute on Aging (NIA) were selected as institutes of approximately the same size in total budget as NICHD. Please note that the percent of total funds used for extramural support is lowest at NICHD, which leads to a lower percent of approved grants which are funded, and smaller awards, that is, less money per grant awarded. This does not appear to be due to inefficiencies, because the dollars managed per staff member is larger at NICHD than at the two institutions of comparable size.

Figure 7

The percent of approved grants funded is presented for all National Institutes of Health (NIH) for the years 1988 to 1997. Data for the National Institute of Child Health and Human Development (NICHD) is connected by a line with the data points as ⋄. Data abstracted fromThe National Institutes of Health: A Resource Guide. The Ad Hoc Group for Medical Research Funding⁽¹⁰⁾.

Figure 8

The four figures present data for four institutes, National Heart Lung and Blood Institute (NHLBI), National Institute of Child Health and Development (NICHD), National Institute on Aging (NIA) and National Institute on Drug Abuse (NIDA). The data are taken from NIH Annual Report, 1996⁽¹¹⁾.

If we examine the funding of clinical research through multicenter trials, contracts, RO1 and PPG mechanisms, using data kindly provided by Dr. Duane Alexander and his staff, we find that ≈$14 million/year were used to fund such clinical research through RO1s or PPGs and ≈$41 million/year through contracts, mandated programs, and networks. It would be interesting to know whether this distribution between investigator-initiated research and the second category is typical of NIH institutes or peculiar to NICHD. In any case, it raises the question whether this distribution is appropriate. I believe that research is essentially a creative process driven by exciting ideas, not a laborious and plodding enterprise. Perhaps that is what bothered some of us about mandated research programs generally, whether directed at the genome project or at AIDS research. To examine the return from this category of contracts and networks, I chose to look a bit more closely at the National Network since it is perhaps the most successful of the many contracts and networks in this category. The neonatal network has had 5 years of support at a rate of $4.2 million/year. The publications resulting from this support are increasing in number as the grant years progress. This is understandable because in the initial years of large programs, especially multiinstitutional programs, there is a major effort directed at organization, planning the research directives, and initiating clinical protocols. Also, it should be emphasized that publications alone cannot be used to evaluate grant productivity. It is astonishing to me, however, that NIH has no criteria to evaluate productivity of such programs. At any rate, I was provided with two different reports of the publications attributed to the network. On the list with the largest number of publications there were 17, of which at least four were not peer-reviewed but comments to the editor, and so forth. This led to 13 peer-reviewed publications derived from the $22 million invested in the program, or $1.7 million per publication. From this viewpoint it is an expensive program, especially if compared with RO1s or other investigator-initiated research. I do not have the time to address the originality or uniqueness of the studies addressed, but I think it is fair to say that many could have been carried out far less expensively, for example birth weight-gestational age-specific mortality rates, or descriptions of the frequency of infections, and so forth. More seriously, I believe there are several ethical issues, which I think need careful evaluation by NIH. One is whether it is appropriate to direct resources at obvious questions of high clinical relevance already being studied at several universities by competent fellow clinical scientists, e.g. the use of surfactant therapy or nitric oxide therapy in neonatal medicine. These were therapies introduced by investigator-initiated research. The creativity rests with the initial investigators. Why not award grants to these investigators with incorporation of other centers of their choosing to complete such studies? There are advantages to this approach. First, it could probably be done at far less cost; second, the centers involved would be selected because of the specific expertise and interest of their faculty; and third, it would involve far less intrusion by NIH staff into the research process. The latter is a cause of considerable concern for me. There is an inherent conflict of interest when NIH staff are participating as co-investigators in studies conducted under one mode of funding and not under another. Within extramural research support, investigator-initiated research rarely involves NIH administrative staff as co-investigators. One could, of course, argue that the staff are not financially rewarded for such participation, but there is no question that they are rewarded academically by their presentation of the data at meetings, by co-authorship of publications, and so forth. At this 1996 meeting of the pediatric research societies, 26 abstracts were submitted by the NICHD neonatal network. Of those 26, only the NIH staff member appears as a co-investigator on all of the studies. It is difficult for me to believe that anyone could even remember the titles of 26 abstracts, let alone contribute significantly to the execution of the studies. Thus, inherent in the contract and network mechanisms of funding are some important oversight issues for NIH to address.

The APS and the Annual Societies Meeting

In closing, I would like to address two issues: 1) the role of the APS in the annual meeting and 2) what is the role of the APS in academics.

Figure 9 presents data provided by Ms. Kathy Cannon of the APS office which I have graphed. The first panel shows that, over the last 3 years, although total attendance has increased, the APS membership represents a fairly constant 10% of those attending. The second panel demonstrates that, of the total APS membership, only 30% attend the meeting, and that figure is not improving. The figures are a bit misleading in that many of our members attend for only 1 or 2 days. There is clearly a problem with membership's interest in the meeting. In part, this is due to a focus on increasing total attendance by encouraging an “in-and-out” approach to the meeting. By that, I mean clustering subspecialty topics into 1 or 2 days, which fosters those subspecialists' coming just for that section of the meeting.

Figure 9

Data kindly provided by Ms. Kathy Cannon, Assistant Executive Director of the American Pediatric Society and the Society of Pediatric Research. The percent APS membership represents total attendance at annual meeting is ≈10% and ≈30% of APS members attend.

Learning from each other was a fundamental characteristic of this meeting in the past, but we can't do this if we meet only with our like-thinking colleagues in a subspecialty area. State of the art symposia often are not arranged to stimulate comment and criticism among the speakers. These sessions become similar to multiauthor textbooks in which half the chapters are good and the other half are mediocre. The program committee is working hard to provide a quality program, but it is the officers of the APS who must address the issue of APS identity. I know that the presidents of the Society who follow me, Dr. Johnston and Dr. Feigin, are more inventive than I and will suggest some APS-focused activities, apart from the general program.

However, we are a Society with a wealth of talent in many areas, not solely in academic research. The APS could be a potent force in addressing the most pressing questions in academics and in the broader arena of public policy as it relates to health care for children. This latter area of public policy was a challenge elegantly presented to our Society by Dr. Julius Richmond at the time of his receiving the John Howland Award⁽¹²⁾. I hope that the officers can find ways to enroll the membership in purposeful ways to work at some of the major issues confronting pediatrics. The first step is always the most difficult, but I have confidence that the officers will begin by a discussion of priorities among these issues and that the discussion will include input from a majority of the membership. For me, the APS resembles a sleeping tiger, some may say “let it sleep” and remain primarily an honorific addition to a CV. I hope the majority of the membership feel as I do, that it is time for the APS to rouse itself and address those academic and public policy issues where the Society can make a unique contribution.

My thanks to all the membership for giving me this opportunity to participate in the Society's activities.