Neurology by MartinArusu

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									The Future of Pediatric Education II: Pediatric Neurology
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                          The Future of Pediatric Education II
                          A Project of the Pediatric Community


                              Summary of Survey Findings:
                                 Pediatric Neurology




Sponsoring Organizations:

American Academy of Pediatrics
American Board of Pediatrics Foundation
American Medical School Pediatric
  Department Chairmen
Center for the Future of Children of The
 David and Lucile Packard Foundation
Project #MCJ379381 from the Maternal
 and Child Health Bureau
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Introduction

The FUTURE OF PEDIATRIC EDUCATION II (FOPE II) Project is a 3 year, grant- funded
initiative launched by the pediatric community in May 1996. As part of this project, key
leaders in the pediatric community are addressing the future supply and training of
pediatricians and the provision of pediatric care into the next millennium. They are
continuing the work begun with a 1978 report entitled: "The Future of Pediatric Education."

The new report, scheduled for completion in 1999, will contain recommendations that will
shape the lifelong learning process of pediatricians. Looking beyond the pediatric
workforce and training of pediatricians, the recommendations encompassed in the 1999
report will also address the role and pediatric training of nonpediatricians, the financing of
graduate medical education, and primary care and subspecialty issues.

The FOPE II Project consists of a 17-member Task Force that has ultimate responsibility
for the development of the final report. Operating under the auspices of the Task Force are
five, topic-specific workgroups:

       •   Pediatric Workforce Workgroup
       •   Pediatric Generalists of the Future Workgroup
       •   Pediatric Subspecialists of the Future Workgroup
       •   Financing GME Workgroup
       •   Education of the Pediatrician Workgroup

Each workgroup will provide an in-depth analysis of key issues under their purview. The
workgroups are charged with generating a report that will, to the extent possible, include
data-driven conclusions and recommendations for the optimal provision of pediatric care to
all infants, children, adolescents, and young adults.

An important component of the FOPE II Project has been the gathering of insights,
information, and data that will inform the deliberations of the workgroups and the Task
Force. A number of venues are being used both to provide and solicit information. One
opportunity is the Survey of the American Academy of Pediatrics (AAP) Medical and
Surgical Subspecialty Sections. Seventeen AAP medical and surgical subspecialty sections
have chosen to participate in this survey process. Several additional sections have provided
the data and information that they acquired from independent survey initiatives.
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The Survey of AAP Medical and Surgical Subspecialty Sections solicits information about
career, education, and practice issues, as well as demographic information. The surveys
have been sent to members of the AAP Section, as well as members of the appropriate
subspecialty organizations, as identified by the Section. This report summarizes the
findings from the surveys of physicians in pediatric neurology.




©1998 by the American Academy of Pediatrics. All rights reserved. No part of this publication
may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise, without prior written permission
from the publisher. Printed in the United States of America.
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Methodology

This report is based on responses that were generated from two questionnaires: a standard
questionnaire (the Workforce Survey for Child Health Care) and a pediatric neurology
questionnaire (the Pediatric Neurology Survey). The Workforce Survey for Child Health
Care was developed by the FOPE II Task Force and was designed to be applicable to most
pediatric surgical and medical specialists.

The Pediatric Neurology Survey was developed by the chairperson of the Section on
Neurology, James Riviello, MD. This questionnaire, which was mailed to neurologists
along with the standard questionnaire, included questions concerning the proportion of
patients of different age groups, common diagnostic categories of patients, how expertise
in child neurology was achieved, sources of competition, time spent with pediatric patients,
types of research, and estimates of the number of child neurologists and neurosurgeons in
the community.

The surveys were mailed to a sample consisting of all 272 members of the AAP's Section
on Neurology (Section) and the 853 US physicians who belong to the Child Neurology
Society (CNS). Five mailings of the survey went out between March and June 1998 to a
total of 947 physicians. (There was some overlap in membership between the Section and
CNS.) Each mailing contained the standard questionnaire and the pediatric neurology
questionnaire, a cover letter emphasizing the importance of the survey, and a return
envelope.

The survey had an effective sample size of 892. Fifty-five potential respondents were
excluded from the sample as it was learned that they were retired, deceased, out of the
country, did not treat children, or did not practice neurology. The final response rate was
63.2% (564 out of 892). Physicians most likely to respond belonged to both the Section
and the CNS (75.8%). Least likely to respond were those physicians who belonged only to
the Section (52.1%).
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Acknowledgments

THE FUTURE OF P EDIATRIC EDUCATION II (FOPE II) Project acknowledges the participation
of all who facilitated the development and implementation of the Pediatric Neurology
Workforce Survey for Child Health Care and this report on the survey findings. The FOPE
II Project Task Force and Workgroup members provided the overall framework for the
surveys of pediatric medical and surgical subspecialists and those non-pediatrician
physicians who provide pediatric care. The Project is grateful to the members and staff of
the American Academy of Pediatrics (AAP). Of particular note is James Riviello, MD,
AAP Section on Neurology chairperson, who wrote the questions for the pediatric
neurology questionnaire.

Sarah E. Brotherton, PhD, and Judy Karacic of the AAP Department of Research worked
diligently on construction of the survey instrument, fielding the survey, and analysis of the
results. Thomas M. Gorey, JD, of Policy Planning Associates, wrote the final report.
Angela Lipinski, AAP Department of Education, handled all aspects of the production and
distribution of this report. The FOPE II Project extends grateful thanks to the many
individuals who took time from their busy schedules to complete and return the survey. The
participation of these respondents has informed the deliberations of THE FUTURE OF
P EDIATRIC EDUCATION II Project.

The Future of Pediatric Education II Project is made possible through the support of the
following sponsoring organizations: American Academy of Pediatrics, American Board of
Pediatrics Foundation, Association of Medical School Pediatric Department Chairmen, Center
for the Future of Children of The David and Lucile Packard Foundation, and Project
#MCJ379381 from the Maternal and Child Health Bureau.

Jimmy L. Simon, MD
Project Chairperson

Russell W. Chesney, MD
Project Vice Chairperson

Errol R. Alden, MD
Principal Investigator

Holly J. Mulvey
Director
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                        Workforce Survey for Child Health Care

Demographics of Respondents

On average, the respondents were 51 years of age and planned to fully retire from the
practice of medicine at age 67; one-third plan on retiring within the next ten years. Seventy
five percent (75%) of the respondents were male and 25% were female. In terms of
ethnicity, 82% were White/Non-Hispanic, 10% were Asian/Pacific Islanders, 4% were
White/Hispanic, and the remaining 4% identified themselves as belonging to other racial or
ethnic groups.

Seventy eight percent (78%) of the respondents were graduates of U.S. medical schools,
2% were graduates of Canadian medical schools, and 20% were graduates of medical
schools in other countries. The respondents’ average year of graduation from medical
school was 1972.

Specialty, Residency Training, and Board Certification

The survey instrument asked the respondents to list the specialties and subspecialties in
which they have been trained, to specify the year they completed residency training, and to
indicate for each specialty/subspecialty listed whether they are board certified or have a
specialty certificate. Respondents could list up to three specialties/subspecialties.

Table 1 below presents a summary of the specialty, residency training, and board
certification information for those who responded to the survey. Eighty two percent (82%)
of the respondents listed child neurology as one of the specialties in which they had been
trained, while 74% listed general pediatrics and 20% listed neurology. Over 80% of those
who trained in each of these three specialties said they are board certified.

    Table 1. Residency Training and Board Certification of Survey Respondents

Specialty                           Number        Percent       Percent        Residency
                                                  of Total      Board          Completion
                                                                Certified            Year
                                                  (#)           (%)            (%)
                                    (Mean)
General pediatrics                  419           74.3          86.6           1979
Child neurology                     465           82.4          83.2           1983
Neurology                           111           19.7          82.0           1978
Clinical neurophysiology             73           12.9          93.1           1985
Neurological surgery                 25            4.4          92.0           1982
Pediatric neurological surgery       19            3.4          89.5           1992
Other                                80           14.2          N/A            N/A
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Main Practice Site

Respondents were asked to specify their main employment site; that is, the setting in which
they spend the most time. Table 2 provides a breakdown of responses for this question.
For the respondents overall, nearly one half (47%) indicated that their main practice setting
was at a medical school. The next most common practice settings mentioned were solo
practice and specialty groups.

                                                                        Table 2. Main
              Practice Site

              Main Site                               % of Respondents
                                                                 (%)
              Medical school                                47.4
              Solo practice                                 18.1
              Specialty group                               17.5
              Multispecialty group                           7.1
              Community hospital                             2.4
              HMO                                            1.9
              Pediatric group                                1.1
              Community health center                        1.1
              Uniformed health services clinic               0.6
              Other                                          2.8

When asked to describe the area in which their primary practice site is located, 45%
indicated that it is an urban--not inner city--area; 30%, urban--inner city; 19%, suburban;
and 6%, rural.

Time Spent in Professional Activities

Table 3 depicts the average percentage of time spent by pediatric neurologists in various
professional activities. On average, approximately two thirds of the total time spent per
week by pediatric neurologists in professional activities is devoted to direct patient care,
while one tenth of their time is spent in teaching. On average, the respondents said they
typically work 60 hours per week.
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        Table 3. Average Percent of Time per Week in Professional Activities

                    Professional Activity             Percentage of Time
                                                              (%)
                    Direct patient care                       67.0
                    Teaching                                   9.7
                    Administration                             8.3
                    Clinical research                          6.6
                    Basic science research                     4.2
                    Health services research                   0.2
                    Resident or fellow in training             0.3
                    Other, non-direct patient care             3.4

Over 90% of the respondents reported spending some of their direct patient care time in
pediatric neurology. On average, these respondents said they spend 87% of their total
direct patient care time in that specialty area. Approximately 5% of the respondents said
they spend some of their direct patient care time in pediatric neurological surgery; these
respondents on average spend 88% of their time in this specialty area. Almost 11%
(10.8%) of respondents reported spending some direct patient care time in primary care
pediatrics. These respondents spend almost a quarter of their direct patient care time in
primary care pediatrics (23.3%).

Referrals

Virtually all (98%) of the respondents reported that they receive referrals for pediatric
patients. Table 4 displays the source of these referrals, by specialty.

Among respondents who receive referrals for pediatric patients, over 90% said they get
referrals from pediatric generalists and family physicians; over 80%, from pediatric
medical/surgical subspecialists; and over 50% from pediatric nurse practitioners.
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          Table 4. Source of Referrals of Pediatric Patients to Neurologists

              Source of Referrals                            Percentage
                                                                (%)
              Pediatric generalists                             96.7
              Family physicians                                 90.4
              Pediatric medical/surgical subspecialists         86.0
              Pediatric nurse practitioners                     55.1
              Physician assistants                              40.4
              Adult medicine subspecialists                     33.8
              General internists                                30.9
              Obstetricians/gynecologists                             20.9
              Others                                            27.1

The respondents also were asked to report whether they receive referrals from urgent care
centers, community agencies, and school districts. Fifty nine percent (59%) of the
respondents reported that they receive referrals from urgent care centers; 68%, from
community agencies; and 70%, from school districts. Nine percent (9%) said they did not
receive referrals from any of those three sources.

Only 10% of the respondents said that their pediatric referrals come exclusively from
within their own practice or managed care network, while 77% said some of their referrals
come from sources outside of their network (13% said they were not in a network).

Among those respondents who reported that they receive referrals, 38% said that neither
the volume nor the complexity of the pediatric referrals they have received in the last
twelve months has changed compared to previously, while 62% said that either the volume,
the complexity, or both have changed.

Among those neurologists who have experienced a change in the volume or complexity of
pediatric referrals, 69% indicated that they have seen an increase in the volume of referrals,
17% said there has been a decrease in the volume of referrals, 52% said there has been an
increase in the complexity of referrals, and 7% said there has been a decrease in the
complexity of referrals. Fifteen percent (15%) said they have experienced no change in the
volume of referrals and 41% said they have experienced no change in the complexity of the
cases referred to them.
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Respondents who indicated that they have experienced a change in the volume or
complexity of pediatric referrals in the last twelve months were asked to describe the
factors to which this change could be attributed (more than one factor could be specified).
Fifty six percent (56%) of the respondents said that an increased likelihood of general
pediatricians and other generalists to treat less complex subspecialty patients has caused a
change in the volume or complexity of pediatric referrals, 44% attributed the change to a
decreased likelihood of generalists to treat more complex subspecialty patients, and 23%
cited increased competition from other pediatric subspecialists. Eighteen percent (18%)
said that increased referrals from adult subspecialists had caused a change in the volume or
complexity of pediatric referrals and 17% said an increased incidence of illness in their
community has affected referrals.

Need for Additional Training

Despite whatever changes are taking place in health care, a majority of the respondents do
not feel that the changes have resulted in a need for additional training on their part.
Seventy five percent (75%) of the respondents indicated that the changes in health care have
not necessitated additional training in primary care, and 71% said the changes have not
necessitated additional training in their subspecialty. Twenty percent (20%) of the
respondents indicated a need for a “little” additional training in primary care and 27%
expressed a need for a little additional training in their subspecialty. Only 5% of the
respondents indicated a need for “much more” training in primary care and only 2%
indicated a need for much more training in their subspecialty. Eight percent indicated that
they needed much more training in another specialty and 17% indicated they needed a little
more training in another specialty.

Competition

Seventy one percent (71%) of the respondents said they face competition for pediatric
subspecialty services in their geographical area. Among those who face competition, the
major source of competition (which was mentioned by 81% of the respondents) was other
pediatric subspecialists. (See Table 5.) The only other significant source of competition
for pediatric neurologists, which was cited by 46% of the respondents, was “physicians
trained in adult medicine in my subspecialty” (i.e., adult neurologists).
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   Table 5. Perceived Source of Competition for Pediatric Subspecialty Services

          Source of Competition                   Percentage of Neurologists Surveyed*
                                                                 (%)
          Other pediatric subspecialists                         80.9
          Physicians trained in adult                            45.9
           medicine in my subspecialty
          Family physicians                                       14.2
          General pediatricians                                   26.3
          Non-physician medical personnel                          7.5
           (eg, advanced practice nurses, chiropractors)
          Urgent care centers                                      4.1
          Related health professionals                             9.5
           (eg, psychologists, nutritionists)
          Other                                                    5.2

            * Percent of respondents who said they face competition from any source

Of those respondents who said they face competition for pediatric subspecialty services in
their geographic area, only 39% have modified their practice as a result of such
competition. Among those who have modified their practices, 48% have increased their
office hours, 35% have increased the number and/or responsibilities of support staff, and
30% have increased the number of physicians in their practice (see Table 6).

When asked whether their practice had been sold to or merged with another practice or
health care organization during the last twelve months, only 7% said “yes.”


               Table 6. Practice Modifications as a Result of Competition

   Change                                         Increased    Decreased     No Change
                                                                 (%)            (%)
   (%)
                                                     Office hours 48.3            4.1
                                                     47.6
                                                     Number/responsibilities of support
   staff                                             35.4         12.2           52.4
   Number of physicians for practice                 29.9          6.1           63.9
   Number of advanced practice nurses                23.8          6.1           70.1
   Amount of research/administrative activities      16.3         20.4           63.3
   Fees                                              10.2         10.9           78.9
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Workforce

Less than one half (42%) of the respondents said they anticipated their communities would
need additional pediatric subspecialists in the next 3-5 years. Thirty five percent (35%)
said there would be a need for more pediatric subspecialists in their discipline and 17% felt
there would be a need for additional subspecialists in other pediatric subspecialties. When
asked whether they or their employer would be hiring additional, non-replacement pediatric
subspecialists in their field in the next 3-5 years, 29% of the respondents said “yes,” 40%
said “no,” and 31% said they were unsure.

Income

Neurologists rely on a variety of payment sources for their income, but fee for service
arrangements are most common (see Table 7). One half or more of the respondents said
they receive some income from traditional or discounted fee for service, while less than
one fourth said they receive some income from prepaid, capitated, salaried arrangements.

                      Table 7. Sources of Income for Neurologists

          Source of Income                               Percentage With Income
                                                         from Each Source
                                                               (%)
          Traditional fee for service                          53.5
          Discounted fee for service                           49.6
          Salary                                               44.4
          Salary with performance incentive                    28.1
          Prepaid, capitated, nonsalaried                      30.6
          Prepaid, capitated, salaried                         23.7
          Other                                                 8.3

Table 8 provides information on the percentage of pediatric neurologists’ income that
comes from various sources. Excluding those who said they did not know the breakdown of
their total income by source, a clear majority of the respondents who said they receive
some income from traditional fee-for-service payment or capitation arrangements indicated
that these sources account for 33% or less of their total income. Among those who said
they receive some income from salaries--or salaries with performance-based incentives--
most said this source accounts for two thirds or more of their total income.
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                          Table 8. Percent of Income by Source

       Income Source                       0-33%      34-66%     67-100% Don’t Know
       Traditional fee for service         57.2       17.7        9.2    15.9
       Discounted fee for service          33.9       33.1       16.9    16.1
       Salary                              15.7        9.9       61.9    12.6
       Salary with incentive               18.9        8.8       52.7    19.6
       Prepaid, capitated nonsalaried      59.0       16.7        1.3    23.1
       Prepaid, capitated, salaried        56.6        4.9        9.0    29.5

Finally, when asked whether they have used telemedicine, fax machines or other forms of
information technology as part of a consultation with another practitioner because of lack
of ready access to appropriate subspecialists (eg, in a rural area), just over two thirds (67%)
answered affirmatively.

                               Pediatric Neurology Survey

Areas of Expertise

Ninety eight percent (98%) of the respondents said they provide direct patient care in the
area of child neurology and 2% said they provide care in the area of pediatric neurosurgery.
Among pediatric neurologists, 97% said they have special competence or added
qualifications in the area of child neurology; 49%, in clinical neurophysiology; and 56% in
other areas.

Eighty two percent (82%) of the pediatric neurologists said they have a special area of
expertise within the field of child neurology. For these respondents, Table 9 illustrates the
percentage with various areas of expertise and the means by which they acquired that
expertise.


Of those who said they have a special area of expertise within the field of child neurology,
nearly two thirds (65%) said their special expertise is in epilepsy; over one half (51%), in
EEG; and over one third (38%) in metabolic/neurodegenerative disease. Two thirds of
those with special expertise in epilepsy and metabolic/neurodegenerative disease, and one
half of those with special expertise in EEG, said they acquired such expertise through
experience.
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             Table 9. Special Areas of Expertise Within Child Neurology

Area                            Percentage                Expertise Acquired By
                                With Expertise       Fellowship CME Experience
                                  (%)
Epilepsy                           64.8                     28.0       21.8        66.7
EEG                                51.3                     45.1       17.2        53.2
Metabolic Disease/                 37.7                     31.0       16.4        67.3
 Neurodegenerative Disease
Neonatal neurology                 28.6                     16.9       13.8        86.2
Critical care                       9.5                     11.6       16.3        76.7
Neuro-oncology                      8.6                     28.2        5.1        66.7
Other                              39.6                     31.1       17.8        69.4

Forty percent (40%) of the respondents said they work in a freestanding children’s hospital;
36%, in a children’s hospital structurally within a general hospital; 41%, in a general
hospital; and 7% in some other hospital setting.

Patient Characteristics

Table 10 displays the primary diagnoses of neurologists’ pediatric patients. The most
common diagnosis by far is epilepsy: on average, epilepsy accounts for over one-third
(34%) of neurologists’ pediatric patients. Headaches, developmental delay, and attention
deficit disorder are the next most common diagnoses among neurologists’ pediatric
patients.

       Table 10. Percentage of Pediatric Neurologists’ Patients by Category

          Primary Diagnosis                                 Percentage of all Patients
                                                                     (%)
          Seizures/epilepsy                                          34.4
          Headaches/migraine                                         16.0
          Developmental delay                                        14.7
          Attention deficit disorder                                 14.4
          Learning disorders                                          7.0
          Neuromuscular disorders                                     6.2
          Other                                                       7.4
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Practice Characteristics

For the respondents overall, 87% of their patients are children (i.e., under eighteen years of
age) and 13% are adults. Twenty seven percent (27%) of the respondents said they only
provide care for children.

In a typical week, the respondents provide an average of 5.9 pediatric inpatient consults and
see 4.6 pediatric inpatients and 36.7 pediatric outpatients. Twelve percent (12%) of the
respondents provide no pediatric inpatient consults and 22% see no pediatric inpatients.

The median amount of time spent by respondents with new pediatric outpatients is 60
minutes and with follow-up pediatric outpatients is 20 minutes. The median amount of time
spent with new pediatric inpatients is 55 minutes and with follow-up pediatric inpatients is
15 minutes.

Pediatric neurologists receive referrals from a variety of sources. Table 11 lists the
primary sources of referrals and provides respondents’ estimates of the proportion of all
referrals accounted for by each specialty. On average, for 74% of the respondents, general
pediatricians account for 26-75% of their child neurology referrals and for 90% or more of
the respondents, family/general practitioners account for 0-50% of their child neurology
referrals, developmental/behavioral pediatricians account for 0-25% of their child
neurology referrals, neurologists account for 0-50% of their child neurology referrals, and
general neurosurgeons account for 0-25% of their child neurology referrals.

     Table 11. Source and Percentage of Child Neurology Referrals by Specialty

Specialty                                        Proportion of All Referrals
                                             None <25% 26-50% 51-75% 76-100%
                                              (%) (%)      (%)       (%)     (%)

General pediatricians                         0.6     10.0     33.1       40.7       15.6
Family/general practitioners                  1.8     54.7     38.6        4.7        0.2
Developmental/behavioral pediatricians       19.4     75.6      4.0        0.9          0
Neurologists                                  8.4     63.5     20.4        5.4        2.4
General neurosurgeons                        10.6     79.1      7.8        1.8        0.7
Other                                        12.5     50.0     37.5          0          0
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Three fourths of the respondents said they face competition in their community for the
services they provide. When asked to rank the top three sources of competition, over three
fourths (77%) of the respondents ranked child neurologists as the number one source of
competition; 29% ranked adult neurologists and 28% ranked developmental/behavioral
pediatricians as the number two source of competition; 24% of respondents ranked
developmental/behavioral pediatricians as the third most significant source of competition;
and 19% of respondents ranked general pediatricians and adult neurologists as the third
most significant source of competition.

Involvement in Medical Education and Research

Eighty five percent (85%) of the respondents have a medical school faculty appointment.
Of those that do, 74% hold full-time appointments and 26% have part-time positions, 89%
have clinical appointments and 11% have non-clinical appointments. Most faculty
appointments are in either a Department of Pediatrics (47%) or a Department of Neurology
(44%). Only three percent (3%) hold positions in a Department of Surgery and only 2%
hold appointments in a Department of Neurosurgery. Five percent (5%) hold appointments
in other academic departments.

Seventy one percent (71%) of the respondents with faculty appointments are involved in
research activities. Of those who are, 87% are involved in clinical research; 39%, in
treatment outcomes; 31%, in longitudinal follow-up; 24%, in lab/bench research; and 2%, in
other research. For those involved in research, 57% have external grants; 26%, salary
support; and 24%, internal grants. Twenty three percent (23%) of those involved in
research do not receive any type of financial support.


Workforce Issues

The median size of the population areas served by the respondents is 1.5 million people.
Among the respondents who were able to estimate the number of child neurologists and
pediatric neurosurgeons in their population center, the median number of full-time
equivalent (FTE) child neurologists was six and the median number of FTE pediatric
neurosurgeons was two. Twenty percent (20%) of the respondents said they did not know
the number of child neurologists in their area and 33% said they did not know the number of
pediatric neurosurgeons.
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Among the respondents who were able to estimate the size population needed to support
one FTE child neurologist and pediatric neurosurgeon, the median number given was one
child neurologist per 500,000 people and one pediatric neurosurgeon per 1.25 million
people. Seventy three percent (73%) of the respondents said they did not know what size
population is needed to support one child neurologist and 99% said they did not know the
size population that is needed to support one pediatric neurosurgeon.

While (based on respondents’ estimates of the population in their area and the number of
child neurologists) the current median child neurologist to population ratio would be one
per 222,222 people, the respondents’ median estimate of the size population needed to
support one FTE child neurologist was 500,000 people. Similarly, while (based on
respondents’ estimates) the current median pediatric neurosurgeon to population ratio
would be one per 750,000 people, the respondents estimated that the size population
needed to support one FTE pediatric neurosurgeon was 1.25 million people. Therefore,
estimates of the population required for one FTE child neurologist and one FTE pediatric
neurologist are roughly double the size of the population to FTE child neurologist or
pediatric neurosurgeon of the respondents’ own communities.

When asked whether they anticipated that their community will need more child
neurologists and pediatric neurosurgeons in the next 3-5 years, 40% said more child
neurologists will be needed and 31% said more pediatric neurosurgeons will be needed.
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Summary


       For nearly one half of pediatric neurologists, their main practice setting is at a
       medical school. The primary practice site for three fourths of pediatric neurologists
       is in an urban area.

       On average, approximately two thirds of the total time spent per week by pediatric
       neurologists in professional activities is devoted to direct patient care, while one
       tenth of their time is spent in teaching.

       Over 90% of pediatric neurologists receive referrals for pediatric patients from
       pediatric generalists and family physicians, and over 80% receive referrals from
       pediatric medical/surgical subspecialists. Approximately 60-70% receive referrals
       from urgent care centers, community agencies, and school districts.

       Among those pediatric neurologists who have experienced a change in the volume or
       complexity of pediatric referrals, approximately 70% have seen an increase in the
       volume of referrals and just over one half have seen an increase in the complexity of
       referrals. The biggest reasons for these changes are an increased likelihood of
       generalists to treat less complex subspecialty patients, and a decreased likelihood of
       generalists to treat more complex subspecialty patients.

       Seven out of ten pediatric neurologists do not feel that recent changes in health care
       have resulted in a need for additional training on their part--either in primary care or
       in their subspecialty.

       Over 70% percent of pediatric neurologists feel they face competition for pediatric
       subspecialty services in their geographical area, with the major perceived source of
       competition being other child neurologists, followed by adult neurologists and
       developmental/behavioral pediatricians.

       Of those who feel they face competition, less than one half have modified their
       practice as a result. The most common changes have been to increase office hours,
       to increase the number and/or responsibilities of support staff, and to increase the
       number of physicians in their practice.

       Just under one half of pediatric neurologists anticipate their communities will need
       additional pediatric subspecialists in the next 3-5 years.

       Pediatric neurologists rely on a variety of payment sources for their income, but fee
       for service arrangements are most common: one half or more of pediatric
       neurologists receive some income from traditional or discounted fee for service.
The Future of Pediatric Education II: Pediatric Neurology
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       Eight out of ten pediatric neurologists say they have a special area of expertise
       within the field of child neurology, with the most common area of special expertise
       being epilepsy. Two thirds of those with special expertise in epilepsy say they have
       acquired such expertise through experience.

       The most common diagnosis by far among pediatric neurologists’ patients is
       epilepsy. On average, epilepsy accounts for over one-third of neurologists’ pediatric
       patients.

       General pediatricians represent the single largest source of pediatric referrals to
       neurologists, followed by family/general practitioners.

       More than eight out of ten pediatric neurologists have a medical school faculty
       appointment, three fourths of which are full-time appointments. Most are clinical
       appointments in either a Department of Pediatrics or a Department of Neurology.

       More than seven out of ten pediatric neurologists are involved in research activities.
       Of those who are, nearly 90% are involved in clinical research and nearly 80%
       receive some type of financial support.

       Forty percent of pediatric neurologists anticipate that their community will need
       more child neurologists in the next 3-5 years, and 31% anticipate a need for more
       pediatric neurosurgeons.

								
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