Division of Rheumatology, MLC 4010, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229-3039, USA.
Pediatr Rheumatol Online J. 2011 Aug 15;9:24. doi: 10.1186/1546-0096-9-23. eCollection 2011.
The United States pediatric population with chronic health conditions is expanding. Currently, this demographic comprises 12-18% of the American child and youth population. Affected children often receive fragmented, uncoordinated care. Overall, the American health care delivery system produces modest outcomes for this population. Poor, uninsured and minority children may be at increased risk for inferior coordination of services. Further, the United States health care delivery system is primarily organized for the diagnosis and treatment of acute conditions. For pediatric patients with chronic health conditions, the typical acute problem-oriented visit actually serves as a barrier to care. The biomedical model of patient education prevails, characterized by unilateral transfer of medical information. However, the evidence basis for improvement in disease outcomes supports the use of the chronic care model, initially proposed by Dr. Edward Wagner. Six inter-related elements distinguish the success of the chronic care model, which include self-management support and care coordination by a prepared, proactive team. United States health care lacks a coherent policy direction for the management of high cost chronic conditions, including rheumatic diseases. A fundamental restructure of United States health care delivery must urgently occur which places the patient at the center of care. For the pediatric rheumatology workforce, reimbursement policies and the actions of health plans and insurers are consistent barriers to chronic disease improvement. United States reimbursement policy and overall fragmentation of health care services pose specific challenges for widespread implementation of the chronic care model. Team-based multidisciplinary care, care coordination and self-management are integral to improve outcomes. Pediatric rheumatology demand in the United States far exceeds available workforce supply. This article reviews the career choice decision-making process at each medical trainee level to determine best recruitment strategies. Educational debt is an unexpectedly minor determinant for pediatric residents and subspecialty fellows. A two-year fellowship training option may retain the mandatory scholarship component and attract an increasing number of candidate trainees. Diversity, work-life balance, scheduling flexibility to accommodate part-time employment, and reform of conditions for academic promotion all need to be addressed to ensure future growth of the pediatric rheumatology workforce.
美国患有慢性疾病的儿科人群正在不断扩大。目前，这部分人群占美国儿童和青少年人口的 12-18%。受影响的儿童通常接受的是零散的、不协调的护理。总的来说，美国的医疗保健体系为这一人群提供的效果并不理想。贫困、没有保险的和少数族裔的儿童可能面临服务协调不佳的风险增加。此外，美国的医疗保健体系主要是为急性疾病的诊断和治疗而组织的。对于患有慢性疾病的儿科患者，典型的以急性问题为导向的就诊实际上成为了护理的障碍。以患者为中心的医学教育模式占主导地位，其特点是单方面传递医疗信息。然而，改善疾病结果的证据基础支持使用慢性病护理模式，该模式最初是由爱德华·瓦格纳博士提出的。慢性病护理模式的成功有六个相互关联的要素，包括自我管理支持和由有准备的、积极主动的团队提供的护理协调。美国缺乏针对包括风湿性疾病在内的高成本慢性病管理的连贯政策方向。美国医疗保健体系必须进行根本性的结构调整，将患者置于护理的中心位置。对于儿科风湿病学劳动力来说，报销政策以及健康计划和保险公司的行动一直是慢性病改善的障碍。美国的报销政策和整体医疗服务的碎片化给慢性病护理模式的广泛实施带来了具体挑战。以团队为基础的多学科护理、护理协调和自我管理是改善结果的关键。美国儿科风湿病学的需求远远超过了现有的劳动力供应。本文回顾了每个医学受训者水平的职业选择决策过程，以确定最佳的招聘策略。教育债务对儿科住院医师和亚专科研究员来说是一个出乎意料的较小决定因素。两年的研究员培训选项可以保留强制性奖学金部分，并吸引越来越多的候选受训者。多样性、工作与生活的平衡、适应兼职工作的日程安排灵活性，以及学术晋升条件的改革，都需要得到解决，以确保儿科风湿病学劳动力的未来增长。
