Coming of age in general pediatrics.

Changes that have occurred in the practice of pediatrics in the last decade are reviewed. It is suggested that in the future, general ambulatory pediatrics be conceptualized for practice and educational purposes by forming three levels of care based on the following determinants: length of time and number of visits required for the specific service provided, level of competence needed, complexity of the problem, involvement of other professionals, setting, and specific needs of the patient. Growth in Level I general ambulatory care services will come from prenatal and adolescent visits and sports medicine. Extension of general ambulatory care at Levels II and III will result from differentiation of general pediatrics into areas of special interest such as child development, behavior, neurology, allergy, developmental disabilities, and adolescence. Arrangements to facilitate the provision of care in Levels II and III by the practitioner are suggested. Pediatric biomedical and psychosocial homeostasis are discussed using a model that encompasses the child, his family, and his environment on one axis and problems, vulnerabilities, strengths, and potentialities on the other. The need to examine the content and outcome of health supervision visits is emphasized.