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Advances in Hospital Ambulatory Services for Children
Symposium on Recent Clinical Advances
Advances in Hospital Ambulatory Services for Children
Joel J. Alpert, M.D.* and Richard I. Feinbloom, M.D.**
Advances in hospital-based ambulatory services for children attract the attention of patients, educators and trainees, administrators, third party payors, and the practicing physician. For patients, the ambulatory services are a place to get needed care. For pediatric educators and trainees these services are where teaching programs are the weakest. For administrators the ambulatory services involve financial loss and for third party payors these same services mean financial savings. Finally, for the practicing physician these services are seen either as a competitor or as a source of coverage, referral, and emergency care for his patients. Despite the establishment of neighborhood health programs, the continued decrease in primary care physicians has meant increased demand in urban hospitals to provide ambulatory services. These services traditionally include the outpatient department, the emergency ward, and in special situations neighborhood health programs. This review of hospital ambulatory services, while briefly examining certain historical aspects, focuses upon the current status and advances in education and service provided for children by hospital ambulatory services. Because of current interest in education, the role of university and university affiliated institutions is emphasized.
THE DEVELOPMENT OF HOSPITAL AMBULATORY SERVICES From the beginning hospital ambulatory services have been expected to provide services to the poor and only recently to the more affiu''Director, Pediatric Service, Boston City Hospital; Professor and Chairman, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts ''"''Chief, Child and Family Health Division, Children's Hospital Medical Center; Medical Director, Family Health Care Program, and Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts Supported in part by grants from the National Center for Health Services Research and Development, Maternal and Child Health Services, HSMHA, and the Bureau of Physician Manpower Health Education, National Institutes of Health.
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ent. This is understandable since the hospital outpatient department had its origins in the dispensaries of the eighteenth century in Europe of which George Armstrong's London Dispensary for the Infant Poor, founded in 1769, was the world's first clinic for children. 18 The first pediatric outpatient department in the United States was established at the Children's Hospital of Philadelphia in 1856, one year after that institution's founding. Today there are over 3000 outpatient departments in the United States which serve children. Until the end of the nineteenth century, the hospital had a poor reputation for care and functioned principally as a custodian for the indigent sick, or more commonly as a place for the poor to die. As scientific advances resulted in improved hospital care, enhancing the reputation of hospitals, the early custodial function of the hospital was incorporated as the modern outpatient department. It is difficult to determine if emergency wards had a beginning which can be differentiated from the outpatient department. The early dispensaries contained both functions. Present day demands on these facilities are of such a different magnitude that for this analysis the emergency ward and the outpatient department must be considered separately. Neighborhood Health Programs, often sponsored by teaching hospitals, are seen as large scale programs developed in the 1960's as part of the war on poverty, but in fact these programs in the United States originated as child health stations, settlement houses, or neighborhood programs over 50 years ago. At that time, however, the neighborhood health programs had little or no relationship with the hospital77 and were most often associated with local health departments. From the beginning, the dispensary, and later the outpatient department, were used for teaching and clinical research. Thus outpatient departments functioned as a "medical soup kitchen" to feed the poor and a "medical feeder" to fill hospital beds. When the recommendations of the Flexner Report25 resulted in a closer relationship between universities, medical schools, and hospitals, the hospital outpatient department formally acquired the educational function. Consequently, the hospital outpatient department is an established part of current medical services and is therefore part of the current national crisis in the organization and education for the provision of health services. The increase in the use of hospital ambulatory services for children, especially when compared with the inpatient service, has been both notable and well described. In 1953, for every one inpatient admission to the hospital there were two outpatient department visits, but by 1967 the ratio had increased to four to one !3° For children the change has been staggering. At Boston City Hospital 75,000 children are seen annually in the ambulatory services and 3100 children are admitted as inpatients which is a ratio· of 25 outpatient department visits to 1 inpatient admission. This experience is not confined to a municipal hospital. The ratio of outpatients at Boston Children's Hospital Medical Center is 20 to 1. It is difficult to know with certainty what this means in terms of all health related services provided to children but in Monroe County, (including the city of Rochester) New York, hospital ambulatory services have been shown to provide at least 15 per cent of all medical services for children.33
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During the last decade, the users of hospital ambulatory services, especially the emergency ward, have been characterized more completely. For the most part, in urban areas, these are low income families who do not have a family physician and who use the hospital as their major source of health care. This use, however, varies from one community to another. In some settings the emergency ward is a trauma center and in others it is a substitute for the private physician on a temporary basis. 82 Factors associated with the increased use of the outpatient department and emergency ward include the changing nature of childhood morbidity (altered infectious diseases, better nutrition, specific therapies, new immunizing agents, better public health practices, and new risks such as accidents and poisonings), the rising demand for medical services, the changing population of cities, the availability of diagnostic services in the hospital, the dramatic fall in number of primary care physicians, and the perception by many patients of the hospital as the most desirable site for securing complex sophisticated medical services.
SERVICES The outpatient department and the emergency ward can offer primary care and secondary care services. Primary care means in the best sense first contact, integrated, and continuous care. 3 Hospital primary care services include emergency and nonemergency care which is usually not integrated and is discontinuous, while secondary services mean referral and consultative care. Modern outpatient departments were developed largely as secondary care clinics and as providers of emergency services (acute first contact service) and were not developed to provide a complete package of primary care.
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Techniques for treating the critically ill emergency patient have steadily improved and new standards for emergency facilities and equipment have developed. Largely in response to the dramatic rise in use of emergency facilities, new physician staffing patterns have emerged. 6 In smaller community hospitals, practicing physicians often share emergency ward responsibilities. In an increasing number of hospitals, full time physicians staff emergency wards either on a fee-for-service or salary basis. Many of these services are provided for children. As already noted, the major use of the outpatient department and emergency ward for children is for non-emergency primary care, and that form of care is sought by users, regardless of socioeconomic background.6s These needs are far more common than emergency, secondary, or tertiary (inpatient) needs in the general population8 n and organized programs in hospitals to provide these services have not developed on any sizeable scale despite the large number of outpatient department sites available.
Secondary Care Services While it is assumed that outpatient departments are properly designed to see secondary (referred) patients, these patients are often not
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appropriately served. Obviously, this is true when the referral should not have been made, i.e., when it is for a primary care problem. Many nonemergency primary care problems are referred or triaged for secondary care. About one half of the referrals of children to the outpatient department are for behavioral and psychological problems. There is evidence that these problems might have been managed more appropriately in another setting since effective management requires continuity and not just diagnosis. 7• 15 • 46 The establishment of more specialty clinics has not helped with the majority of patient referrals. While technically competent, the specialty clinics by their very nature are unable to cope with a problem beyond or even on the fringe of the specialty. Specialty clinics are established because of the interest of a particular physician or investigator, educational priorities, or in response to a categorical funding program and are frequently not related to the needs of patients. What is an appropriate specialty clinic in one setting when related to patient needs may be completely inappropriate in another. Many referrals of patients by physicians to hospitals are arranged by the patient solely to gain access to the clinic with little actual participation by the physicians.88 Other referrals are entirely self-initiated. Another kind of referral is the "referral" of a patient who receives primary care in the emergency ward to a part of the outpatient department. This is a paradoxical referral because there is usually no referring physician to whom the patient returns after consultation. This may be one of the important unexplored reasons for the high no show rate associated with such referrals. For example, most of these patients who are medically indigent would just as soon continue in the emergency ward for convenience, and see no benefit in following through with the outpatient department referral. For hospital ambulatory services the provision of coordinated and integrated care whether primary or secondary remains a major problem.28 • 32 • 75 • 84 The complex nature of most illnesses in children is appreciated. In the outpatient department, there have been multidisciplinary approaches in the diagnosis and management of children with chronic disorders, and efforts made to deal effectively with psychosocial issues presented in the care of such patients. 1• 29 There have been a number of attempts to modify outpatient department services in the direction of greater continuity and comprehensiveness. Many of these have been demonstration projects for teaching and few have been undertaken to change service in significant ways.t.so Costs to patients (or third party groups) for ambulatory services are generally higher in the hospital than in the private office. Major reasons for this difference are the inclusion of the more costly overhead of the inhospital services in setting outpatient department fees, increased utilization of the laboratory in the hospital, and high follow-up in the hospital. 34 It is also deceptive to compare costs only within the ambulatory area. For example, patients may be unnecessarily hospitalized for studies which are paid for by third parties only as inpatients. 41 • 63 While the "cost" of ambulatory care per se is lowered, the overall cost to society, although not perhaps to the individual patient, is considerably increased by this practice.
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TEACHING The teaching role of hospital ambulatory services and manpower needs for ambulatory care are closely related. From its inception, the outpatient department has been identified as the site where conditions of patient care most Closely approximate those seen in practice, and, therefore, as a fertile field for medical education. 16 • 18 A number of studies have called attention to the gap between the educational requirements for the practice of pediatrics and the traditional training of the pediatrician and have called for improved teaching in ambulatory care. 31 • 89 Already a high percentage of the pediatrician-in-training's time occurs with ambulatory patients.49 Nevertheless, the emphasis in most pediatric programs is still on in-hospital patients who are likely to have rarer illnesses. Less attention in the hospital is given to the common but no less complex problems of children such as health supervision, common infections, learning disorders, developmental difficulties, drug use, and accidents. Especially in pediatrics, teaching programs have been developed seeking to correct the educational gap that existed between career and training. Such programs were easy to establish because of the availability of patients .and because most teaching hospitals had outpatient departments that served children. Since most of these patients were indigent, meeting their needs did not put the institution directly in competition with private practitioners. The hospital administration could also hope to have more patients to fill beds. As already noted, most of these programs were demonstration efforts and did little to change the actual function of the outpatient department. Such attempts at reorganization began in the 1930's13 and continued after the second World War, reaching a peak in the 1950's.3 • 80 Many teaching programs emphasized interviewing skills and were coordinated pediatric and psychiatric programs. 70 Other programs emphasized well child care60 and still others the opportunity for students to follow families. 43 Evaluation of these teaching programs has been mostly descriptive and their history has been a short one. Even the limited goals of teaching interviewing may not have been achieved. 21 The specialty emphasis, the hospital bureaucracy, the usual hospital de-emphasis of the patient, and the difficulty in coordinating services in the long run proved to be unsurmountable obstacles.23 The best that could be said was that such programs attracted students whose motivation was patient care and who were interested in related psychosocial issues. 3
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EVALUATION AND RESEARCH The only national data available on the quality of care in hospital ambulatory services is provided by the reports of the Joint Commission on Accreditation. The Joint Commission has generally given more attention to inpatient than to outpatient department care, examining records and physical facilities, and has been concerned to a lesser extent with the content of care. This, of course, is rapidly changing, with significant emphasis on the peer review process and establishing standards of care. The .i.
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initial emphasis of such peer review will be on inpatient review. Chart reviews in the outpatient department have been valuable in teachinga 5 • 52 but not widely used to study quality. Attempts to develop methods of reviewing ambulatory charts for quality assurance are in progress such as the study program of the Joint Commission on Quality Assurance, 81 a consortium of nine national professional organizations including the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association. The measures of quality used in the past have been mainly ones of technical adequacy of how well a step in the process of providing care was performed, but they do not answer such questions as whether the incident of care could have been prevented or whether it could have been more effectively handled in a different way, in a different place, or by different personnel. Structure and process are examined but little effort has been addressed toward measuring outcome. Outcome measures are needed since the ultimate test of effectiveness of any health program is the health of the population served, regardless of the source of care. Unmet needs cannot be determined by looking only at those who come for care regardless of how well the users are characterized. A necessary index of effectiveness is the health status of the target population. Such data are at present not available for users of the ambulatory services. Nor can the precise role of the outpatient department or emergency ward in the health care system be understood without knowing what distinguishes users from nonusers. 45 Another major problem in conducting such research is the absence of any widely used coding system which would be based on ambulatory patient problems rather than the usual hospital disease and mortality index. There are coding systems available such as has been developed by the Royal College of General Practitioners in the United Kingdom, 22 but the use of such systems is not widespread. Based on limited available data, evaluating the quality of hospital ambulatory services currently depends almost entirely on the reputation of the particular hospital. Reputation, unfortunately, does not equal quality. One study of the quality of care in a university hospital emergency ward showed that only 27 per cent of patients received "effective" care 12 and another, examining outpatient department specialty clinics, that quality of patient care as measured by record review was grossly deficient.52 These studies indicate that even the technical performance of hospital ambulatory services may not be of consistently high quality. The major criticism regarding quality has been, of course, that outpatient departments and emergency wards ministering. to the poor are symbolic of what is a two-class health system and provide care to people whose morbidity and mortality experience is among the poorest in our society _II· 47 • 58 • 76 Data from a number of recent experimental programs demonstrate a relationship between the organization of services and certain health indices. 4 • 48 Improvements in various measures of health occur in families offered a comprehensive pediatric care program with an on-going doctor-patient relationship. When compared to control families who continued to receive their medical care in the outpatient clinic, emergency ward, and well baby clinic, experimental families receiving
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comprehensive care showed altered utilization of health services, with a reversal of the ratio of sickness visits to well child visits, lower rates of hospitalization, lower rates of elective surgery, and improved ability to use the telephone. 4 These benefits are similar to those observed in prepaid group practices41 • 67 and in neighborhood health programs.8 • 45 From these studies, the setting seems less important than the principle of providing continuity of care. As greater interest in ambulatory services has developed, methods for describing and analyzing ambulatory care have improved and a closer collaboration has developed between the behavioral scientist and clinician.78· 79 Under the economic incentive of improved efficiency, analytical approaches found useful in the business community are being applied increasingly to ambulatory services and operationsP· 36• 41 Research in the ambulatory services has become a recognized area of clinical investigation2· 37 but obviously much more is needed.
PLANNING FOR HOSPITAL AMBULATORY SERVICES I
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The future role of hospital ambulatory services as a source of health care for children and of education of health professionals cannot be considered in isolation but must be related to overall needs for change in health care. 61 • 71 This will require some form of national health insurance, stable financing of programs, incentives for efficiency and cost control, rationalization of training and use of health manpower, and the equalization of the present two classes of care. In this regard, recent federal legislation and cutbacks are to be deplored for emphasizing two class health delivery. The essential question regarding costs is how much does total care cost, not how much does ambulatory care cost. The control of costs, a major challenge to health services, depends on rationalizing the entire spectrum of needed services, and not just the ambulatory component. While these points are obvious in the long run, the short run demands that certain changes in the functions of the ambulatory services take place if these services are to serve children better. Historically, as noted, attempts to improve services in the ambulatory services have usually meant another specialty clinic or more effective triage. These efforts do relatively little to meet the needs of patients but they may improve the efficiency of the particular outpatient department. With some necessary modifications, hospital ambulatory services should continue to perform and improve upon emergency care for the critically ill patient and referral-consultative functions. Civilians should receive emergency care as technically competent as a serviceman in a war zone. The trend toward multidisciplinary clinics should be intensified. Close communication with the primary source of care must be maintained. A frank exploration of the mutual responsibilities of the emergency service and private practitioners who use it for coverage is essential. In addition, the outpatient department should continue to perform a non-emergency function, however restricted, for that segment of the population which is unable to use comprehensive care even when of-
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fered. 87 Preventive services should be offered to this group within the outpatient department, probably by establishing a special primary care clinic which will have defined goals and an identified population. This special clinic can incorporate features of prepaid group practice57 and should not necessarily be confined to the poor. Risks of this approach are that this effort is viewed as simply another specialty clinic and not as a means of reorganizing the outpatient department. There is also the risk of giving two classes of health care within the outpatient department. For that larger segment of the population which is capable of using comprehensive services outside of the hospital the primary care function of the present outpatient department and emergency ward should be eliminated as inappropriate and efforts made to enlarge private group practice and neighborhood health programs. 14 The best hope for reorganization of present services exists in those settings where there is a close relationship between neighborhood health programs and hospital ambulatory services. Since the hospital is generally a poor place to receive comprehensive care, it is probably a poor place to learn how to provide this care. The statement that the ambulatory services is the place to learn pediatric practice is clearly an oversimplification. The two class health care system has penalized all classes of society because the poor habits leamed and practiced on the class which has constituted "teaching material" are later transferred to the private sector. The trainee becomes expert at functioning in a suboptimal setting. Development of skills is left to chance. He is asked to serve as a consultant before he has leamed how to make a referral, and to delegate aspects of his work, such as health supervision, to non-physicians before he has ever fully understood the nature of the work he is delegating. One advantage of a model practice within the outpatient department is that this could also be the teaching model and minimize these risks. Evaluation of these teaching programs are needed to confirm that this is a benefit. At Boston City Hospital an attempt is now being made to establish a more efficiently organized outpatient department by separating emergency, walk-in, primary care, and consultative functions as has been done in other institutions. In addition, a teaching program in primary care for internists and pediatricians in the hospital ambulatory services has been developed. It is much too soon to know what success this effort will have but it will be evaluated. The teaching program will serve those patients who use the outpatient department as a source of primary care. A unit in the hospital will be staffed by faculty and residents in pediatrics and internal medicine who can establish a continuQus relationship with the patients they serve. The focus will be on the family as the unit of health and disease. Services for children and adults will be closely integrated. The primary care unit will be the point of entry for all care for the population served and will have firm linkages with referral and inpatient sources of care. Its staff will assume responsibility for securing needed services and relieve families of this complex task. Its emphasis will be on managing common disorders, and on prevention of disease, early detection, and health maintenance. At the same time the professionals will be skilled in the management of chronic illness and the unit
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will be a place to which hospitalized patients can be returned for coordinated, flexible follow-up, and long term care, a major deficiency in present outpatient department services. 54- 56 A similar unit will be established in a neighborhood health center. Here there are the advantages of lower overhead compared with the hospital, meaningful community participation, and greater likelihood of developing a family care system with teams and family records. This unit, however, has the disadvantage for the resident that he is asked to go a distance from the hospital and out of the traditional academic mainstream. Even for a short period of time (one half day a week for example) physical distance may be a significant barrier. The outpatient department does not have these disadvantages but does have the cost and organizational disadvantages. Part of the new primary care program will be to compare the two primary care sites as to their effectiveness as educational settings. Quality of teaching, career choices, and prestige are directly related to the priorities of the educational institution. If the teaching institutions cannot provide optimal care in the ambulatory services, how will the level of instruction and prestige in primary care careers rise and the present imbalance in career choices be corrected? Teaching can be improved, conferences upgraded, even visit rounds made in the outpatient department but the answer may once again require looking beyond the outpatient department or emergency ward. Formation of model group practices, the development of teaching and service programs in health centers, and conceptualizing health care as a system should add impetus to a full professionalization of the primary care role in educational programs. The hospital ambulatory services will play a part but cannot any longer be said to be the best place to learn medical practice. The success of these programs will require faculty and a hospital commitment. Within the past decade a new career line has developed in directing outpatient services and in teaching and research in ambulatory pediatrics. The Ambulatory Pediatric Association was begun in the early 1960's to improve research, teaching and patient care in the pediatric outpatient area. The American Academy of Pediatrics established a Community Pediatric Section in 1969. Despite these efforts there is no evidence that the needed number of academic generalists are being educated and that either of these efforts, or related efforts, have had a major impact on medical education. Hospital pediatric services must recognize that such phenomena as the falling birth rate and liberalized abortion programs will further affect childhood morbidity and one result will be even less demand for inpatient beds. Hospitals can take the initiative in changing their services within the framework of the desirable characteristics of a revised health care system and new needs of patients. Hospitals should abandon the position of traditional isolation and coordinate efforts with other hospitals and providers of health services in their communities. No one pediatric institution can meet the needs of all children who come for care and provide all of the education for needed health professionals. Hospitals, whatever institutional identity may be at stake, must begin to share both service and educational tasks.
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Because of the numbers of patients involved, the ambulatory service remains an important setting to serve, to teach, and to do research. Moreover, the hospital ambulatory services is the hospital's basic contact point with its community. Experiments and demonstrations with careful evaluation should be undertaken as a part of hospital ambulatory services medical practice. Rational decisions will, however, require careful planning and a change in priorities on the part of the hospital and medical school.
SUMMARY This paper describes the background, services, research function, effectiveness and educational role of hospital ambulatory services in the care of children in the United States. The explosive increase in utilization of hospital ambulatory services, not limited to the poor alone, is mainly for primary care needs, precisely that function for which these services as presently organized are largely inappropriately designed. The future role of the ambulatory services must be considered as part of the needed restructuring of a costly two class health care system. Within this restructuring, the emergency ward and outpatient department would continue to perform emergency and referral care functions, but should make major modifications in the primary care functions for patients. The major reason for offering primary care services within the teaching hospital is most likely educational and to provide service to a limited population who do not or cannot use community facilities. Neighborhood health programs and the physician's office should be strengthened as the proper place for delivery of primary care services. Attempts to rationalize the delivery of primary care services should be carefully studied and evaluated. Current changes in medicine require hospitals and medical schools to examine their roles in health care education and delivery. Whether hospitals and medical schools will lead or follow the changes ahead will hinge largely on the seriousness and excellence of its considerations of responsibilities in primary care. In operational terms, the answer to this question depends on how these institutions will deal with their ambulatory patients.
REFERENCES 1. Allen, J. E., and Lelchuck, L.: A comprehensive care program for children with handicaps. Amer. J. Dis. Child., 111:229-235, 1966. 2. Alpert, J. J.: Research in ambulatory care. In Green, M., and Haggerty, R. ]., eds.: Ambulatory Pediatrics, Philadelphia, W. B. Saunders Co., 1968. 3. Alpert, J., and Charney, E.: The Education of Physicians in Primary Care. National Center Health Services Research and Development, Government Printing Office, In press. 4. Alpert, J. J., Heagarty, M. C., Robertson, L., et al.: Effective use of comprehensive pediatric care. Amer. J. Dis. Child., 116:529-533, 1968. 5. Alpert, J. ] .• Kosa, ]., Haggerty, R. ]., et al.: The types of families that use an emergency clinic. Medical Care, 7:55-61, 1969. 6. A.M.A. Department of Hospitals and Medical Facilities: The emergency department problem. ].A.M.A., 198:380-383, 1966.
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7. Anderson, I. P., Rowe, D. S., Dean, V. C., et al.: An approach to the problem of noncompliance in a pediatric outpatient clinic. Amer. j. Dis. Child. 122:142-143, 1971. 8. Bellin, S. S., Geiger, H. J., and Gibson, C. D.: Impact of ambulatory health-care services on the demand for hospital beds. New Eng. j. Med., 280:808-812, 1969. 9. Beloff, j. S., and Weinerman, E. R.: Yale studies in family health care. I. Planning and pilot test of a new program. j.A.M.A., 199:383-389, 1967. 10. Bergman, A. B., and Haggerty, R. J.: The emergency clinic. Amer. J. Dis. Child., 104:3644, 1962. 11. Bergner, L., and Yerby, A. S.: Low income and barriers to use of health services. New Eng. J. Med., 278:541-546, 1968. 12. Brook, R. H., and Stevenson, R. L.: Effectiveness of patient care in an emergency room. New Eng. J. Med., 283:907, 1970. 13. Burwell, C. S., and Youmans, J. B.: Methods and objectives in the organization of the outpatient department of a teaching hospital. J. Assoc. Amer. Med. Coli., 10:65-69, 1935. 14. Carnegie Commission on Higher Education: Higher Education and the Nation's Health. New York, McGraw Hill, 1970. 15. Chamberlain, R. W., Jr.: Social data in evaluation of the pediatric patient: Deficits in outpatient records. J. Pediat., 78:111-116, 1971. 16. Child Health Services and Pediatric Education. American Academy of Pediatrics, The Commonwealth Fund, New York, 1949. 17. Clinic Self-Evaluation Manual for the Determination and Improvement of Clinic Efficiency. The Johns Hopkins University School of Medicine and the Health Systems Department, Westinghouse Electric Corporation, November, 1969. 18. Cone, T. E., Jr.: The history of pediatric ambulatory services. In Green, M., and Haggerty, R. J., eds.: Ambulatory Pediatrics. Philadelphia, W. B. Saunders Co., 1968. 19. Cornfeld, D., Barness, L. A., Mellman, W. J., et al.: An outpatient oriented pediatric residency. Amer. j. Dis. Child., 103:116-119, 1962. 20. Dorsey, j. L.: Physician Distribution in Boston and Brookline 1940 and 1961. Medical Care, 7:429-440, 1969. 21. Duff, R. S., Rowe, D. S., and Anderson, T. P.: Patient care and student learning in a pediatric clinic, Pediatrics, 50:839-846, 1972. 22. Eimerl, T. S.: Organized curiosity. J. Coll. General Practitioners, 8:246, 1960. 23. Fink, D., Malloy, M. J ., Cohen, M., et al.: Effective patient care in the pediatric ambulatory setting: A study of the acute care clinic. Pediatrics, 43:927-935, 1969. 24. Fink, D., Martin, F., et al.: The management specialist in effective pediatric ambulatory care. Amer. j. Publ. Health, 55:982-993, 1965. 25. Flexner, A.: Medical Education in the U.S. and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4, New York, 1910. 26. Goodrich, C. H., Olendzki, M., Buchanan, J. R., et al.: TheN ew York Hospital-Cornell Medical Center Project: An experiment in welfare medical care. Amer. j. Publ. Health, 53:1252-1259, 1965. 27. Goodrich, C. H., Olendzki, M., and Reader, G. G., The New York Hospital-Cornell Medical Center: A progress report on an experiment in welfare medical care. Amer. j. Publ. Health, 55:88-93, 1965. 28. Green, M.: Comprehensive pediatrics and the changing role of the pediatrician. In Solnit and Provence, eds.: Modern Perspectives in Child Development. New York, International Universities Press, 1963. 29. Green, M.: Integration of ambulatory services in a children's hospital. Amer. j. Dis. Child, 110:178-184,1965. 30. Guide Issue. J. Amer. Hosp. Assoc., August 1, 1967. 31. Haggerty, R. j.: Family medicine: A teaching program for medical students and pediatric house officers. J. Med. Educ., 37:531-580, 1962. 32. Haggerty, R. J.: Science and ambulatory health services for children, Amer. J. Dis. Child., 119:36-44, 1970. 33. Haggerty, R. j., and Roughman, K.: Rochester Child Health Survey. 1973, Unpublished data. 34. Heagarty, M. C., Robertson, L. S., Kosa, J., et al.: Some comparative costs in comprehensive versus fragmented pediatric care. Pediatrics, 46:596-603, 1970. 35. Helfer, R. E.: Estimating the quality of patient care in a pediatric emergency room. J. Me d. Educ., 42:244-248, 1967. 36. Hospital Outpatient Services Guide to Surveying Clinic Procedures. Department of Health, Education and Welfare, U.S. Public Health Service Pub. No. 930-C4, 1964. 37. Huntley, R. R., Steinhauser, R., et al.: The quality of medical care: Techniques and investigation in the outpatient clinic. J. Chronic Dis., 14:1-16., 1961. 38. James, G.: Medical advances in the next ten years: The implications for the organization and economics of medicine. Bull. N.Y. Acad. Med., 41:14-26, 1965. 39. James, G., and Jacobziner, H.: A pediatric health service. An extension ofthe child health conference. Amer. J. Publ. Health, 55:982-993, 1965.
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40. Kahn, L., Anderson, M., and Perkoff, G. T.: Patients perceptions and uses of a pediatric emergency room. Social Sci. Med., 7:155-160, 1973. 41. The Kaiser Foundation Medical Care Program: Appendix IV, Report on the National Advisory Commission on Health Manpower, Vol. II, 1967. 42. Kendall, C.: Improvement of hospital pediatric clinics. Pediatrics, 51 :1110-1111, 1973. 43. Kennell, J. H.: Experience with a medical school family study. J. Med. Educ., 36:16491716, 1961. 44. Kirkpatrick, J. R., and Taubenhause, L. J.: The non-urgent patient on the emergency floor. Medical Care, 5:19-24, 1967. 45. Klein, M., Roghmann, K., Woodward, K., et al.: Impact of neighborhood health center on hospitalization. Pediatrics, 51:833-839, 1973. 46. Korsch, B. M., Negrete, V. F., Merar, A. S., et al.: How comprehensive are well child visits? Amer. J. Dis. Child., 122:483-488, 1971. 47. Lesser, A. J.: Closing the gaps in the nation's health services for mothers and children. Bull. N.Y. Acad. Med., 1965. 48. Lesser, A. J.: The federal government in child health care. PEDIAT. CLIN. N. AMER., 16: 894-895, 1969. 49. Levine, M.D., Robertson, L. S., and Alpert, J.: Descriptive study of a pediatric internship. Pediatrics, 44:986-990, 1969. 50. McCarroll, J. R., and Skudder, P. A.: Hospital emergency departments. Conflicting concepts of function shown in national survey. Hospitals, 34:35-38, 1960. 51. Magraw, R. M.: Ferment in Medicine, W. B. Saunders Co., Philadelphia, 1966. 52. Meyers, A.: Deficiencies of pediatric specialty clinics. Pediatrics, 51:22-26, 1973. 53. Miller, W. R.: A system to provide and teach comprehensive medical care. J.A.M.A., 189:89-93, 1964. 54. Nathanson, C. A.: Peer surveillance and patient orientation in a pediatric outpatient clinic. Human Organization, 30:255, 1971. 55. Nathanson, C., and Becker, M., Control structure and conflict in outpatient clinics. J. Health Soc. Behav., 13:251-261, 1972. 56. Nathanson, C. A., and Becker, M. H.: Work satisfaction and performance of physicians in pediatric outpatient clinics. Health Serv. Res., 8:17, 1973. 57. Neuman, C. G., Boostrum, E. R., McKown, L., et al.: Prepaid pediatric health care in a university teaching hospital: A working model for pediatric education and health care delivery. J. Pediat., 83:670-678, 1973. 58. Norman, J. C.: Medicine in the ghetto. New Eng. J. Med., 281:1271-1275, 1969. 59. Odoroff, M. E., and Abbe, L. M.: Factors in outpatient visits, Pub!. Health Rep., 72:478483, 1957. 60. Parmalee, A. H., Jr., Swenjel, E., and Adams, J. M.: The family in medical education. J. Med. Educ., 34:644-648, 1959. 61. Pellegrino, E. D.: Outpatient services-Focal point in comprehensive health. Hospitals, 38:56-58, 1964. 62. Robertson, L.: On the intraurban ecology of primary care physicians. Soc. Sci. Med., 4:227-238, 1970. 63. Roemer, M. I., and DuBois, D. M.: Medical costs in relation to the organization of ambulatory care. New Eng. J. Med., 280:988-993, 1969. 64. Roth, J. A.: Utilization of the hospital emergency room. J. Health Soc. Behav., 12:312-320, 1971. 65. Satin, D. G.: Help. The hospital emergency room as community physician, Medical Care, 10:248-260, 1972. 66. Schulman, J., Jr.: The role of hospital ambulatory service in medical education. J. Med. Educ., 46:246-248, 1971. 67. Shapiro, S., Williams, J. J., Yerby, A. S., et al.: Patterns of medical use by the indigent aged under two systems of medical care. Amer. J. Pub!. Health, 57:784-790, 1967. 68. Shortliffe, E. C., Hamilton, T. S., and Noroian, E. H.: The emergency room and the changing pattern of medical care. New Eng. J. Med., 258:20-25, 1958. 69. Snoke, P. S., and Weinerman, E. R.: Comprehensive care programs in university medical centers. J. Med. Educ., 40:625-657, 1965. 70. Solnit, A. J., and Senn, M. J. E-: Teaching comprehensive pediatrics in an outpatient clinic. Pediatrics, 14:547, 1954. 71. Solon, J. A.: Outpatient care, a term in search of a concept. Hospitals, 39:61-65, 1965. 72. Solon, J. A.: Patterns of medical care: Sociocultural variations among a hospital's outpatients. Amer. J. Pub!. Health, 56:884-894, 1966. 73. Solon, J. A., eta!.: Patterns of medical care among users of hospital emergency units. Med. Care, 10:60-72, 1972. 74. Solon, J. A., Sheps, C. G., and Lee, S. S.: Patterns of medical care: A hospital's outpatients. Amer. J. Pub!. Health, 50:1905-1913, 1960. 75. Somers, A. R.: Basic determinants of medical care and health policy. Health Serv. Res., 1 :193-209, 1966.
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76. Stewart, W. H.: The unmet needs of children. Pediatrics, 39:157-160, 1967. 77. Stoekle, J. D., and Candie, L. M.: The neighborhood health center reform ideas of yesterday and today. New Eng. ]. Med., 280:1385-1391, 1969. 78. Stoekle, ]. D., and Zola, I. K., Views, problems and potentialities of the clinic. Medicine, 43:13-22, 1964. 79. Sussman, M. B., Caplan, E. K., Haug, M. R., etal.: The Walking Patients: A Study in Outpatient Care: Cleveland, Ohio, The press of Western Reserve University, 1967. 80. Tayler, J. M., and Johnson, R. G.: A residency program in primary medical care: The physician as provider-manager.]. Med. Educ., 48:654-660, 1973. 81. Thompson, H., and Osborne, C. E.: Joint Committee on Quality Assurance, Criteria for the Quality of Child Health Care. In press. 82. Torrens, P.R., and Yedvab, D. G., Variations among emergency room populations. A comparison of four hospitals in New York City. Medical Care, 8:60-65, 1970. 83. Walker,]. E. C.: Prospects of ambulatory medicine in teaching hospitals. Ann. Intern. Med., 64:1315-1324, 1966. 84. Weinerman, E. R.: Yale studies in ambulatory medical care. IV. Outpatient-clinic services in the teaching hospital. New Eng. J. Med., 272:947-954, 1965. 85. Weinerman, E. R., Rutzen, S. R., and Pearson, D. A.: Effects of medical "triage" in hospital emergency service. Pub. Health Rep., 80:398-399, 1965. 86. White, K. L.: The ecology of medical care. New Eng.]. Med., 265:885-892, 1961. 87. White, M. K., Alpert, J. ]., and Kosa, J.: Hard-to-reach families in a comprehensive care program. ].A.M.A., 201:801-806, 1967. 88. Williams, T. F., White, K. L., Andrews, L. P., et al.: Patient referral to a university clinic: Patterns in a rural state. Amer. ]. Publ. Health, 50:1493-1507, 1960. 89. Wingert, W. A.: The utilization of the intern in a pediatric outpatient setting.]. Med. Educ., 41 : 756-765, 1966. 90. Wingert, W. A., Friedman, D. B., and Larson, W. R.: Pediatric emergency room patient. Amer. ]. Dis. Child., 115:48-56, 1968. 91. Wingert, W. A., Friedman, D. B., and Larson, W. R.: The demographical and ecological characteristics of a large urban pediatric outpatient population and implications for improving community pediatric care. Amer. ]. Publ. Health, 58:859-876, 1968. 92. Wingert, W. A., Larson, W., and Friedman, D. B.: The influence of family organization on the utilization of pediatric emergency services. Pediatrics, 42:743-751, 1968. Boston City Hospital 818 Harrison Avenue Boston, Massachusetts 02118
Advances in Hospital Ambulatory Services for Children
Joel J. Alpert, M.D.* and Richard I. Feinbloom, M.D.**
Advances in hospital-based ambulatory services for children attract the attention of patients, educators and trainees, administrators, third party payors, and the practicing physician. For patients, the ambulatory services are a place to get needed care. For pediatric educators and trainees these services are where teaching programs are the weakest. For administrators the ambulatory services involve financial loss and for third party payors these same services mean financial savings. Finally, for the practicing physician these services are seen either as a competitor or as a source of coverage, referral, and emergency care for his patients. Despite the establishment of neighborhood health programs, the continued decrease in primary care physicians has meant increased demand in urban hospitals to provide ambulatory services. These services traditionally include the outpatient department, the emergency ward, and in special situations neighborhood health programs. This review of hospital ambulatory services, while briefly examining certain historical aspects, focuses upon the current status and advances in education and service provided for children by hospital ambulatory services. Because of current interest in education, the role of university and university affiliated institutions is emphasized.
THE DEVELOPMENT OF HOSPITAL AMBULATORY SERVICES From the beginning hospital ambulatory services have been expected to provide services to the poor and only recently to the more affiu''Director, Pediatric Service, Boston City Hospital; Professor and Chairman, Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts ''"''Chief, Child and Family Health Division, Children's Hospital Medical Center; Medical Director, Family Health Care Program, and Assistant Professor of Pediatrics, Harvard Medical School, Boston, Massachusetts Supported in part by grants from the National Center for Health Services Research and Development, Maternal and Child Health Services, HSMHA, and the Bureau of Physician Manpower Health Education, National Institutes of Health.
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ent. This is understandable since the hospital outpatient department had its origins in the dispensaries of the eighteenth century in Europe of which George Armstrong's London Dispensary for the Infant Poor, founded in 1769, was the world's first clinic for children. 18 The first pediatric outpatient department in the United States was established at the Children's Hospital of Philadelphia in 1856, one year after that institution's founding. Today there are over 3000 outpatient departments in the United States which serve children. Until the end of the nineteenth century, the hospital had a poor reputation for care and functioned principally as a custodian for the indigent sick, or more commonly as a place for the poor to die. As scientific advances resulted in improved hospital care, enhancing the reputation of hospitals, the early custodial function of the hospital was incorporated as the modern outpatient department. It is difficult to determine if emergency wards had a beginning which can be differentiated from the outpatient department. The early dispensaries contained both functions. Present day demands on these facilities are of such a different magnitude that for this analysis the emergency ward and the outpatient department must be considered separately. Neighborhood Health Programs, often sponsored by teaching hospitals, are seen as large scale programs developed in the 1960's as part of the war on poverty, but in fact these programs in the United States originated as child health stations, settlement houses, or neighborhood programs over 50 years ago. At that time, however, the neighborhood health programs had little or no relationship with the hospital77 and were most often associated with local health departments. From the beginning, the dispensary, and later the outpatient department, were used for teaching and clinical research. Thus outpatient departments functioned as a "medical soup kitchen" to feed the poor and a "medical feeder" to fill hospital beds. When the recommendations of the Flexner Report25 resulted in a closer relationship between universities, medical schools, and hospitals, the hospital outpatient department formally acquired the educational function. Consequently, the hospital outpatient department is an established part of current medical services and is therefore part of the current national crisis in the organization and education for the provision of health services. The increase in the use of hospital ambulatory services for children, especially when compared with the inpatient service, has been both notable and well described. In 1953, for every one inpatient admission to the hospital there were two outpatient department visits, but by 1967 the ratio had increased to four to one !3° For children the change has been staggering. At Boston City Hospital 75,000 children are seen annually in the ambulatory services and 3100 children are admitted as inpatients which is a ratio· of 25 outpatient department visits to 1 inpatient admission. This experience is not confined to a municipal hospital. The ratio of outpatients at Boston Children's Hospital Medical Center is 20 to 1. It is difficult to know with certainty what this means in terms of all health related services provided to children but in Monroe County, (including the city of Rochester) New York, hospital ambulatory services have been shown to provide at least 15 per cent of all medical services for children.33
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During the last decade, the users of hospital ambulatory services, especially the emergency ward, have been characterized more completely. For the most part, in urban areas, these are low income families who do not have a family physician and who use the hospital as their major source of health care. This use, however, varies from one community to another. In some settings the emergency ward is a trauma center and in others it is a substitute for the private physician on a temporary basis. 82 Factors associated with the increased use of the outpatient department and emergency ward include the changing nature of childhood morbidity (altered infectious diseases, better nutrition, specific therapies, new immunizing agents, better public health practices, and new risks such as accidents and poisonings), the rising demand for medical services, the changing population of cities, the availability of diagnostic services in the hospital, the dramatic fall in number of primary care physicians, and the perception by many patients of the hospital as the most desirable site for securing complex sophisticated medical services.
SERVICES The outpatient department and the emergency ward can offer primary care and secondary care services. Primary care means in the best sense first contact, integrated, and continuous care. 3 Hospital primary care services include emergency and nonemergency care which is usually not integrated and is discontinuous, while secondary services mean referral and consultative care. Modern outpatient departments were developed largely as secondary care clinics and as providers of emergency services (acute first contact service) and were not developed to provide a complete package of primary care.
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Techniques for treating the critically ill emergency patient have steadily improved and new standards for emergency facilities and equipment have developed. Largely in response to the dramatic rise in use of emergency facilities, new physician staffing patterns have emerged. 6 In smaller community hospitals, practicing physicians often share emergency ward responsibilities. In an increasing number of hospitals, full time physicians staff emergency wards either on a fee-for-service or salary basis. Many of these services are provided for children. As already noted, the major use of the outpatient department and emergency ward for children is for non-emergency primary care, and that form of care is sought by users, regardless of socioeconomic background.6s These needs are far more common than emergency, secondary, or tertiary (inpatient) needs in the general population8 n and organized programs in hospitals to provide these services have not developed on any sizeable scale despite the large number of outpatient department sites available.
Secondary Care Services While it is assumed that outpatient departments are properly designed to see secondary (referred) patients, these patients are often not
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appropriately served. Obviously, this is true when the referral should not have been made, i.e., when it is for a primary care problem. Many nonemergency primary care problems are referred or triaged for secondary care. About one half of the referrals of children to the outpatient department are for behavioral and psychological problems. There is evidence that these problems might have been managed more appropriately in another setting since effective management requires continuity and not just diagnosis. 7• 15 • 46 The establishment of more specialty clinics has not helped with the majority of patient referrals. While technically competent, the specialty clinics by their very nature are unable to cope with a problem beyond or even on the fringe of the specialty. Specialty clinics are established because of the interest of a particular physician or investigator, educational priorities, or in response to a categorical funding program and are frequently not related to the needs of patients. What is an appropriate specialty clinic in one setting when related to patient needs may be completely inappropriate in another. Many referrals of patients by physicians to hospitals are arranged by the patient solely to gain access to the clinic with little actual participation by the physicians.88 Other referrals are entirely self-initiated. Another kind of referral is the "referral" of a patient who receives primary care in the emergency ward to a part of the outpatient department. This is a paradoxical referral because there is usually no referring physician to whom the patient returns after consultation. This may be one of the important unexplored reasons for the high no show rate associated with such referrals. For example, most of these patients who are medically indigent would just as soon continue in the emergency ward for convenience, and see no benefit in following through with the outpatient department referral. For hospital ambulatory services the provision of coordinated and integrated care whether primary or secondary remains a major problem.28 • 32 • 75 • 84 The complex nature of most illnesses in children is appreciated. In the outpatient department, there have been multidisciplinary approaches in the diagnosis and management of children with chronic disorders, and efforts made to deal effectively with psychosocial issues presented in the care of such patients. 1• 29 There have been a number of attempts to modify outpatient department services in the direction of greater continuity and comprehensiveness. Many of these have been demonstration projects for teaching and few have been undertaken to change service in significant ways.t.so Costs to patients (or third party groups) for ambulatory services are generally higher in the hospital than in the private office. Major reasons for this difference are the inclusion of the more costly overhead of the inhospital services in setting outpatient department fees, increased utilization of the laboratory in the hospital, and high follow-up in the hospital. 34 It is also deceptive to compare costs only within the ambulatory area. For example, patients may be unnecessarily hospitalized for studies which are paid for by third parties only as inpatients. 41 • 63 While the "cost" of ambulatory care per se is lowered, the overall cost to society, although not perhaps to the individual patient, is considerably increased by this practice.
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TEACHING The teaching role of hospital ambulatory services and manpower needs for ambulatory care are closely related. From its inception, the outpatient department has been identified as the site where conditions of patient care most Closely approximate those seen in practice, and, therefore, as a fertile field for medical education. 16 • 18 A number of studies have called attention to the gap between the educational requirements for the practice of pediatrics and the traditional training of the pediatrician and have called for improved teaching in ambulatory care. 31 • 89 Already a high percentage of the pediatrician-in-training's time occurs with ambulatory patients.49 Nevertheless, the emphasis in most pediatric programs is still on in-hospital patients who are likely to have rarer illnesses. Less attention in the hospital is given to the common but no less complex problems of children such as health supervision, common infections, learning disorders, developmental difficulties, drug use, and accidents. Especially in pediatrics, teaching programs have been developed seeking to correct the educational gap that existed between career and training. Such programs were easy to establish because of the availability of patients .and because most teaching hospitals had outpatient departments that served children. Since most of these patients were indigent, meeting their needs did not put the institution directly in competition with private practitioners. The hospital administration could also hope to have more patients to fill beds. As already noted, most of these programs were demonstration efforts and did little to change the actual function of the outpatient department. Such attempts at reorganization began in the 1930's13 and continued after the second World War, reaching a peak in the 1950's.3 • 80 Many teaching programs emphasized interviewing skills and were coordinated pediatric and psychiatric programs. 70 Other programs emphasized well child care60 and still others the opportunity for students to follow families. 43 Evaluation of these teaching programs has been mostly descriptive and their history has been a short one. Even the limited goals of teaching interviewing may not have been achieved. 21 The specialty emphasis, the hospital bureaucracy, the usual hospital de-emphasis of the patient, and the difficulty in coordinating services in the long run proved to be unsurmountable obstacles.23 The best that could be said was that such programs attracted students whose motivation was patient care and who were interested in related psychosocial issues. 3
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EVALUATION AND RESEARCH The only national data available on the quality of care in hospital ambulatory services is provided by the reports of the Joint Commission on Accreditation. The Joint Commission has generally given more attention to inpatient than to outpatient department care, examining records and physical facilities, and has been concerned to a lesser extent with the content of care. This, of course, is rapidly changing, with significant emphasis on the peer review process and establishing standards of care. The .i.
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initial emphasis of such peer review will be on inpatient review. Chart reviews in the outpatient department have been valuable in teachinga 5 • 52 but not widely used to study quality. Attempts to develop methods of reviewing ambulatory charts for quality assurance are in progress such as the study program of the Joint Commission on Quality Assurance, 81 a consortium of nine national professional organizations including the American Academy of Pediatrics, the American Academy of Family Physicians, and the American Medical Association. The measures of quality used in the past have been mainly ones of technical adequacy of how well a step in the process of providing care was performed, but they do not answer such questions as whether the incident of care could have been prevented or whether it could have been more effectively handled in a different way, in a different place, or by different personnel. Structure and process are examined but little effort has been addressed toward measuring outcome. Outcome measures are needed since the ultimate test of effectiveness of any health program is the health of the population served, regardless of the source of care. Unmet needs cannot be determined by looking only at those who come for care regardless of how well the users are characterized. A necessary index of effectiveness is the health status of the target population. Such data are at present not available for users of the ambulatory services. Nor can the precise role of the outpatient department or emergency ward in the health care system be understood without knowing what distinguishes users from nonusers. 45 Another major problem in conducting such research is the absence of any widely used coding system which would be based on ambulatory patient problems rather than the usual hospital disease and mortality index. There are coding systems available such as has been developed by the Royal College of General Practitioners in the United Kingdom, 22 but the use of such systems is not widespread. Based on limited available data, evaluating the quality of hospital ambulatory services currently depends almost entirely on the reputation of the particular hospital. Reputation, unfortunately, does not equal quality. One study of the quality of care in a university hospital emergency ward showed that only 27 per cent of patients received "effective" care 12 and another, examining outpatient department specialty clinics, that quality of patient care as measured by record review was grossly deficient.52 These studies indicate that even the technical performance of hospital ambulatory services may not be of consistently high quality. The major criticism regarding quality has been, of course, that outpatient departments and emergency wards ministering. to the poor are symbolic of what is a two-class health system and provide care to people whose morbidity and mortality experience is among the poorest in our society _II· 47 • 58 • 76 Data from a number of recent experimental programs demonstrate a relationship between the organization of services and certain health indices. 4 • 48 Improvements in various measures of health occur in families offered a comprehensive pediatric care program with an on-going doctor-patient relationship. When compared to control families who continued to receive their medical care in the outpatient clinic, emergency ward, and well baby clinic, experimental families receiving
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comprehensive care showed altered utilization of health services, with a reversal of the ratio of sickness visits to well child visits, lower rates of hospitalization, lower rates of elective surgery, and improved ability to use the telephone. 4 These benefits are similar to those observed in prepaid group practices41 • 67 and in neighborhood health programs.8 • 45 From these studies, the setting seems less important than the principle of providing continuity of care. As greater interest in ambulatory services has developed, methods for describing and analyzing ambulatory care have improved and a closer collaboration has developed between the behavioral scientist and clinician.78· 79 Under the economic incentive of improved efficiency, analytical approaches found useful in the business community are being applied increasingly to ambulatory services and operationsP· 36• 41 Research in the ambulatory services has become a recognized area of clinical investigation2· 37 but obviously much more is needed.
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The future role of hospital ambulatory services as a source of health care for children and of education of health professionals cannot be considered in isolation but must be related to overall needs for change in health care. 61 • 71 This will require some form of national health insurance, stable financing of programs, incentives for efficiency and cost control, rationalization of training and use of health manpower, and the equalization of the present two classes of care. In this regard, recent federal legislation and cutbacks are to be deplored for emphasizing two class health delivery. The essential question regarding costs is how much does total care cost, not how much does ambulatory care cost. The control of costs, a major challenge to health services, depends on rationalizing the entire spectrum of needed services, and not just the ambulatory component. While these points are obvious in the long run, the short run demands that certain changes in the functions of the ambulatory services take place if these services are to serve children better. Historically, as noted, attempts to improve services in the ambulatory services have usually meant another specialty clinic or more effective triage. These efforts do relatively little to meet the needs of patients but they may improve the efficiency of the particular outpatient department. With some necessary modifications, hospital ambulatory services should continue to perform and improve upon emergency care for the critically ill patient and referral-consultative functions. Civilians should receive emergency care as technically competent as a serviceman in a war zone. The trend toward multidisciplinary clinics should be intensified. Close communication with the primary source of care must be maintained. A frank exploration of the mutual responsibilities of the emergency service and private practitioners who use it for coverage is essential. In addition, the outpatient department should continue to perform a non-emergency function, however restricted, for that segment of the population which is unable to use comprehensive care even when of-
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fered. 87 Preventive services should be offered to this group within the outpatient department, probably by establishing a special primary care clinic which will have defined goals and an identified population. This special clinic can incorporate features of prepaid group practice57 and should not necessarily be confined to the poor. Risks of this approach are that this effort is viewed as simply another specialty clinic and not as a means of reorganizing the outpatient department. There is also the risk of giving two classes of health care within the outpatient department. For that larger segment of the population which is capable of using comprehensive services outside of the hospital the primary care function of the present outpatient department and emergency ward should be eliminated as inappropriate and efforts made to enlarge private group practice and neighborhood health programs. 14 The best hope for reorganization of present services exists in those settings where there is a close relationship between neighborhood health programs and hospital ambulatory services. Since the hospital is generally a poor place to receive comprehensive care, it is probably a poor place to learn how to provide this care. The statement that the ambulatory services is the place to learn pediatric practice is clearly an oversimplification. The two class health care system has penalized all classes of society because the poor habits leamed and practiced on the class which has constituted "teaching material" are later transferred to the private sector. The trainee becomes expert at functioning in a suboptimal setting. Development of skills is left to chance. He is asked to serve as a consultant before he has leamed how to make a referral, and to delegate aspects of his work, such as health supervision, to non-physicians before he has ever fully understood the nature of the work he is delegating. One advantage of a model practice within the outpatient department is that this could also be the teaching model and minimize these risks. Evaluation of these teaching programs are needed to confirm that this is a benefit. At Boston City Hospital an attempt is now being made to establish a more efficiently organized outpatient department by separating emergency, walk-in, primary care, and consultative functions as has been done in other institutions. In addition, a teaching program in primary care for internists and pediatricians in the hospital ambulatory services has been developed. It is much too soon to know what success this effort will have but it will be evaluated. The teaching program will serve those patients who use the outpatient department as a source of primary care. A unit in the hospital will be staffed by faculty and residents in pediatrics and internal medicine who can establish a continuQus relationship with the patients they serve. The focus will be on the family as the unit of health and disease. Services for children and adults will be closely integrated. The primary care unit will be the point of entry for all care for the population served and will have firm linkages with referral and inpatient sources of care. Its staff will assume responsibility for securing needed services and relieve families of this complex task. Its emphasis will be on managing common disorders, and on prevention of disease, early detection, and health maintenance. At the same time the professionals will be skilled in the management of chronic illness and the unit
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will be a place to which hospitalized patients can be returned for coordinated, flexible follow-up, and long term care, a major deficiency in present outpatient department services. 54- 56 A similar unit will be established in a neighborhood health center. Here there are the advantages of lower overhead compared with the hospital, meaningful community participation, and greater likelihood of developing a family care system with teams and family records. This unit, however, has the disadvantage for the resident that he is asked to go a distance from the hospital and out of the traditional academic mainstream. Even for a short period of time (one half day a week for example) physical distance may be a significant barrier. The outpatient department does not have these disadvantages but does have the cost and organizational disadvantages. Part of the new primary care program will be to compare the two primary care sites as to their effectiveness as educational settings. Quality of teaching, career choices, and prestige are directly related to the priorities of the educational institution. If the teaching institutions cannot provide optimal care in the ambulatory services, how will the level of instruction and prestige in primary care careers rise and the present imbalance in career choices be corrected? Teaching can be improved, conferences upgraded, even visit rounds made in the outpatient department but the answer may once again require looking beyond the outpatient department or emergency ward. Formation of model group practices, the development of teaching and service programs in health centers, and conceptualizing health care as a system should add impetus to a full professionalization of the primary care role in educational programs. The hospital ambulatory services will play a part but cannot any longer be said to be the best place to learn medical practice. The success of these programs will require faculty and a hospital commitment. Within the past decade a new career line has developed in directing outpatient services and in teaching and research in ambulatory pediatrics. The Ambulatory Pediatric Association was begun in the early 1960's to improve research, teaching and patient care in the pediatric outpatient area. The American Academy of Pediatrics established a Community Pediatric Section in 1969. Despite these efforts there is no evidence that the needed number of academic generalists are being educated and that either of these efforts, or related efforts, have had a major impact on medical education. Hospital pediatric services must recognize that such phenomena as the falling birth rate and liberalized abortion programs will further affect childhood morbidity and one result will be even less demand for inpatient beds. Hospitals can take the initiative in changing their services within the framework of the desirable characteristics of a revised health care system and new needs of patients. Hospitals should abandon the position of traditional isolation and coordinate efforts with other hospitals and providers of health services in their communities. No one pediatric institution can meet the needs of all children who come for care and provide all of the education for needed health professionals. Hospitals, whatever institutional identity may be at stake, must begin to share both service and educational tasks.
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Because of the numbers of patients involved, the ambulatory service remains an important setting to serve, to teach, and to do research. Moreover, the hospital ambulatory services is the hospital's basic contact point with its community. Experiments and demonstrations with careful evaluation should be undertaken as a part of hospital ambulatory services medical practice. Rational decisions will, however, require careful planning and a change in priorities on the part of the hospital and medical school.
SUMMARY This paper describes the background, services, research function, effectiveness and educational role of hospital ambulatory services in the care of children in the United States. The explosive increase in utilization of hospital ambulatory services, not limited to the poor alone, is mainly for primary care needs, precisely that function for which these services as presently organized are largely inappropriately designed. The future role of the ambulatory services must be considered as part of the needed restructuring of a costly two class health care system. Within this restructuring, the emergency ward and outpatient department would continue to perform emergency and referral care functions, but should make major modifications in the primary care functions for patients. The major reason for offering primary care services within the teaching hospital is most likely educational and to provide service to a limited population who do not or cannot use community facilities. Neighborhood health programs and the physician's office should be strengthened as the proper place for delivery of primary care services. Attempts to rationalize the delivery of primary care services should be carefully studied and evaluated. Current changes in medicine require hospitals and medical schools to examine their roles in health care education and delivery. Whether hospitals and medical schools will lead or follow the changes ahead will hinge largely on the seriousness and excellence of its considerations of responsibilities in primary care. In operational terms, the answer to this question depends on how these institutions will deal with their ambulatory patients.
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