The use of handheld computers in medicine has grown dramatically. This session is intended for those who have a handheld computer (Palm or Pocket PC), or are considering purchasing one, but who have not yet learned how to use it. The goal of the session is to help the beginner achieve a working familiarity with handheld computing such that they will leave the session ready, able and eager to use their own device in their daily life and clinical practice. Ideally, all participants should bring their own handheld. The session will include an overview of the devices and their desktop software; mastery of the basic (built-in) functions: datebook/calendar, address book, memo pad, to-do lists; and add-on applications: where to find them, how to install them and what applications are available specific to clinical pediatrics. Participants should be familiar with the use of personal computers and the Internet, but no prior knowledge of handheld computing is assumed.

Introductions and Overview of Mini Course

Lecture (with Audience Participation)—PDA Basics, Hardware and Software, the Palm OS and Its Functions

Palm OS Functions, Continued; PPC OS

Medical and Pediatric Applications for the PDA
 

This 6-hour mini course is intended for faculty who teach and do research on pediatric environmental health problems. We will use an evidence-based approach and focus on research that is needed to clarify unresolved issues. The challenges and controversies in the field of pediatric environmental health will be presented, and there will be time to discuss prevention strategies for the clinic and the community. The participants will develop and share ideas to use in teaching, research and practice. (There is a separate workshop for Chief Residents on May 4, 2003.)

Content of this session is similar to session 6200 An Introduction to Children's Environmental Health

In the current climate of funding opportunities, the ability to successfully obtain extramural support involves applying for grants that are appropriate for an investigator's career stage and drafting a clear and focused application. In this session, we will discuss career-stage-appropriate funding opportunities from the NIH. We will also address how to write a grant application, focusing on strategies with proven success. The working of NIH study sections will be reviewed along with how to best address the concerns of review panels. We will also focus on how to obtain funding for fellowship postdoctoral training and early stages of an academic career.
 

Background: Observational research studies have become increasingly complex. The results of observational research studies can be driven by properties other than chance or causation. While these factors may drive the p values of the results, they also change the appropriate interpretation.

Workshop Methods: In the first half of this workshop, we will formally define confounding, effect modification, restriction vs. heterogeneity of exposure, intermediate variables, selection bias and differential vs. nondifferential information bias. In the second half, we will use a case-based approach to illustrate examples of studies in which the results are driven by these factors and compare differences in the appropriate interpretation in the presence and absence of these factors. Minimal math skills will be needed, however, familiarity with basic concepts of study design and data analysis (case control vs. cohort study, interpretation of Ors, etc.) is recommended. We will specifically illustrate examples of effect modification vs. confounding, intermediate variables vs. confounding, selection bias, underpowered studies, and the role of measurement error in determining effect estimates.
 

To improve child health outcomes, pediatricians will need to expand their expertise to include population-based knowledge and skills. Collaboration with local health departments and public health practitioners can provide assets and resources to pediatricians to support them in these efforts. This workshop will: (a) establish a framework for linking pediatrics and public health on the local level; (b) identify and demonstrate the inventory, relevance and use of public health resources to child advocacy, clinical pediatrics and population-based child health; and (c) develop approaches for practitioners and pediatric educators that integrate pediatrics and public health to improve child health. Healthy People 2010 and Community Oriented Primary Care will be used to provide context to the discussion.

After an introductory didactic presentation, participants will be engaged in an interactive case study and scenario development process to demonstrate and generate potential strategies to improve child health. This will include: access to data relevant to clinical practice and child advocacy, introduction of population-based practices into clinical practice and the application of the principles and practice of public health to common health issues affecting children, e.g., asthma, obesity, diabetes, infant mortality, substance use. Names of local health officials in communities and a set of relevant websites will be provided.
 

The field of medicine is replete with examples of ways that handheld computers may be used to educate, organize and inform clinicians. There are also examples of how researchers may benefit from this technology. During this more advanced session, we will discuss some of these uses of handheld computers. We will provide examples of software in a variety of domains and discuss their historical, current and future use. We also will demonstrate some future technology and discuss its implications. At the conclusion of this session, participants will have increased familiarity with state-of-the-art applications, techniques to install them and the future of handheld computers and wireless networking.

Introductions and Overview of Mini Course

Lecture with Audience Participation: The Top 10 Novel Uses of PDAs in Health Care

Exercises and Demonstrations
 

Pediatricians are often asked to evaluate children for sexual abuse, yet deciding when, where, how and by whom the evaluation should be done are problematic given the rapidly changing interpretation of physical findings and testing and the paucity of data regarding the optimal provision of health services for this population.

This workshop will address the multiple decisions facing the primary pediatrician in sexual abuse evaluation by using an interactive, case-based approach and clinical decision analysis in a 60–90-minute workshop session. Participants will receive a brief introduction to the literature regarding triaging sexual abuse cases based on child age, gender and recency of contact and will be updated regarding interview techniques, interpretations of findings and medical and legal outcomes.

Using predictive values for outcomes based on timing, behaviors, disclosure and physical findings, participants will then select and evaluate the effects of their various choices at each clinical decision point (triage, type of evaluation, testing, referral) in 4–6 test cases. Clinical decision analysis will be used to optimize health and legal outcomes based on the participants’ choices. Potential strategies for health services for child sexual abuse will be reviewed with participants based on locally available resources.
 

This session will provide an overview of the Healthcare Cost and Utilization Project (HCUP)—a family of databases and tools maintained by the Agency for Healthcare Research and Quality (AHRQ)—and will include presentations by child health services researchers of their projects utilizing one of HCUP’s databases, the Kid’s Inpatient Database (KID). The KID is a unique and powerful database of hospital inpatient stays for children age 0–18 years. The KID was specifically designed to permit researchers to study a broad range of conditions and procedures related to child health issues. Researchers and policymakers can use the KID to identify, track and analyze national trends in health care utilization, access, charges, quality and outcomes. The KID contains approximately 1.9 million hospital discharges for children and includes a sample of pediatric discharges from over 2,500 U.S. hospitals. Since the KID has a large sample size it can be used for analyses of both common and rare conditions such as congenital anomalies, uncommon treatments and organ transplantation. Users will receive detailed packets of information about KID products. Research studies on congenital birth defects, hypoplastic left heart syndrome, adolescent depression and others will be used to illustrate application of the KID data and tools.
 

This 6-hour mini course is intended for faculty who teach and do research on pediatric environmental health problems. We will use an evidence-based approach and focus on research that is needed to clarify unresolved issues. The challenges and controversies in the field of pediatric environmental health will be presented, and there will be time to discuss prevention strategies for the clinic and the community. The participants will develop and share ideas to use in teaching, research and practice. (There is a separate workshop for Chief Residents on May 4, 2003.)

Content of this session is similar to session 6200 An Introduction to Children's Environmental Health

This interactive session will provide the attendee with basic information on publication of a manuscript, as derived from the perspective of an editor. Issues (with data provided when possible) to be discussed are:

A. View From the Inside

1. Characters involved
2. Manuscript flow
3. Peer review process
4. Working with the author

B. View From the Outside

1. How to choose the right journal for your paper
2. How to prepare the cover letter
3. How to prepare the abstract
4. How to prepare the body of the manuscript
5. How to prepare the references

C. Conflict of Interest and Ethics
 

With their numbers continuing to grow at an alarming rate, health care needs of the more than 500,000 children in foster care often remain unmet. Children in foster care suffer from inordinately high rates of acute and chronic illnesses, lack of preventive health care, mental illness and developmental delays. Inefficient child welfare agencies, inadequate health care funding and a dearth of qualified health care and mental health care professionals willing to treat this population of children compound the problems.

Audience Questions

The 21st century heralds a paradigm shift in medical education with a focus turned to competence and outcomes. The Accreditation Council for Graduate Medical Education (ACGME) is spearheading a competency-based system of graduate medical education coincident with the American Board of Pediatrics’ (ABP) initiative to transition from periodic "recertification" to "maintenance of certification." Our greatest challenge as educators lies in developing tools to evaluate competence during training and to equip all trainees with the skills necessary to achieve quality continuous professional development in order to maintain their certification in pediatrics.

The overarching goal of this workshop is to explore the value of using technology as a tool for promoting self-assessment and lifelong learning in continuous professional development. We will demonstrate how physicians can use an innovative web-centered tool to document competence in practice-based learning and improvement. Participants will discover how to create and manage a personal list of educational needs based on their professional experiences, develop individualized learning plans to address these needs and then document the impact of learning on their practice.

The outcome of implementing this web-based technology will be the ability to demonstrate competence of our trainees in the domain of practice-based learning and improvement to the ACGME and the preparation of tomorrow’s physicians to demonstrate evidence of continuous professional development in maintaining their certification.
 

What should you do when parents want you to continue burdensome treatments, which you think are futile? What should you do when parents want you to stop intensive care treatment, the continuation of which you think is in the best interests of the child? Who ought to make decisions for the not yet competent? Is it the parents, the doctors, the ethics committee, society or some other disinterested third party? The goal of this seminar is to consider the complexity of these difficult decisions, looking at factual and evaluative considerations. Through interactive case discussion we will identify the problems and potential pitfalls in decision-making for the pediatric population.
 

The purpose of this symposium is to describe the benefits to pediatricians of collaborating with public health specialists and to offer examples of some effective collaborations. Speakers will identify resources available to pediatricians who want to engage in public health efforts.

This program will give a "pediatric perspective" to smallpox bioterrorism preparedness planning efforts now under way within federal, state and local public health agencies. It will include a review of smallpox epidemiology, clinical disease, smallpox (vaccinia) vaccine and lessons learned from the WHO Smallpox Eradication Program. The nature of the current threat and responses to that threat will be discussed.

American Indians and Alaska Natives (AI/AN) represent the smallest ethnic group in the United States. Large disparities exist between child health status indicators in this population and the rest of the U.S. population. The AI/AN population is also unique in that tribally enrolled AI/AN members have access to a unique healthcare system sponsored by the federal Indian Health Service (IHS). Increasingly, the IHS is turning over control of Indian health care to tribal health entities, thereby encouraging autonomy and self-determination. A consequence of this transfer of responsibility, IHS is providing fewer centralized administrative and consultative services to independent tribes. As a result, tribes will become increasingly reliant on alternative sources of assistance. Potentially rewarding new opportunities exist for pediatricians from universities and pediatric organizations to provide clinical and public health consultation to these newly independent tribes and their regional consortia. This workshop is aimed at clinician-teachers and investigators interested in developing closer ties to tribes and urban Indian organizations in their area. The following topics will be discussed during the session: 1. The evolution and devolution of the IHS: a contextual history of health services for AI/AN’s (didactic); 2. community-based participatory research in Indian communities: tribal expectations (panel discussion); 3. creating and optimizing educational opportunities for medical students and residents in AI/AN health sites (panel discussion). 4. advocacy for Native American health: how can we help? (interactive presentation).
 

Since 1989 New York State has had regulations that specifically prescribe resident work hours. Now, legislation that restricts resident work hours is being considered in many states and on the national level. In addition, the ACGME has instituted new regulations to take effect in July 2003. Clearly such regulations will have an impact on the structure of most residency training programs. The goals of this workshop are to explain the regulations and learn ways to accommodate to the regulations—not only meeting the work hour limits but how to continue to incorporate teaching in the lives of the residents. The presenters are all experienced New York residency directors who have taken different approaches to meeting the 405 regulations. After an introduction reviewing the regulations the presenters will explain some specific methods that have been successfully used, including creative scheduling, night float systems, and the incorporation of additional providers. The attendees will then break into small groups to work on the challenge of meeting the regulations in their own programs, facilitated by the presenters. The session will end with each small-group sharing their ideas. This workshop is intended for anyone involved in residency training. The presenters have no conflicts of interest to declare.
 

The Institute of Medicine has challenged health care leaders to redesign health care systems to achieve care that is more patient centered, timely, efficient, effective, equitable and safe (in "Crossing the Quality Chasm: A New Health System for the 21st Century"). Dramatic improvements in patient care, in alignment with the IOM challenge can be made with innovative clinical models. At the Open Access Workshop at the 2002 PAS meeting, the basics of the Open Access concept were presented. Improvements include increased access to care and productivity, optimal utilization, decreased urgent care visits and improved preventative health care outcomes. At this session, participants will understand the Open/Advanced Access model applications. Lessons learned from the Institute for Healthcare Improvement (IHI) National Initiatives, along with Mayo Clinic experience in primary care and specialty care areas, will be shared. Implementation in primary care and specialty clinics, as well as academic settings, will be reviewed. The format for the session will be highly interactive with the understanding that many pediatricians already have substantial understanding and experience with the Open/Advanced Access model of care.
 

Receive helpful pointers to make your talks memorable and useful. This session will introduce methods of planning and organizing presentations, preparing and designing visual aids, handouts and clear delivery.
 

The 2001 World Trade Center and anthrax attacks established terrorism as a reality in this country. In addition to anthrax, critical biological agents include smallpox, plague, tularemia, botulinum toxin, and viral hemorrhagic fever. Release of sarin nerve gas in the Tokyo subway system by the Aum Shinrikyo cult in 1995 resulted in some 5,000 casualties, including 12 deaths, and the threat of a radiation incident perpetrated by terrorists is also real. Pediatricians have a key role in the management of illness after a terrorist incident, including biological, chemical or nuclear releases. Effective preparedness requires an increased index of suspicion for unusual diseases or clusters of illness, with prompt reporting to public health authorities to facilitate recognition of an outbreak and subsequent intervention. Psychological effects of a domestic terrorist disaster on children will also need to be managed appropriately. This workshop will address the epidemiologic, clinical, preparedness and response issues relevant to biological, chemical and nuclear threats to children, who are especially vulnerable. Specific and detailed diagnostic and management information will be provided, as well as emergency contact and educational resource information.
 

In the face of dramatic alterations in health care delivery during the 1990s, the roles of pediatric generalists and subspecialists have changed. This has led to national debate as to how general pediatricians and subspecialists should be trained, how they should interact and what final product or solution is desired. Both the United States and Canada are affected by these changes. In this session three experts will cover important aspects of this emerging problem.

In low- and middle-income countries where more than 80% of the world’s population lives, birth defects and other perinatal problems cause more loss of healthy years of life to early mortality and disability than almost any other condition. Yet, development of strategies for the prevention and care of birth defects has received insufficient international attention to date. The reasons for this include: a general lack of knowledge of the problem and of the considerable social and economic toll it imposes; a lack of awareness of the potential for prevention; and, as important, the absence of an international framework of mechanisms for promoting cooperative actions and solutions.

This session will present statistics on the global toll of birth defects and discuss a recent report of the U.S. Institute of Medicine commissioned to identify cost-effective opportunities for care and prevention of birth defects in developing countries. Specific recommendations for priority research, capacity building and institutional efforts to reduce adverse birth outcomes will also be discussed. The session will explore the applicability of the report’s findings to developing countries. It will also suggest what actions are required to implement appropriate public health strategies. It will conclude with a presentation on research directions for care and prevention.

Family presence for procedures is a relatively new concept in pediatric medicine. Studies have shown that many parents prefer to be with their children when they undergo painful or invasive procedures. Some physicians are reluctant to accept this break with tradition and refuse to allow parents in the room. The purpose of this workshop is to develop an approach to successful procedures with parental presence. Workshop leaders (including physicians, social work, housestaff) will address critical issues such as:

• Review of the literature—what do parents/families want?
• What is best for the children?
• What rights do the parents have? How about the physicians?
• Are some situations/procedures (i.e., resuscitations) "off-limits"?
• How can we instill confidence in trainees when the family is watching?
• Can we preserve teaching opportunities?
• Are there safety risks? Legal issues?
• Enlisting the help of others: the role of liaisons, social workers, therapists

Using case scenarios and role-playing, workshop leaders will address the pros and cons of family presence for procedures. Participants will be expected to share their experiences and ideas to move forward with this "unconventional" approach to medical care. It is expected that through discussion and debate we will implement a system for success.
 

Patients and their families in low-income communities require a multidisciplinary healthcare team that includes lawyers to protect the health of their children and to navigate the bureaucratic barriers to government benefits. These patients often require assistance that extends beyond the traditional training of physicians. Doctors must become familiar with advocacy resources and learn to use new tools to assist their patients with diverse social-medical problems. The goals of the workshop are to:

• Teach pediatricians and other health care providers about the basics of legal advocacy by providing them with the necessary tools and resources to proactively address the social issues that affect children’s health and wellness.
• Introduce pediatricians to new tools including eight innovative ‘Advocacy CPGs’ and the ‘Advocacy Code Card.’ These tools guide physicians’ assessment of families’ social needs and provide appropriate resources, general tips and a sample advocacy letter.
• Demonstrate and offer access to The Online Advocate – a new, web-based tool that prints ‘Rx for Advocacy’ prescriptions to facilitate the referral process and helps providers ascertain which referrals could help a family.
• Emphasize the unique ability of collaborations with legal services located within pediatric clinics to comprehensively care for children’s health. Participants will learn methods to establish legal liaisons and review cases involving medical-legal alliances.
   

The incidence of lawsuits in the United States continues to rise. Within this environment, pediatricians are vulnerable to litigation yet often have limited experience and information about the legal process and relevant principles of law. Legal dilemmas are particularly common in acute care settings and frequently are managed without the immediate advice of counsel. In this workshop, participants will explore basic legal issues that impact on medical practitioners, gain familiarity with the litigation process and examine strategies for testifying in court. A team of specialists in pediatric emergency medicine, malpractice issues, court testimony and forensic medicine will begin the workshop with an interactive presentation of case scenarios that highlight common statutory dilemmas, malpractice issues and the litigation process (civil and criminal). Participants will then view videotapes of court testimony and discuss strategies for testifying as a fact or expert witness. Workshop leaders and participants will conclude the session with small group discussions of individual experiences with civil or criminal proceedings and legal testimony. A complete syllabus will be provided for the workshop that is designed for use as a teaching manual.
 

1. Resident Advocacy Poster Session: We will solicit abstracts from residency programs, including recipients of past Resident CATCH Planning Grants. We will select up to12 abstracts for poster presentation at the SIG.
2. APA Policy Statement: Last year, we discussed the idea of sponsoring a Policy Statement on Advocacy Training that reflects our understanding of the needs to nurture young advocates in the same way as the APA nurtures new researchers or educators. We will use the meeting to develop and refine such a consensus for submission to the Board.
    

Al Aynsley-Green, National Clinical Director for Children, Department of Health, Her Majesty's Government, Nuffield Professor of Child Health, The Institute of Child Health, University College London
University of London, Director of Clinical Research & Development, Great Ormond Street Hospital for Children and The Institute of Child Health, London

What happens when there is a public national concern about excessive poor outcomes at a Children's Medical Center? This was the scenario in Bristol, England, where a crisis in the outcome of children after cardiac surgery developed even when well–trained, committed, concerned clinicians and subspecialists were intimately involved. Because of this, Professor Al Aynsley-Green, President of the Academic Paediatricians, was appointed to the new post of National Clinical Director for Children by Parliament and to Chair a Children's Taskforce to answer the question of how can such a negative experience like this be turned into positive outcomes for children? He is charged to secure the health and well-being of all children throughout childhood into adult life by developing a National Service Framework for children's services across health, social care and education.

Lessons he has learned and experiences he has lived will be shared to help pediatricians around the world with our quest to improve the lives and health of children. The goals, activities and experiences of the Children's Taskforce, as well as six external working groups, are exportable, practical and logical. Strategies used for developing opportunities not only to improve child health at a local level but also at a national level will be discussed.

Opportunities for questions and discussion will be provided so attendees can share effective techniques to improve child life and health.
 

Newborn screening programs, which have been in place for more than 40 years, are facing major challenges. Technological advances permit the addition of an increasing number of diseases, including many for which the benefits are not as clear-cut as for PKU, congenital hyperthyroidism or sickle cell disease. As pilot projects evaluate the addition of new tests, the importance of involving parents in decision-making is being actively discussed. Originally established with a "public health imperative," the predominant state model has been one of "informed dissent." Various models for informing and involving parents will be discussed, as well as their feasibility and cost. There are a number of legislative developments under consideration locally and nationally, and these will be presented and analyzed. As new diseases are considered for addition to screening batteries, it is possible to screen for disorders that have no effective interventions defined. It is clear that if we do not screen for these diseases, no improvements in care will advance. We will discuss whether such arguments justify screening. In summary, technological advances are forcing policy decisions. We will discuss the impacts of these challenges.

This symposium covers four issues in vaccination. The American Academy of Pediatrics and CDC currently are moving toward a recommendation for universal annual vaccination of infants with killed or live influenza vaccine. Why is this? Now that Rotashield is off the market, a new rotavirus vaccine is needed and may be on the way. Despite good protection of children by vaccination, pertussis infections are rising in adolescents and adults. Can they be controlled? Recent disruptions in vaccine supply have caused pediatricians significant problems. What are the causes and solutions?

• Advocacy/Community Health
   

Background: Many children present to the Emergency Department or other acute care setting with forensic-related issues, but few training programs prepare physicians to properly deal with these issues. Clinical forensic medicine is the branch of medicine that deals with cases involving both medical and legal aspects of patient care.

Objective: This workshop is designed to increase participant awareness of their patients’ forensic and legal needs and to review with them forensic techniques for initial evaluation.

Methods: Experts in the fields of pediatric emergency medicine, child abuse and neglect, toxicology and forensic medicine will work side-by-side with participants, teaching them to evaluate survivors of non-accidental injury. Workshop leaders will actively engage participants and provide hands-on instruction of the following skills: the detection, collection and preservation of evidence; documentation of injuries (including photography in the ED); pattern injury recognition; interpretation of injuries; and reporting requirements and regulations. All registrants will receive a comprehensive syllabus containing vital information and references related to the practice of Clinical Forensic Medicine.
 

Environmental health is an increasingly important field within public health. This course will focus on children's environmental health. Children are different than adults in their exposure and susceptibility to environmental hazards. The workshop will emphasize the special needs of children from epidemiologic, physiologic and public policy perspectives. Participants will be provided with several case studies and access to reference material. They will work through the cases to discover clinical information or public policy approaches to dealing with environmental health problems. Participants will be able to: identify the characteristics of children that make them especially vulnerable to environmental insults; describe the unique exposures that children have to environmental hazards; describe the effects of certain specific pollutants on children, and identify components of federal, state and local governments that have an impact on children's environmental health.

The creation of this workshop is funded by a grant from the Association of Occupational and Environmental Clinics.

Content of this session is similar to session 3151 Pediatric Environmental Health (Part I) and 3650 Pediatric Environmental Health (Part II)
 

Recent financial scandals affecting successful and respected companies have focused public attention on conflicts of interest involving corporate officers, stockholders, and customers. In the medical research world, too, recent events have raised questions about conflicts of interest affecting investigators, research subjects and patients. Examples of the latter include the financial interests of gene-transfer experimenters (the Gelsinger case at the University of Pennsylvania) and study goals versus individual subject/patient interests in the Kennedy Krieger law suit (Hopkins lead abatement study). Despite the potential pitfalls, pediatric researchers receive only perfunctory training in handling them. This workshop will provide investigators with a framework for and experience with considering real and perceived conflicts of interest in their research. We seek to provide guidance and support for investigators who need to recognize and face ethical concerns that may arise from proposed and actual research. During the workshop, we will describe potential conflicts of interest affecting: (1) individual researchers, (2) institutions (hospitals and universities), (3) research subjects/patients and (4) the public at large, including the mass media. Short presentations will set the stage for attendees to participate in role playing with a variety of scenarios and to present and discuss their own cases.
 

This session will address the topic of "perinatal origins of adult disease." The three speakers will address different aspects related to the early origins of adult disease. Dr. Kent Thornburg will address the issues related to the fetal origins of adult-onset cardiovascular disease, Dr. Guiseppe Colasurdo will discuss the impact on adult-onset reactive airway disease due to postnatal exposure to environmental stimulants, and Dr. Pinchas Cohen will cover the influence of postnatal insulin-like growth factor on the development of carcinogenesis. All three speakers will shed light on the mechanisms underlying the phenomenon of "Perinatal Origins of Adult Disease" in three different disease states using various animal models. This session will provide cutting edge information that will help set the stage for future interventions targeted at the mechanisms outlined.

Academic Medical Centers (AMCs) are the result of unique partnerships between medical schools, research institutes, and teaching hospitals and are among the treasures of our society. During the past century, AMCs have evolved in response to need and opportunity as well as to social and economic forces. They have made possible unprecedented advances in human health, in biological sciences, in medical technology, and in the education of a very specialized and knowledgeable cadre of scientists, physicians, and other health care professionals. In the process, AMCs have grown large and ever more complex and require continuous inputs of resources to sustain them. Despite the apparent success of AMCs and their widely appreciated intrinsic value, they are challenged as never before. The diversity and complexity of missions has created stresses upon the social order. Financial pressures resulting from a fragmented, market driven reimbursement system, lack of adequate attention to preventive services and to cost of care issues, questions about true measures of quality, ever more expensive research infrastructure requirements, changing social expectations combined with a relative illiteracy regarding science and health in the general public threaten AMCs existence as we know them. Despite fears that these factors have the potential to create a "perfect storm" that will derail the momentum for progress, a detailed understanding of AMCs history, current circumstances, and future prospects gives cause for optimism. With thoughtful leadership, commitment to values, and a willingness to lead change in many areas, AMCs can continue to thrive and achieve even greater success.

The speakers in this symposium are a practitioner of medicine and historian who has written two very widely read and highly acclaimed books about these issues, Learning to Heal and Time to Heal (Kenneth Ludmerer) and a former medical school clinician, teacher, investigator, and dean who is now one of the nations most ardent and eloquent spokespersons for AMCs in his role as president of the Association of American Medical Colleges (Jordan Cohen).

Over the past several years, it has become increasingly apparent that there are major disparities in health status among different segments of our population. This is as true for children as it is for adults. The causal factors responsible for these differences are multiple and complex. They include genetic factors (e.g. susceptibility to disease, response to environmental challenges, and drug metabolism), cultural and environmental factors (e.g. diet, activity, and ecological exposures), and factors that determine access to health care services. If we are to have a positive impact on the incidence and outcomes of many of these major health issues for children, we will need to better understand the causes of these differences and to determine which interventions will provide the most positive results.

Discussion