The Ambulatory Pediatric Association
Joel J. Alpert, MD
Pediatrics 95(3):422-426.

Used with Permission.

The Ambulatory Pediatric Association (APA) held its 34th annual meeting in Seattle, Washington from May 2 to 5, 1994. Registrants participated in 31 workshops and 18 special interest groups. The Association of Ambulatory Pediatric Services held its first meeting in Swampscott, Massachusetts on May 2, 1960. Thirty-two pediatricians attended, most of whom were directors of pediatric outpatient departments (OPDs). The first Association of Ambulatory Pediatric Services scientific meeting was held at the Traymore Hotel in Atlantic City, New Jersey on May 3, 1961. Five of ten papers submitted were presented in one evening session.

This essay describes the remarkable story of four decades of the APA and how this organization of over 1,500 members became the recognized voice of ambulatory academic pediatrics. The story is of achievements hoped for by the APA founding parents and accomplished by three generations of APA members.

Personal Involvement and Background

My involvement with the APA began at the 1962 meeting in Atlantic City. I presented my first paper at a national meeting at the 1965 APA meeting and I was elected to the APA Board in 1966, becoming president in 1969. My APA activity continued through regular attendance at annual meetings, as a participant in a number of APA projects, as an APA spokesman regarding federal funding of primary care residencies and workforce issues, and as a continued presenter, frequent commentator, and debator at the annual scientific and business meeting. The APA has been my most important scholarly affiliation, and it is an honor to tell the APA story. There have been two written histories of the APA, the first by Fred Blodgett and Dick Olmsted in 1971 and the second by Ruth Stein in 1990 on the occasion of the APA's 30th anniversary. These two histories have provided valuable documentation for this essay, as have past APA minutes and newsletters.

The Beginnings

The APA founders met at the 1952 meeting of the American Pediatric Society and the Society for Pediatric Research (APS/SPR). In that group were Barbara Korsch, Andrew Hunt, Loren McKinney, and Victor Vaughan. They shared a need to study and to improve the delivery of outpatient care. In the spring of 1953, Barbara Korsch, who was the Clinical Director of the OPD of New York Hospital, wrote a number of Pediatric Chairmen who had recently appointed full- or part-time directors of their OPDs. She invited her colleagues to meet at the time of the APS/SPR meeting in Atlantic City.

On May 6, 1953, about 30 pediatricians met in Atlantic City. Barbara Korsch was elected Chairman. Most present believed that no formal organization was needed. In 1954, the group met and more names were added. Again, the majority considered it unnecessary to create an official organization. There was a presentation of the Comprehensive Care Clinic at Cornell, which was one of the pioneering medical education experiments in comprehensive care. In 1955, Barbara Korsch attempted to relinquish her responsibilities as Chair but was persuaded to continue. In 1956, the APS/SPR moderator announced that all persons interested in outpatient clinics should meet. He appeared to hesitate and wonder what investigator would be interested in outpatient clinics. Barbara Korsch passed the gavel to Dick Olmstead. In 1957, there was a small meeting in California. The meeting was described as a testimony to revivalism. Plans were made to carry out a survey of OPD directors.

In 1958, the director survey was discussed. Barbara Korsch published the survey results in 1959. Charles May, the editor of Pediatrics, wrote in his introduction to the paper:

The need to develop pediatric outpatient departments for better service to patients and for the teaching of students and physicians is being generally recognized. Pediatric department heads are more or less reluctantly turning their attention to this phase of work because the composition of pediatric practice has changed.

A group consisting of Phil Ambuel, Morris Green, Fred Blodgett, and Bob Haggerty worked through the winter of 1959 to plan for the new organization. A constitution was approved at the American Academy of Pediatrics (AAP) meeting in Chicago on October 18, 1960. The objectives of the APA spelled out in the constitution were “to improve the teaching of general pediatrics, to improve services in general pediatrics and to affect public and government opinion regarding issues vital to teaching, research, and patient care in general pediatrics.” The first officers elected were Chairman Dick Olmsted, Vice Chairman Morris Green, Secretary Fred Blodgett, and Board Members Barbara Korsch, Phil Ambuel, and Luigi Luzzati.

The papers presented at the 1961 scientific meeting dealt with the teaching potential of the emergency clinic, development of a poison control center, hospital services for children, the relationships of physicians-in-training in pediatric OPDs, and the biochemical and psychological aspects of the dietary management of children with phenylketonuria.

The founders had generally been placed in the OPD by their chiefs to hold the OPD together for a few years and then move to their chosen subspecialty. However, the founders discovered an exciting laboratory, the challenges of which far exceeded what the chiefs had in mind.

What's In a Name

Association for Ambulatory Pediatric Services was chosen as the name for the new organization. Association was used rather than Society because the former suggested openness. This was a clear hint that the APA did not intend to be elitist but was to be advocacy driven. Membership was to be seen not as an honor but as a call to action. Ambulatory was to emphasize concern about the child out of the hospital, including outpatient emergency clinics, community settings, and private practices. Services was never questioned, as the group had agreed that although research and teaching were the means, the goal was better services for children. In 1968, the APA Board believed a name modification was needed. Hugie Smith authored the change, and to avoid confusion with the AAP, he reversed the order of AAPS to obtain Ambulatory Pediatric Association, dropping the word Services. The name change and other constitution amendments were accepted without a recorded vote.

Discussion about further name changes continued, and a major effort to change the name occurred in the early 1980s. The Robert Wood Johnson Foundation had sponsored programs in General Academic Pediatrics, providing new legitimacy to the term general. The APA Board felt that it was time to signal that education and research were the major purposes of the APA, and submitted to the membership that the name become The Society for General Academic Pediatrics. The Board also recommended that membership criteria be developed. The idea of membership criteria and the name change were debated and resoundingly defeated at the 1984 annual meeting.

The name-change issue persisted, and in 1993 the APA Board recommended that the APA become The Society for General Pediatrics, which was judged as politically correct. The recommended change was similar to that of the general internists' abandoning their original name of the Society for Research and Education in Primary Care Internal Medicine and becoming the Society for General Internal Medicine (SGIM).

To change the name, a mail ballot was completed as required by the constitution. A majority of the membership voted for the change, but the necessary two-thirds vote was not reached. So much for adhering to constitutional rules!

The major argument for change was that the name APA was confusing and that general pediatrics was clearer and timely. The argument against the change was largely tradition and resistance to changing a name whenever a new term became popular. For example, the name could have been the Association for Primary Care Pediatrics or Association for Community Pediatrics! And so the organization remains the Ambulatory Pediatric Association, at least until the name-change issue emerges again.

Membership

APA members have been health care professionals involved in teaching, patient care, and research in general pediatrics. There was no research requirement, nor was entry to be based upon the quantity or quality of publications. The member would likely be a physician but did not have to be. Only on extremely rare occasions was membership denied. Being nominated, completing the application, and being willing to pay dues (especially as dues increased) were viewed as sufficient criteria. In 1976, Maggie Heagarty had written, “members of this group are discontents who seek to reform pediatric education and delivery.” The lack of membership criteria probably was one reason the APS/SPR delayed acceptance of the APA as a meeting partner. Until the late 1960s, there was separate and reserved front seating for APS/SPR members. Entry was gained by the color of the name tag, suggesting that APS/SPR membership was a badge of honor to which the young should aspire. This practice was abandoned in the mid-1960s as the front rows remained unoccupied and such obvious elitism made the APS/SPR uncomfortable.6

In 1986, the APA, now some 1,200 members strong, carried out a membership survey. Based upon an 85% response rate, the membership profile was 93% physicians, of whom 98% were pediatricians. More than half of the members had completed fellowship training. Most fellowships were in ambulatory care, general pediatrics, child development, and behavioral pediatrics, but a number were in organ subspecialty medicine. A few fellowships were in the newer areas of medical education, chronic illness, and emergency pediatrics.

The majority of APA members worked in urban settings, usually in medical schools or affiliated hospitals. Fifty-seven percent were full-time faculty. Sixty-three percent reported that they were engaged in research. Despite the relatively young membership (56% were younger than 45), there were 66 department chairmen among the respondents and 57 directors of residency programs.

The founders were 14% women. In 1986 the Association's membership was 37% women, and in 1994 it was 44%. The APA has always had women in leadership positions, but it was not until 1973 that the Association elected Kate Lobach as its first female President. Since then, seven women have served as President.

Relationships with the APS/SPR and Other Organizations Acceptance of the APA by the APS/SPR came about for pragmatic reasons. The APA agenda, namely ambulatory pediatrics and health care reform (well before it was labeled such), graduate medical education, primary care, and the nation's medical workforce, became the agenda for all of the major pediatric organizations. The APS/SPR had attempted to develop meeting subsections in epidemiologic and behavioral pediatrics but were not happy with the submitted abstracts. In 1968, believing that the better abstracts were going to the APA, Dav Cooke and Bob Greenberg as secretaries of the APS and SPR reached out to the APA, hoping for joint sessions in 1970.

From 1960 to 1967, the APA annual meeting was an evening meeting so that there was no direct competition with the APS/SPR. For the first time in 1968 there were two APA sessions, one of which overlapped with an APS/SPR session. After 1968 as the APA meeting grew, the need for space for the APA time became substantial. The APA was often treated in a forgetful manner by the APS/SPR leadership. At the 1976 national meeting, topic plenary sessions were instituted in addition to workshops, allowing more papers to be presented.

Meetings are planned as long as 5 to 6 years in advance. When the American Societies were invited in 1969 to meet in Toronto at the 100th anniversary of the Hospital for Sick Children, only the APA accepted. Relations with the APS/SPR were at a low at this time, and so the APA acceptance was understandable as a gesture of independence! As the time for the Toronto meeting approached, there was a rapproachment with the APS/SPR, but it was too late to change direction and the APA went to Toronto, joined by the Society for Adolescent Medicine and the Canadian Pediatric Society. Attendance at both meetings—namely the APA, the Society for Adolescent Medicine, and the Canadian Pediatric Society in Toronto, and the APS/SPR in Atlantic City—was down, and the combined leadership of the APA and the APS/SPR realized the need to avoid the isolation and lost dollars that they had experienced. The separation issue smoldered and as late as 1980, during the annual business meeting, the APA debated and fortunately defeated a motion to split from the APS/SPR.

In 1968, the first bound volume of APA abstracts appeared. In 1973, there was one registration fee for the APA/APS/SPR annual meeting. In 1986, the APA/APS/SPR programs were published in a single volume, but it was not until 1993 that the first full planning meeting of the APA/APS/SPR took place.

The APA has faced internal organizational issues. The Society for Behavioral Pediatrics (SBP) began as an APA Special Interest Group (SIG) in 1979 and soon requested status as a section. The APA debated the issue and concluded that sections were a contradiction to the generalist mission. The SBP in 1982 organized as an independent society. The APA membership was asked to vote on creating SIGs. The idea was approved after the 1984 business meeting, largely to avoid a repeat of the SBP exodus.

In 1988, a Pediatric Clerkship Directors SIG was established. The clerkship directors received full support from the APA as a SIG. The need for a clerkship directors organization was presented to the Association for Medical School Pediatric Department Chairmen, which determined that the Student Clerkship Director Organization was Pediatric Department Chairmen's territory. The clerkship directors now meet with the chairmen every third year. The APA leadership nurtured the clerkship directors through their early development, and the close relationship between the organizations remains. The clerkship SIG continues to meet at the APA annual meeting. As of 1994, SIGs include injury control, school health, emergency medicine, adolescent medicine, continuity clinic, and managed care.

The APA presently has well over a dozen liaison relationships. The APA is a founding parent of both the Society of Teachers of Family Medicine (STFM), founded in 1966,7 and SGIM, founded in 1977. In 1981, SGIM, STFM, and the APA met in a North American Primary Care Summit, and they continue to meet regularly as the Primary Care Organization Consortium (PCOC). The PCOC now includes the Bureau of Health Professions and the North American Primary Care Research Group.

The SGIM was provided start-up financial support by the American College of Physicians (the internist's AAP) and received additional support from the Robert Wood Johnson Foundation. SGIM publishes the Journal of General Internal Medicine. STFM was provided start-up financing by the American Academy of Family Physicians. Today, the STFM publishes the Journal of Family Medicine.

Why Not Have a Journal?

In 1964, the APA initiated a newsletter called the Voice of the Vertical Pediatrician. Morris Green was the first editor, and Evan Charney designed the logo. Having a journal was discussed often. The debate occurred most often about the issue of publishing the annual meeting abstracts. Relationships were explored with a number of journals. Periodically, the major pediatric journals offered editorial-board positions to APA nominees, but this outreach did not provide the APA with its own journal. A few journals approached the APA with the proposal of becoming the APA official journal. There was a trial relationship with Clinical Pediatrics. In 1983 and 1990, the American Journal of Diseases of Children (AJDC) published both the program and the presented abstracts. In 1993 and 1994, the AJDC, now The Archives of Pediatrics and Adolescent Medicine, published the program and all abstracts as a special supplement. History offers us a few lessons. The American Pediatric Society 75 years ago viewed the AJDC as their journal, but the American Medical Association did not. The AAP was associated with the Journal of Pediatrics, but there was a falling out with the publisher, and the AAP started Pediatrics as its journal. Not having a journal has represented a missed opportunity for the APA because without indexing, considerable work has not been available for scholarly analysis. Although the relationship with the Archives, especially with Cathy DeAngelis as editor, may work, pediatric history and the success of SGIM and STFM counsel the APA to have its own journal.

A number of publications have resulted because of APA activities. Among these are the 26 Ross Seminars on Common Pediatric Problems. In 1978, the APA published guidelines for standards for education in ambulatory pediatrics. In 1985, the educational guidelines for training in general ambulatory pediatrics appeared. In 1993, a second edition of the Guidelines for Fellowship Training was published, as was Training Residents to Serve the Underserved: A Resident Education Curriculum.

These publications were direct outgrowths of presidential projects. Additional presidential projects have included a consultation program, development of a clinical research manual, residency training hours, women in pediatrics, community pediatrics, and an interdisciplinary generalist curriculum.

The Annual Meeting and Special Events

However active the APA is during the year and whatever other meetings, projects, or summits occur, the major focus of the APA remains the annual meeting and the presentation of scientific work and related events.
In 1965, an annual lectureship was established to recognize outstanding individuals for their contributions to ambulatory pediatrics. The lecture is named for George Armstrong, a successful English consultant who established the first recorded dispensary for the infant poor in London in 1769. The list of Armstrong awardees is a who's who of pediatric generalists, although on a few occasions the APA Presidents, who select the lecturer with the approval of the Board, strayed into the social/political world by selecting worthy groups such as OXFAM, the Children's Defense Fund, and the Children's Television Workshop.

The Debate

In 1985, the APA initiated an annual-meeting debate to address controversial topics in general pediatrics. The first topic debated before a large and appreciative audience was that primary care is not for pediatricians and pediatric departments. It was not quite in the full Oxford tradition, but it was very good theater!
Other debate topics have included the following: Current resident review requirements do not foster the education of pediatricians to be specialists in the maintenance of health and the treatment of illnesses in children; there should not be clinical tracks for full-time faculty in pediatric departments; shortening resident working hours will contribute to more patient care and better education for training pediatricians; the proliferation of subspecialties is not in the best interest of general pediatrics; federal dollars that support graduate medical education should be redirected to support primary care training; and there should not be universal screening for lead.

In 1990, the APA held its 30th anniversary gala in Anaheim, California. Bob Haggerty, Barbara Korsch, Abe Bergman, and Cathy DeAngelis spoke. Barbara Korsch, to a standing ovation, was honored with Hollywood fanfare with a special career award. As Job Lewis Smith is considered the father of the American Pediatric Society, Barbara was clearly acknowledged as the mother of the APA! Steve Shelov collected all available Armstrong Lectures, and these lectures were printed along with the APA histories.

Advocacy and the Annual Meeting Along with maturity comes efficiency. Perhaps this is why APA business meetings in recent years have begun on time and concluded on time, with little fanfare in between. Imagine meetings where corporal punishment, formula boycotts, accepting industry funds, abortion, infant auto restraints, nuclear arms, the environment, daycare, and Vietnam were debated. Imagine officers resigning after their election because of the members' voting to increase dues or endorse choice. Imagine an organization in which debate was spontaneous, passionate, and entertaining, but not bitter. Consider an organization in which child health care delivery and social action and policy committees regularly identified advocacy issues and produced resolution after resolution. Imagine an organization expounding on academic hubris with Abe Bergman, Barry Pless, and Ray Helfer leading the charge. A bylaw was soon passed that limited resolutions from the floor, not to inhibit democracy but to allow the business meeting to end. Today the APA is organized in 10 regions, and regional meetings occur throughout the year. In 1977, the Board allocated funds to enable the regions to begin to take on local activities. A decision was made to provide supplemental resources on a per capita basis, depending on the size of the region's membership. Regional chairpersons became involved in national activities and participate in Board meetings.

Growth and Expansion

In the mid-1980s, the APA joined forces with other pediatric organizations and pursued promotion of the welfare and interests of children through the AAP's Council on Government Affairs. The APA is a member of a number of organizations, including the Council Of Academic Societies, The Federation of Pediatric Organizations, and the PCOC. The APA has official liaisons with key AAP committees. The APA is a nominating society of the American Board of Pediatrics and the Pediatric Residency Review Committee. These organizational relationships have produced consensus on many issues and enabled the pediatric community to present a unified voice on child health policy, workforce, and other legislative issues affecting children. The APA, among the pediatric societies, has been the most persistent and vocal advocate for the Title VII programs, which have supported residency training in general pediatrics, general internal medicine, and family medicine.
Beginning in 1991, a financially secure APA has used available funds to support special projects using a competitive review process. Since 1991, approximately four health services research projects have been approved yearly.

The Future

What does the future hold for the APA? There have been two major long-range planning retreats which provide guidance. The first retreat was in 1983 (Fred Burg, President) and the most recent was in 1993 (Tom DeWitt, President).
At the 1983 retreat, there were debates about the relative balance of education, research, clinical care, and public policy in driving the Association's activities; the issue of membership qualifications; the question of whether the domain was ambulatory or general academic pediatrics; and the controversy about the subdivisions or sections within the Association. There was support for establishing general pediatric divisions.

The second APA long-range planning retreat took place in October 1993. An operating philosophy was proposed which described APA members as advocates for children who would work to influence those responsible for the provision, governing, and regulation of child health care in federal and state government, academic organizations, academic health complexes, and professional organizations. An action plan was developed that would expand knowledge about general pediatrics and support excellence in education. Though still not elitist, the APA was now conscious that it was positioned as the premier pediatric organization, whose voice would be recognized as speaking for general academic pediatrics.

The future of the APA is in good hands, and the founders can take pride in what has been accomplished. Charles May wrote in 1959:

....the organization which seizes the opportunity to play the role of responsible statesmanship through appropriate cultivation of public appreciation of the new pediatrics will be sure to earn a loyal following and more important foster the welfare of the children of the future.12

The APA has a loyal following. The APA will, for the foreseeable future, foster and add to our knowledge as a learned and active society invested in and concerned about the ambulatory care of children.

Acknowledgment

I acknowledge with gratitude the valuable assistance of Marge Degnon, Diane Langkamp, John Pascoe, Evan Charney, Tom DeWitt, Morris Green, Steve Shelov, and Cathy DeAngelis in the preparation of this paper.

References

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2. Shelov S, Blodgett F, Olmsted R, Stein R. 30th Anniversary. The Ambulatory Pediatric Association: History and the Collection of the George Armstrong Lectureships (1960-1990). McLean, VA: Ambulatory Pediatric Association; 1990.
   
   
3. Reader GG. Organization and development of a comprehensive care program. Am J Public Health. 1964;44:760-765.
   
   
4. Korsch B. Pediatric outpatient departments. Pediatrics. 1959;23:162-165.
   
   
5. Noble J, et al. Conception and development of the Society for General Internal Medicine. J Gen Intern Med. (in press).
   
   
6. Pearson HA. The Centennial Hisory of the American Pediatric Society 1888-1988. Hew Haven, CT: Yale University Printing Service; 1988.
   
   
7. Bishop FM. Celebrating Our Past, Creating Our Future. Kansas City, KS; The Society of Family Medicine; 1992.
   
   
8. Ambulatory Pediatric Association Program. Clin Pediatr. 1980;19:305-309.
   
   
9. Ambulatory Pediatric Association program and abstracts of the 30th Annual Meeting. Am J Dis Child. 1990;144:397-448.
   
   
10. Faber HK, McIntosh R. History of the American Pediatric Society 1887-1965. New York: McGraw-Hill; 1966.
    
    
11. Hughes J. American Academy of Pediatrics: The First 50 Years. Evanston, IL: American Academy of Pediatrics; 1980.
    
    
12. May C. On the teaching and practice of the new pediatrics. Pediatrics. 1959;23:1038.

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