The American Academy of Pediatrics recognizes the important role physicians play in promoting the optimal biopsychosocial well-being of children in the school setting. Although the concept of a school physician has existed for more than a century, uniformity among states and school districts regarding physicians in schools and the laws governing it are lacking. By understanding the roles and contributions physicians can make to schools, pediatricians can support and promote school physicians in their communities and improve health and safety for children.

Physicians associated with schools have held a variety of titles over the years. For the purpose of this article, a school physician is any physician who serves in any capacity for a school district, such as, but not limited to, an advisor, consultant, medical director, volunteer, team physician, medical inspector, or district physician.1 This statement does not address the role of physicians in school-based health centers2 or the role of community pediatricians as private providers to school-aged children. Information on these topics is available on the American Academy of Pediatrics (AAP) Council on School Health Web site (http://www.aap.org/sections/schoolhealth/).

The tradition of a school physician dates back to the late 1800s, as parents and public officials recognized that public school facilities needed national systematic medical inspection.3 Over time, the role of the school medical inspector expanded to include containment of prevalent infectious diseases of childhood3,4 and eventually as an important vehicle to manage universal immunization.5 Modern school physicians focus on the needs of individual children as well as the public health of the school community.3,6,7 They often assist schools in accommodating students who have special health care needs, manage acute and chronic illness, and oversee emergency response, environmental health and safety, health promotion, and education.8,9 

Millions of children spend roughly 7 hours per day, 180 days per year, in school10 and may only visit their medical home once annually. In 1999, Dr Joycelyn Elders acknowledged the interdependence of health and education when she said, “You cannot educate a child who is not healthy, and you cannot keep a child healthy who is not educated.”11 In addition, Bright Futures, a national health care promotion initiative, encourages public schools and public health communities to become partners in prevention efforts.12 Despite the value of coordinating health and education, physicians are not effectively and consistently involved in schools across the nation. As a result, US children have varying levels of medical support and safety, depending on the community in which they live. Well-placed school physician expertise can contribute to the creation of policies and practices that provide sound, evidence-based structure to coordinated school health teams.

Currently, there is no single national set of school health laws. School health services are primarily regulated by state or local governments or individual school districts, and these regulations vary.13,15 Some states mandate school physicians; most do not.16,17 However, “no one has systematically identified the full range of relevant legal authorities pertinent to schools that may help shape the health of children and adolescents.”15 

Federal law guarantees antidiscrimination and equal protection to individuals who have disabilities.18,20 These laws require federally funded states to provide “related services,” such as school nursing, as part of a child’s Individualized Education Plan. However, the US Supreme Court ruled that school districts are not required to provide physician services for individual students, except for diagnostic or evaluative purposes for special education services.13,15 This ruling’s broad interpretation has limited funding to schools for physician services, despite the fact that many states, and the AAP, established basic minimal health services schools should provide without established guidance for pediatrician involvement.21,22 

The AAP recommends that all schools have a registered professional school nurse, hereafter referred to as school nurse, to provide health services in schools.23 The American Medical Association not only recommends that school health be provided by “a professionally prepared school nurse” but also that “health services in schools must be supervised by a physician, preferably one who is experienced in the care of children and adolescents. Additionally, a physician should be accessible to administer care on a regular basis.”24 

Despite a scarcity of laws addressing school physicians, pediatricians remain leaders in child health care and are integral members of the school health team.22,25,29 Certainly, pediatricians need to know the laws that apply to their patients and themselves and will benefit from collaboration with their AAP chapter, state and local health departments, and school district to understand the laws specific to their role in the schools. However, the lack of uniformity of laws or standards of best practice for school physicians complicates the role physicians have in schools and results in a difference of health care for children based on the schools they attend.

Ideally, school physicians should be board-certified pediatricians or physicians with expertise in pediatrics.24 In addition to basic training in child growth and development, disease processes, and well-child maintenance including adolescent and reproductive health and sports medicine, physicians who work with schools need additional expertise in key school health topics.30,32 The degree of mastery required depends on the extent of the physician’s role with the schools. Overall, a school physician can become a positive liaison between the medical home, the family, and the school.8Table 1 contains a nonexclusive list of essential areas of expertise required of a school physician.

TABLE 1

Critical Knowledge Base for School Physicians

Infectious diseases (eg, outbreak control) 
Public health (eg, risk assessment and management, resources) 
Immunizations (eg, school requirements and medical contraindications) 
Medical-legal issues 
 State and district school and public health laws, regulations, and policies 
 IDEA, Section 504, and ADA 
 FERPA and HIPAA and how they intersect in the school setting 
Adolescent health (eg, brain development and reproductive health) 
Sports medicinea 
 The value of physical education and physical activity at school 
 Injury prevention 
 Conditioning 
 Disqualifying conditions 
 Hydration 
 The effects of climate extremes on athletes 
 Concussion management 
 Adaptive physical education 
Emergency preparedness (eg, children with special health care needs) 
Environmental and occupational health (eg, indoor air quality) 
Health and learning (eg, medical, emotional, attentional, and learning problems that affect learning) 
Social services resources (eg, access to health insurance and assistance programs) 
A coordinated school health model (eg, health services, health education, healthy and safe environment, physical education and activity, nutrition services, counseling/psychology/social services, staff health promotion and family/community involvement) 
Infectious diseases (eg, outbreak control) 
Public health (eg, risk assessment and management, resources) 
Immunizations (eg, school requirements and medical contraindications) 
Medical-legal issues 
 State and district school and public health laws, regulations, and policies 
 IDEA, Section 504, and ADA 
 FERPA and HIPAA and how they intersect in the school setting 
Adolescent health (eg, brain development and reproductive health) 
Sports medicinea 
 The value of physical education and physical activity at school 
 Injury prevention 
 Conditioning 
 Disqualifying conditions 
 Hydration 
 The effects of climate extremes on athletes 
 Concussion management 
 Adaptive physical education 
Emergency preparedness (eg, children with special health care needs) 
Environmental and occupational health (eg, indoor air quality) 
Health and learning (eg, medical, emotional, attentional, and learning problems that affect learning) 
Social services resources (eg, access to health insurance and assistance programs) 
A coordinated school health model (eg, health services, health education, healthy and safe environment, physical education and activity, nutrition services, counseling/psychology/social services, staff health promotion and family/community involvement) 

ADA, Americans With Disabilities Act; FERPA, Family Education Rights and Privacy Act; HIPAA, Health Insurance Portability and Accountability Act; IDEA, Individuals With Disabilities Act.

a

Unless there is a separate team physician.

The roles and types of relationships for physicians working in schools are broad. Involvement can range from fulfilling mandated services, serving as an advisor to a school health advisory group, or being the leader of a coordinated school health program. School physicians function based on the medical and social needs or demands of the community, the school district’s priorities, and state laws. School physicians not only bring value to the quality of health services but also may provide a cost savings to districts, with decreased liability from physician oversight of sound school health programs. For example, school physician–coordinated concussion management programs, established climate standards for outdoor activity, or guided anaphylaxis management protocols can potentially save lives, reduce morbidity, improve outcomes, and prevent potential costly litigation against school districts.33,36 Because states fund schools on the basis of student attendance, a school physician can potentially save schools money by decreasing absenteeism through advocacy and education, such as in improved asthma or diabetes management.37,40 The Council on School Health Web site (http://www.aap.org/sections/schoolhealth/) provides guidance on these activities and how pediatricians can work with schools (Table 2).

TABLE 2

Roles for School Physicians

Mandated Services 
 Physical exams (grade mandated, special education, work permits, sports participation) 
 Oversight of return to sports (eg, concussion management programs) 
 Active member on teams/committees (eg, special education, wellness, health education) 
Consultation 
 Write standing nursing orders/protocols 
 Athletic advisor/team physician 
  Oversee health aspects of athletic programs and best practice standards 
   Infectious diseases esp. for close contact sports 
   Participation of athletes with serious medical conditions 
  Adaptive physical education for acutely injured or chronically disabled youngsters 
  Mixed gender competition 
 Develop policies 
  Contagious diseases/pandemics 
  Restraint, suspension, expulsion 
  Bullying 
  Reproductive health 
  Chronic school absenteeism 
 Develop protocols 
  Delivery of medications 
  Seizure management 
  Diabetes care 
  Anaphylaxis management 
  Asthma education and management 
 Assist in the management of specific medical emergencies or immediacies 
 Participate at the building level in comprehensive, multidisciplinary teams and wellness councils 
Programmatic leadership 
 Health program evaluation and quality improvement 
  Health education 
  Mental health promotion programs 
  Nutrition and food services 
  Physical activity and education 
  Staff wellness 
  Family and community education 
 Liaison with primary care physicians regarding specific concerns 
 Professional performance development 
 Evaluation and collaborative oversight of nursing staff and other health service providers, including one-on-one nurses and door-to-door transportation 
 Reviews of emergency care plans for children with life-threatening conditions. 
 Classroom observations of children with special needs 
 Health education curriculum development 
Direct consultation with principals or the superintendent 
 Medical-legal issues 
 Parent attorneys or advocates in accommodation disputes and hearings 
 Building and playground health and safety 
 Bloodborne pathogen incidents 
 School closure related to illness or weather extremes, or infections that affect public health 
Mandated Services 
 Physical exams (grade mandated, special education, work permits, sports participation) 
 Oversight of return to sports (eg, concussion management programs) 
 Active member on teams/committees (eg, special education, wellness, health education) 
Consultation 
 Write standing nursing orders/protocols 
 Athletic advisor/team physician 
  Oversee health aspects of athletic programs and best practice standards 
   Infectious diseases esp. for close contact sports 
   Participation of athletes with serious medical conditions 
  Adaptive physical education for acutely injured or chronically disabled youngsters 
  Mixed gender competition 
 Develop policies 
  Contagious diseases/pandemics 
  Restraint, suspension, expulsion 
  Bullying 
  Reproductive health 
  Chronic school absenteeism 
 Develop protocols 
  Delivery of medications 
  Seizure management 
  Diabetes care 
  Anaphylaxis management 
  Asthma education and management 
 Assist in the management of specific medical emergencies or immediacies 
 Participate at the building level in comprehensive, multidisciplinary teams and wellness councils 
Programmatic leadership 
 Health program evaluation and quality improvement 
  Health education 
  Mental health promotion programs 
  Nutrition and food services 
  Physical activity and education 
  Staff wellness 
  Family and community education 
 Liaison with primary care physicians regarding specific concerns 
 Professional performance development 
 Evaluation and collaborative oversight of nursing staff and other health service providers, including one-on-one nurses and door-to-door transportation 
 Reviews of emergency care plans for children with life-threatening conditions. 
 Classroom observations of children with special needs 
 Health education curriculum development 
Direct consultation with principals or the superintendent 
 Medical-legal issues 
 Parent attorneys or advocates in accommodation disputes and hearings 
 Building and playground health and safety 
 Bloodborne pathogen incidents 
 School closure related to illness or weather extremes, or infections that affect public health 

Physicians can have a professional relationship with schools in many ways, such as a full- or part-time employee, an independent contractor, or a volunteer on a school health advisory group. Where feasible, a school physician does not serve as a private physician for a child in that school district, however, because it can create a potential conflict of interest between the physician as representative/advocate for a patient versus the school.

Whatever the relationship, once a school district asks a physician to participate in hands-on medical practice for compensation in exchange for services, a clear definition of district expectations of the physician is essential. An agreement, accounting for laws governing the relationship of the physician to the public school district, should define indemnification and liability. It is critical that physicians understand the specifics of their relationship and that the legal implications are articulated clearly in a written agreement renewed periodically. Although community volunteerism is attractive, physicians should take some precautions before volunteering to serve as a school or team physician. It is essential that he or she knows and understands state laws that address whether a district has an obligation to hire a medical director. Regardless of the type of relationship, the physician should notify his or her professional liability insurance company of involvement in school health activities and determine whether the insurance covers such activities. If covered, this decision should be noted in writing. If a district has an obligation to provide compensation for physician services, this will allow the physician to schedule time for the school district and to improve the quality and consistency of service.

Given the contribution a school physician can make to the overall well-being of a child within the context of the school setting, the AAP recommends the following:

  1. Pediatricians should advocate that all school districts have a school physician to oversee health services. The school physician’s roles and responsibilities should be well defined, fairly compensated, and outlined within a written contract.

  2. Pediatricians should support their patients and local school health programs by working closely with the school health services team. In districts without school physicians, pediatricians should educate these districts about the benefits of having a school physician and work to foster private-public partnerships for school physicians.

  3. School physicians should be experts in key school health topics and be educated about the medical-legal environment in which they practice. They need to provide proper notification of their role and responsibility to their medical liability insurer and should collaborate with their AAP chapter, state and local health departments, and school district to understand the laws specific to their role in the schools.

  4. Community pediatricians should be knowledgeable about key school health topics and how to work effectively with schools their patients attend.

  5. Pediatricians should consider becoming a school physician or serving on school boards or school health advisory groups to develop sound school health policies and community programs.

  6. All physicians who work with school-aged children should recognize the value to the child when there is a comprehensive, coordinated team effort among the child’s medical home, the school, and family.

  7. Pediatric medical investigators should consider further research to determine how comprehensive coordinated school health programs under the direction of a school physician can improve health care in schools and enhance the goals of the medical home without attempting to replace it.

  8. AAP districts and chapters should support school health and school physicians and use the school physician’s expertise to advocate for important changes to state and local school health policy. In addition, AAP districts and chapters should advocate to develop and promote school health policies that benefit children by advocating for additional research on the benefits of school physicians in school health services.

Cynthia DiLaura Devore, MD

Lani S.M. Wheeler, MD

Cynthia Devore, MD, Chairperson

Mandy Allison, MD, MSPH

Richard Ancona, MD

Stephen Barnett, MD

Robert Gunther, MD, MPH

Breena Welch Holmes, MD

Jeffrey Lamont, MD

Mark Minier, MD

Jeffery Okamoto, MD

Lani Wheeler, MD

Thomas Young, MD

Robert Murray, MD, Immediate Past Chairperson

Mary Vernon-Smiley, MD, MPH – Centers for Disease Control and Prevention, Division of Adolescent and School Health

Linda Grant, MD, MPH – American School Health Association

Veda Johnson, MD – National Assembly on School-Based Health Care

Carolyn Duff, RN, MS, NCSN – National Association of School Nurses

Linda Davis-Alldritt, RN, MA, PHN – National Association of School Nurses

Madra Guinn-Jones, MPH

     
  • AAP

    American Academy of Pediatrics

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

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