I liked Dr Pappelbaum's presentation a lot. My response? Read it; reread it; understand it; adjust to its doctrines; follow its prescriptions and program plan and be flexible and resilient. I totally concur with Dr Pappelbaum's belief that managed care need not be an end to one's pediatric career, but a program that can and must continue to work for our patients. Managed care will not go away; it is chronic, and we must adapt to it.

The theme of both Dr Pappelbaums's article and of this meeting—as a whole and for every part of it—is that change is the "here and now," and that we must adapt to it. The constant message is that pediatricians must go forward in their communities with all the peer help and all the consultative help that each can muster. They must work within the structure and boundaries of change, striving for the most benefit for the patients they care for and for themselves.

Dr Nazarian, whose presentation was equally excellent, has a good view of medicine now and medicine in the future. I have no challenge to his views or conclusions.

Like Dr Nazarian and like Dr Elsa Stone, who spoke yesterday, I employ pediatric nurse practitioners (PNPs) in my clinical practice. I am the senior partner of an eight-physician (four male and four female) practice in an academic community. We have two full-time PNPs and one physician assistant associated in our practice. As valued and contributing members of our health care team, they are true physician extenders.

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