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ID Consult: How to provide the best quality care for our pediatric patients
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I do not believe there are data, but I suspect that among all pediatric subspecialties, the pediatric infectious disease practitioner receives the most unofficial consults — phone calls, emails and in the hallways — and the least patient visits per actual number of questions asked overall.
Although not a health care financial wizard, my calculation estimates reveal a high value to cost ratio lurking here somewhere. Perhaps in a future model of health care delivery, the true value will be reflected in direct reimbursement, or at least credit thereof. However, it seems unlikely any time soon — even here in Vermont, where we are well on our way to a single-payer system by 2014.
Thinking about the best way to improve the care provided in our offices in the area of infectious disease, I would argue that in most cases, the scenario above results in better practice and improved quality of care. It likely involves a direct question-and-answer dialogue among colleagues, an exchange of clinical information, and a delineation of a presumed diagnosis and an appropriate care plan. The patient is cared for within the primary care office and the responsibility for the care of the patient remains with the general practitioner. Within a community of practice, the consultant and the practitioner likely have an ongoing relationship in which the individual strengths and weaknesses are known, even if not specifically acknowledged. Follow-up to both physicians is also likely, thus allowing a learning opportunity for both.
Consultion, communication
Without procedures, the infectious disease (ID) consultant is truly cerebral and often a generalist at heart (sometimes in name as well as disposition, with fellowship-trained infectious disease specialists practicing primarily as pediatric generalists). Specific consultation on every patient is obviously not warranted. For well-defined clinical scenarios such as newborn sepsis, infant sepsis/meningitis, pneumonia, bone and joint infection and methicillin-resistant Staphylococcus aureus, the ID consultant can disseminate clinically useful information in many ways. The traditional grand rounds/lecture format at hospital or medical society meetings can bring practitioners together. Local guidelines or national guidelines adapted to the local environment can also be effective tools. Journal reviews of ID topics are also common modalities of learning opportunities.
Pediatric continuing medical education courses can also highlight ID topics. As a course director for a pediatric CME seminar for the past 16 years, I can attest to the annual demand for ID content delivered in an interactive setting. Always asked for by participants are AAP Red Book and immunization updates, as well as practical reviews of common and important pediatric infections. Maintenance of certification through the American Board of Pediatrics (ABP) also provides the opportunity for practitioners to update their ID clinical knowledge base, either directly through the ABP or its affiliated programs with the AAP and other regional and national networks. Quality improvement programs, some of which can meet maintenance of certification mandates, also often involve clinical infectious disease issues.
These “public consults” are the standard for the transmission of medical knowledge outside of an individual patient consultation, but it is unlikely in most cases that they truly change practice methods. However, with a local, well-known advocate and an appreciation of the clinical practice environment by the consultant, journal editor, CME course director or board member, the likelihood of successful practice improvement increases.
I will, again, make a plea for practitioners to demand such a structure for life-long learning opportunities. Clearly, the increased importance already being placed on better practice models of care will require shifts in how we teach each other, and the voice of those actually on the driver’s side of the otoscope should be appreciated.
Pediatric ID, generalists working together
Our ID colleagues also need to be on the forefront of advocacy for issues we hold dear as generalists. Many require the wearing of a public health hat for issues such as immunization practice, school health, approaches to new or novel infections, and annual updates of seasonal illnesses. Although advocating with a nod to public health, our ID colleagues also need to be honest brokers between the glamour of the pharmaceutical companies and the realities of the data set. Many requests for consultation involve the application of general guidelines to the specific needs of individual patients. These, of course, generally require direct consultation with the patient, but not always. Some areas, such as travel health or care for international adoptees, often involve cooperation between the ID clinic and the pediatric office. Of course, there will always be an intersection between the family and the specific recommendation of either the primary care provider or the consultant, or both — but that is the world we live in, mostly happily, in our office practices.
And now, by the way, what should I do with the four 3-year-old children whose day care provider found a bat behind the door in the sleep room and then let the bat go?
William T. Gerson, MD, is clinical professor of pediatrics at the University of Vermont College and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Gerson reports no relevant financial disclosures.