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Finding a system that works
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To have striven, to have made an effort, to have been true to certain ideals — this alone is worth the effort. – William Osler, MD, a founding professor of Johns Hopkins Hospital
It will take only a few additional minutes to document this in the EMR. – Anonymous Hospital Administrator
I have greatly appreciated the feedback from readers over the past year. From California to Maine and from Alaska to Texas, you have reminded me of the depth of fellowship among general pediatricians. Perhaps the most touching comments are from the front lines of practice, where the global needs of patients often overwhelm the ability to provide the comprehensive care required to succeed in addressing those needs — many of which are not traditionally “medical.”
A pediatrician in Chicago describes her frustration with the limited resources her clinic provides, her attempt to care for an impoverished population while making increased demands to document, document and document. I am sure our colleagues in the teaching and nursing professions have similar tales. We cannot continue to take the best and brightest in any field, let alone medicine with the intensity and duration of its training, and fail to provide a practice that is rich in challenges and rewards. I am more convinced than ever that we need to create an organized movement to improve children’s well-being by focusing first on the child and in doing so redefine our model of pediatric care.
Evolution of the medical home
The model must be firmly rooted in our communities. Organic in it best sense. The medical home is misplaced. Our patients have only one home, and that is hopefully in a functional family. Our offices must be grounded in a collaborative model of care that integrates across all of the domains our patients travel — home, day care, preschool and elementary to college education. Hospital practice is vital and certainly must be a portion of the whole. The special expertise and responsibility of our leading children’s hospitals is a key element in any model of health care provision in pediatrics. Our top children’s hospitals, tied to their respective medical schools and universities, must be our leaders. They have the potential of organized voice and an established philanthropic base. Our pediatric departments now have a generation of public and community health pediatricians who already bring outcome-based research to bear on the critical nature of investing in children and in models of care. As office-based generalists, we need to advocate for our needs in the larger effort to put children first. Just as care at tertiary and quaternary pediatric hospitals is evolving at a rapid pace, so will our practice.
William T. Gerson
Where some may see a future in which pediatricians are no longer providing primary care, I see a future in which such a position is critical. For the pediatrician of the future will be an expert not only in the care of infants, children and young adults — but as the individual best in position to guarantee the ultimate success, the overall health and well-being, of each of our patients. Who else will be able to interpret the implications of identification of genomic linkages to common and uncommon human conditions? Who else is an expert on human growth, nutrition and development? Who else has spent training years caring for the health consequences of acute and chronic pediatric disease? Who else has spent years in medical education integrating scientific knowledge across the entire lifespan, before focusing on pediatric health? If you were in charge — no, if you were a parent — whom would you want to care for your child in the office?
If I were to rank where to build first, I would suggest early child care, early education and parent support. Such models already exist.
Rethinking our current position
We must re-think our current position. For too many of us the challenges appear overwhelming and the rewards of providing one-to-one office-based care diminishing. I have tried to point out in this column the true joy and love of pediatric practice. I feel it, as most of you do; however, we can and must do better. There is not only a lack of public/political focus and will in placing children first in our society, but as it directly affects our practice, there is a draining system failure.
A small example: I recently traveled to a surrounding county for a school conference for an 8-year-old patient with OCD whose behavior is spinning out of control both at home and at school, overwhelming both parents and school personnel. Ten people were present, including the parents, school principal, district special educator, community mental health provider, school-based behavioral interventionalists, classroom teacher and special educators, all of whom were well meaning and dedicated. Many hours of professional time were utilized to discover what added resources could be brought to bear on the child’s and his family’s needs. I am certain that you all have been in similar situations. Important, surely, but it was hardly efficient or effective in creating a generalizable system of care for the entire community. I am, unfortunately, confident that after the meeting an enormous amount of documentation took place.
For all our children, we must build a future that puts children’s well-being first.
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Disclosure: Gerson reports no relevant financial disclosures.