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An attempt to better ensure wellness
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“When we strengthen families, we ultimately strengthen the community. Our goal is that parents everywhere work with supportive providers, feel confident in their parenting role, and form strong, resilient attachments with their children. To help achieve this, providers must be responsive to parents, knowledgeable about child development, and eager to see every parent succeed.”
– T. Berry Brazelton, MD, pediatrician and author of books on parenting and child development
Deliver your children to the good good life
Give’em peace and shelter and a fork and knife
Shine a light in the morning and a light at night
And if a thing goes wrong you’d better make it right
– Paul McCartney, songwriter and musician, “Deliver Your Children”
I wonder what will happen when we truly are able to predict the future — when our ability to read the human genome makes current newborn screening appear quaint and deciphering epigenetics necessitates addressing children as future adults — and what our offices will look like.
For that matter, I wonder what our pediatric offices would look like today if our prime focus was wellness. I know what you are thinking: We already do focus on wellness. We have well visits, anticipatory guidance, and follow-up visits for patients with chronic conditions — some of us even call our offices “medical homes.” But what I mean is what would it look like if we could truly build an office based upon the needs of children? Can we design for the future and still improve the today?
William T. Gerson
Ensure wellness
To ensure children’s wellness, a more fundamental structural change needs to happen in our offices. As generalists, we confront needs and attempt to allocate resources to meet them. In the process, we too readily abdicate our position as experts in children’s health and development.
In the office setting, we are often asked to see patients whose acute symptoms are more clearly chronic in nature or reflect mental health concerns. Even if appropriately triaged to longer visit times and the underlying issues clearly identified, their ongoing management is often lengthy and poorly reimbursed. For many situations, patient and often parental needs may require subspecialty consultation to allow diagnosis or improved adherence to care suggestions.
Timely consultation is not always easy to accomplish. Our pediatric subspecialty consultants face their own host of difficulties with access. In some areas of plenty, children’s hospitals have required specialty services to see patients within a proscribed time period (also known as marketing), but most areas have a dearth of specialists. In those areas, physician extenders are often utilized as the solution to access.
Neither of these alternatives seems to me to be meeting the best interest of our patients. If we are really interested in our patients’ well-being, I question whether this goal is best met by quick access. I think not always. Shouldn’t we, the pediatric physician community, determine the better (best is not a useful concept) model of care?
Take, for example, an infant with an innocent murmur. Is that child best served by a ready referral to a pediatric cardiologist for an ECG, echocardiogram and then an exam? Is the family reassured or do they continue to harbor concerns about their child’s “heart disease?” Would a patient with chronic abdominal pain be better served by care that remained within the office? Likely, but that takes time, appropriate training and attention to continued care. The same is true for many conditions often referred to as “functional” in nature.
Generalist vs. specialist care
There is a fine line that exists between generalist care and specialty care. Medicalization of the human condition is not our goal. Anticipatory guidance is often misinterpreted as a list of potential issues that can be electronically checked off in the medical record and then quickly referred to a subspecialist. Better yet, a “tool” can be devised so anyone can “identify” and “classify” a problem, without taking up the valuable time of the physician who, in fact, is well trained in the field and who might not appreciate being sidelined.
If we focused redesign on well-being and delineated the areas of common chronic conditions that we see frequently — anxiety, depressed mood, abdominal pain, headache, fatigue, infant spitting and encopresis — our offices would likely be very different. With the assistance of our subspecialty colleagues, we could design anticipatory interventions with our patients and their families to better ensure wellness. Age-based group sessions and symptom-based group sessions (less anticipatory but perhaps more efficient) could supplement well visits. Communities interested in pediatric wellness could, of course, extend these efforts beyond our office walls.
Placing the etiologies of these conditions (and, of course, others) into the framework of child development and well-being would allow offices to leverage our expertise as pediatricians, our training, and most importantly, our knowledge of our families to enhance the health of our patients. We could appropriately keep care in our offices and unload specialty offices of the burden of low risk, high frequency complaints, thus allowing rapid evaluation of those patients we identify in our offices as of greater concern for underlying significant illness. In the process, perhaps we could deliver to all our children a good life.
For more information:
William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.Disclosure: Gerson reports no relevant financial disclosures.