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Forging a future health care model: The pediatrician’s role
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No more looking back, No more living in the past. Yesterday’s gone, that’s a fact. Now there’s no more looking back. No more looking back. No more living in the past. Yesterday’s gone, that’s a fact. Now there’s no more looking back. — The Kinks (Ray Davies), “No More Looking Back,” 1975
Once there was a way to get back homeward Once there was a way to get back home Sleep pretty darling do not cry And I will sing a lullaby. — The Beatles (Paul McCartney), “Golden Slumbers,” 1969
Call out the instigator Because there’s something in the air We’ve got to get together sooner or later Because the revolution’s here And you know it’s right And you know that it’s right. We have got to get it together We have got to get it together, now. — Thunderclap Newman (Speedy Keen), “Something in the Air,” 1969
In the February issue of Infectious Diseases in Children, I spoke to the need of an honest conversation about the future of pediatric care within the larger picture of contemporary American medicine. Driven by concerns that medicine — education, training, and practice — has been led astray by the current generation of educational and organizational leadership, a call to the barricades was composed.
I am mindful of criticism of celebrating the past without a vision forward. Reactionary thought and appeals are not my purpose. My worries are that we have given up too much of what defines the profession, often to the exigency of money, and that the current direction drives us closer to a dark side whose gravitational pull increases as the generations of remembrance recede.
My conflict is reflected in the juxtaposition of lyrics by the Kinks and the Beatles: there is “no more looking back/no more living in the past/yesterday’s gone, that’s a fact” and there probably is and should not be a way back home unless in a “golden slumber” lullaby.
To those frequent readers, however, you should realize my belief in the power of the lullaby, the song, and imagine a better future rooted in the best of the past where the art and practice of medicine is valued, students welcomed as colleagues, and the pursuit of excellence again represents a duty to our patients and to our profession that is reflected in the strengthening of our foundational social contract.
Let’s now have a good craic
Who should be at the table? Who should be at the dance? Let’s speak about pediatrics, although many from the rest of medicine may wish to join. We need a new model of pediatric training and community-based care. Medical schools, children’s hospitals, pediatric group practices and pediatric subspecialists and pediatric residency program directors all need dance cards. But so do community representatives, day care providers, elementary school teachers, social workers, nurses, community activists and philanthropists.
The leaders of those many organizations that are defined by their commitments to promoting child well-being also need dance cards — AAP, Annie E. Casey Foundation, Big Brothers/Big Sisters, Boy’s and Girl’s Clubs, Center for the Study of Social Policy, Child Welfare League, Children’s Defense Fund, Doris Duke Charitable Foundation, GLSEN, Head Start, National Center for Children in Poverty, NEA, YMCA/YWCA, Special Olympics, Zero to Three — and so many more.
Our role
As pediatricians we need to define the basis for our practice. Tied, as we are now, to a chronologic model has limitations. A developmental model based on the needs of our patients and the known risk periods, perhaps, is better. Anticipatory guidance linked to the clear vulnerabilities of early childhood and parenthood and woven into a meshwork of family-based and parental services could define an exciting future. Extended to the known “touchpoints” of pediatric and young adult life, a new model for office-based care begins to emerge: community-based, derived from the existing institutions that have struggled to maintain children’s well-being, able to be forged into a sustainable future.
Layered onto this wellness-focused, developmentally driven and vulnerability-defined timeline are the acute and chronic care duties that we as pedia-tricians perform. Our strength as pediatricians is our knowledge base of growth and development and our ability to recognize and appropriately manage disease as well as health maintenance. How we structure a future model to provide all these services, let alone its physical structure will likely be a product of a workforce vision that is being conveniently ignored because of its complexity. Physician- or nurse practitioner-based? Hybrid model? Individual or group visits, or both? Integrated with pediatric residency? Links to children’s hospitals? Pediatric subspecialty presence in? Role of family medicine?
Something in the air
Those individual pediatricians who in the 1970s and 1980s forged individual and small-group practices — independent and community-based and often with close ties to an academic pediatric hospital — have created a legacy that should be mined to create a practice paradigm. Our strength as advocates for children rests in our offices, our neighborhoods and our communities. A vision for these sites — encompassing not only “traditional” care but co-located with mental health, nutritional and social services and structured for graduate education and training — is again perhaps a way forward while acknowledging the best of the past.
Call me an instigator
The investment in our children needs to be seen and, ultimately, measured in terms of health outcomes, disease prevention and community strength. What do we as pediatricians bring to the craic? We must present an evidence-based, community-located, comprehensive, sustainable and optimistic program for the well-being of our children. There is indeed something in the air. The revolution’s here and you know that it is right. Or, at least, I hope you do.
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- 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 William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.