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Pediatric Health Maintenance in the 21st Century: A View From the Trenches

2006; American Academy of Pediatrics; Volume: 118; Issue: 4 Linguagem: Inglês

10.1542/peds.2006-0500

1098-4275

Bruce Bedingfield,

School Health and Nursing Education

There have been quite a few articles in Pediatrics lately on the general topic of well-child care.1–8 At the risk of seeming presumptuous, I would like to join the discussion from the viewpoint of a private pediatrician. It often seems that many of the authors on pediatric health maintenance concepts these days are academic behavioral pediatricians. I suppose this behavioral approach to health maintenance is appropriate, because the “new morbidity” is now the only morbidity many of us have ever known. But, when all is said and done, it is the general pediatricians, family practitioners, and nurse practitioners who struggle to provide quality well-child care.Actually, I can write with some semblance of authority. I have been in private-practice pediatrics for close to 25 years, and I am honored to be a member of the Bright Futures Users Panel. Looking at pediatric health maintenance and how best to perform it has long been of interest to me. As I see it, we have 4 things to accomplish. We need to spend enough time during the encounter to be thorough and complete. We must do it all in the allotted period of time so as not to keep other families waiting. Yet, we must see enough patients to be productive—pay the bills and make a bit of a profit. Finally, we want to work at a comfortable enough pace that we stay calm and friendly through it all. To do any 3 at the expense of a fourth may be quite feasible, but achieving all 4 can be a profound challenge.Thus, any suggestions toward enhancing pediatric health maintenance become challenges at best and intrusions at worst. The possible topics we can cover for anticipatory guidance can be daunting. I once mentioned to another member of the Bright Futures panel that I use “refrigerator sheets,” single pages with anticipatory-guidance information the family can put on their refrigerator for frequent reference. She said, “That’s a great name; they probably need to be as big as a refrigerator!” Also, it often seems that every pediatric article includes the authors’ urging that we discuss and/or screen for their pet topic at every well-child visit.At the same time, we are all aware of the competing information and messages that families receive from neighbors, family, television talk shows, and the Internet. Talk shows can spend an hour on topics we have but moments to cover; conversations around a kitchen table can last even longer. (I am sure we have all experienced telephone calls asking about starting 2-month-olds on cereal the Monday morning after holiday family get-togethers.)I do not pretend to have profound answers to these common and frustrating challenges, but please allow me to make a few suggestions.We, as physicians, naturally think of ourselves as healers, providing medical care and treatment. Yet, we rarely really cure anything. Perhaps our surgical colleagues do. Medical scientists who develop medicines do. Clearly, Mother Nature is usually the real healer. We, at best, are teachers.And yet, the role of teacher is an extremely important one. We strive to teach new parents how to care for their infants. We instruct families on how to raise their children to be healthy, happy, and valuable members of society, and we can mentor our patients themselves, teaching lifelong healthy habits. Health maintenance in general and well-child care in particular are primarily opportunities for education.There are 2 principal types of education that pediatric clinicians typically provide. The first is anticipatory guidance, anticipating a situation that the parent or child will soon experience and trying to prepare them for it. Indeed, there must be some consolation in being able to say, “Our pediatrician said there would be days like this!”The other way we teach is through the use of “teachable moments.” Situations arise that put families into a vulnerable state that leave them open to our advice and guidance. Therefore, they come to us with questions and concerns, and our job is to try to answer those questions and provide guidance through those dilemmas. If we cannot always solve these problems, at least we can refer the family to a specialist, a book, a Web site, or a community resource that can.Often, however, we are tempted to teach too much. There are simply too many anticipatory-guidance topics we could conceivably cover. Yet, we realize that people can only digest so much information. The National Survey of Early Childhood Health (NSECH) found that although longer well-child visit length was associated with greater parental satisfaction, information satisfaction actually decreased when visits exceeded 20 minutes.4 One recent study showed that parental recall of anticipatory guidance declines when too many topics are covered.9 Still another study indicated that many parents even resent pediatricians asking questions and giving advice too far “outside the realm of routine medical care.”10 Of course, we ourselves may go to a lengthy medical conference and feel satisfied if we bring back only 2 or 3 “pearls.” Truly, the impact of our teaching can be increased if the amount we teach is limited.However, those teachable moments come up as well, and we must assume, of course, that these urgent concerns are the patient’s and family’s top priority. But, we can often provide written information on those topics too. If we find ourselves saying the same thing repeatedly, we can write it all down as a handout. We know also that numerous pamphlets and books already address these topics now. The American Academy of Pediatrics (AAP) itself certainly provides us with plenty of these tools.Indeed, often the best thing we can do is to inform the family where to look for additional information. Naturally, in the 21st century we can, and must, help families sort through all the information on the Internet. However, some of the most helpful anticipatory guidance I can give includes telling parents-to-be about the AAP’s infant-care books and Brazelton’s Touchpoints,11 whereas parents of 3-year-olds need to know about Touchpoints 3 to 6.12 Parents of 5-year-olds are told about the AAP’s Your Child From Five to Twelve.13 Once those children hit 12, their parents find out about the AAP’s Caring for Your Teenager.14 Many other books are appropriate for our recommendation at various ages; families disinclined to read whole books can still be given relevant information sheets and pamphlets. I may not spend a great amount of time dealing with various topics, but I can certainly help families find the information they need.Although I do believe that answering the family’s questions and addressing their concerns are of paramount importance, that does not mean we must simply turn the agenda over to them. I find it helpful to establish a template of general questions to cover the common areas of concern. I ask questions, of course, about the child’s health—both current and interval (since the last well-child visit.) I then ask about nutrition and feeding problems of anyone from newborn through college age. I inquire about sleep problems. Questions on development begin at ∼4 months and evolve into school readiness at 5 and school concerns at 6 and beyond. Behavior and discipline concerns are explored at ∼2 years and beyond. Questions on sports and fitness begin at 6. I find that this “holistic” approach to looking at a child’s life seems to cover the vast majority of parental concerns. My usual inquiry regarding any additional concerns is typically answered, “No, that pretty much covers it.”As we think about the ideal length for well-child visits, we realize that not every family requires the same amount of time. First-time parents very naturally may require more time than families with 1, 2, or more other children. That does not mean, however, that experienced parents do not benefit from our teaching and guidance. Professional athletes have coaches; even Cy Young Award–winning pitchers use pitching instructors. Nonetheless, we could certainly consider scheduling more time for new parents than we do for experienced ones.Yet, if we are honest with ourselves, we can admit that some families are simply and consistently more “needy.” We find that certain parents will consistently take up a disproportionate amount of our time with their questions and their concerns. Of course, in some situations this is a very justified need; a child with chronic health needs will naturally require more time. Justified or not, we are often wise to “flag” some families for extra time, because we know we will be giving it to them anyway.Be that as it may, we need not feel obligated to address every complex issue within the limitations of a well-child visit. We must never hesitate to say, “You seem to have a great deal of concern about Jimmy’s behavior, and I am afraid we will not be able to do it justice in today’s visit. Let’s set up an appointment later in the month and concentrate just on that issue.”In the NSECH, 98% of parents reported having a regular place to take their child for well-visits, but only 46% said they saw the same provider at each visit.3 One essay that accompanied that article, “Mommy, Who Is My Doctor?” by Alpert et al, came down hard on that statistic, arguing that each child should have one doctor to call his or her own.15 Yet, as any of us who have been in solo practice can attest, few things are as scary in pediatrics as being the only physician who sees a given child. Medical care seems to be enhanced by having more than one set of eyes examining the patient at various times. In fact, my associates and I seem to have our own unique strengths that we bring to various patient encounters (points we are more inclined to stress or abnormalities we are more apt to look for). Nurse practitioners also add a wonderful new dimension to our care.We can and should emphasize the importance of the medical home. However, different providers bring different viewpoints, and nurses and receptionists offer their own observations and contributions. We are, after all, a team. If it “takes a village to raise a child,” then perhaps it takes a whole practice to provide that child with optimal medical care.There is no doubt about it—we practice in the age of evidence-based medicine. There is pressure, therefore, to emphasize only those aspects of health promotion that have been well studied and proven. I have a theory, however, that evidence-based medicine is a left-brain activity, whereas health maintenance is a right-brain activity. We enter into a conversation with the family that they most likely have already had with family, friends, and neighbors. We hope that our contribution is based on a professional background and experience that those other opinions cannot offer. Yet, if we restrict our voices to only giving advice that has been irrefutably proven in the medical literature, we restrict our influence considerably.That does not mean that the evidence is not important. Such research is a truly fertile area into which we all should enter—private practitioners and academic physicians together. They have the research sophistication; we can provide the volume of statistics. In the meantime, however, we can still provide our own “experience and reason.”As behavioral pediatricians have gotten more involved in writing theories on pediatric health management, they have taught us better ways of asking facilitative and open-ended questions. However, it is of significant interest that in the NSECH survey, 91.5% of families who were able to ask all their questions expressed satisfaction with well-visit length versus only 33.6% of those who were not.4Granted, not all new parents are going to know just what questions they should ask. Prompt sheets listing possible questions, given before a visit, can be helpful for these parents. Group sessions, such as our practice’s new-parent support groups, allow participants to hear each other’s questions. Surveys of parents with young children reveal topics they eventually wish had been covered.2,16,17 Actually, we might be even wiser to survey parents of older teens and young adults as to those topics they wish we had covered through the years. Of course, the idea behind anticipatory guidance is to answer questions before they even arise.Still, it would seem that the most important question we can ask is not, “How does Carlos spend his day?” or “What is Susie really good at?” The most important question is, “Does that answer all your questions and accomplish everything you wanted to today?”The truth is, we are very fortunate to have the honor of providing well-child care to our pediatric patients over an extended period of time. Nazarian refers to it as our “rare and special privilege.”18 Few tasks in any line of work could be more fun, and it is humbling to realize that we are now guiding some of our patients toward healthy and productive lives into the 22nd century.