Healthcare Reform

A Burning Platform for Child Health Services Reform

By: Paul H. Dworkin, MD

Several months ago, I had the opportunity to address a Hartford convening of the New England Pediatric Program Directors hosted by our own UCONN Department of Pediatrics. Dr. Ed Zalneraitis, our esteemed program director, requested that I set the stage for colleague Dr. Patricia Garcia’s description of our revamped community child health curriculum, which includes our Resident Education in Advocacy and Community Health (REACH) pathway, an option available to residents with career interests in population health.

I was delighted to have the opportunity to share my thoughts on pediatric residency training reform with a group of educational leaders who were positioned to champion change. I am, admittedly, quite concerned with the extent to which we are not optimally preparing pediatricians for critically-important, contemporary roles as health care services rapidly transform to focus on value-based care, population health and well-being. Indeed, I often emphasize that, while some specifics have modestly changed over recent years to decades, the general content of health supervision services for children (i.e., well-child visits) is basically the same today as in the 1960’s. Yet advances in our knowledge of brain development, early child development, and the so-called “biology of adversity” should inform our approach to promoting children’s optimal health, development and well-being. Despite our and other’s urging to revamp child health services to strengthen families to promote the best outcomes for children, the focus of such visits continues to be predominately on the early detection of diseases and disorders, with some consideration afforded the prevention of diseases, injuries, and other problems. The failure to restructure pediatric encounters to best enable providers to promote children’s optimal health and development is currently a lost opportunity.

In planning the content for my brief remarks, I was conflicted as to how best encourage program leaders to consider the need for training reform. Should I assume a positive approach and extol the benefits of embracing the explosion in our knowledge of brain development, early child development, and the biology of adversity, while encouraging the application of this knowledge to inform practice change? Or, should I raise the specter of the potential demise of pediatric practice in its current form, given the limited evidence of efficacy beyond the proven value of immunizations, and the lack of evidence of superior performance of pediatricians as compared to less-expensive clinicians in such easily accessible venues as pharmacy-based retail clinics? In short, do I assume a positive stance based on the exciting opportunity to apply our knowledge gains, or do I advance a “doomsday scenario,” with the potential demise of current pediatric practice as a “burning platform” demanding our most urgent attention and action. Admittedly unsure as to which might ultimately be more effective, I ultimately decided to do both.

Following the session, I wondered if my suggesting a potential doomsday scenario for primary care pediatric practice was viewed as hyperbole. Furthermore, I was not impressed by the effectiveness of my “call to action,” at least as evidenced by the lack of any post-presentation questions or comments.

While still wallowing in my thoughts, my anxiety was somewhat alleviated by a viewpoint simultaneously published in the journal, JAMA Pediatrics. In an article entitled, “Consumerism, Innovation, and the Future of Pediatric Primary Care,” Fiks and colleagues from the Children’s’ Hospital of Philadelphia use the sobering tale of Blockbuster, the dominant movie rental company of its time, to warn against complacency and urge pediatricians, despite the current thriving of pediatric primary care, to consider how “a new wave of pressures from disruptive, consumer-focused competitors” threatened to undermine the medical home and to recognize the “urgent need for pediatricians to rethink the delivery of pediatric care.”

In advancing their argument, the authors cite two prominent business concepts: creative destruction and the “innovator’s dilemma.” The former describes how all businesses pass through phases from formation to decline, and how they can either disappear, as Blockbuster did, or reinvent themselves.  The latter concept refers to common ways in which existing businesses succumb to innovators who create new, improved, and often less expensive ways to deliver services. They argue that practices can protect themselves against a downward spiral by embracing such approaches as team-based preventive care, retail-based clinic models, and telemedicine.

While offering its own “doomsday scenario,” I paradoxically found this commentary to be encouraging. I no longer questioned whether advancing a call to action to transform child health services was unjustified hyperbole. Furthermore, the commentary validated our long-standing advocacy for tailoring preventive-care services to address families’ needs and priorities, in contrast to our all-too-predominant, uniform approach to care delivery. Indeed, I am reminded of the cogent advice offered by the pediatric pioneer Barbara Korsch in the 1960’s that we should align the content of child health supervision visits with families’ cognitive, cultural, and psychological readiness.

I am also heartened by the authors’ call for pediatricians to embrace divergent thinking that enables new models. In the work of Connecticut Children’s Office for Community Child Health, we are actively engaged in the design, implementation, and dissemination of evidence-based innovations to strengthen the capacity, efficacy, and efficiency of the pediatric medical home. Failure to proactively embrace such innovations by taking full advantage of our knowledge of brain development, early child development, and the biology of adversity may doom us to our own Blockbuster scenario. Indeed, we must heed Fiks final admonitions and “…embrace divergent thinking, allow for a faster pace of change, and proactively address innovations …” Fortunately, we know how to do this work.  The future does lie within our hands.

Read other blogs from Dr. Dworkin here.

Reference:

Fiks AG, Friesen R, and Biggs L. Consumerism, innovation, and the future of pediatric primary care. JAMA Pediatrics 2018;172:797-798. doi:10.1001/jamapediatrics.2018.1501.

Paul H. Dworkin, MD is the executive vice president for community child health at Connecticut Children’s, the director of Connecticut Children’s Office for Community Child Health and the founding director of the Help Me Grow® National Center. Dr. Dworkin is also a professor of pediatrics at the UConn School of Medicine. Learn more »

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