Published online March 1, 2005
PEDIATRICS Vol. 115 No. 3 March 2005, pp. 831 (doi:10.1542/peds.2004-2871)
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Rethinking the Rethinking About "Well-Child" Care

Glenn Austin, MD, FAAP
Beaverton, OR 97007

Dr Schor's call for "a single authoritative source of standards for well-child care"1 has stirred considerable angst and soul searching about primary care pediatrics in both the academic and private sectors. Half a century ago, Dr Ed Shaw, Chair of Pediatrics at the University of California San Francisco, discussed the concept of well-child care at a local meeting. His basic premise was that we needed to get the children into the office so that, "among other things," they would get their immunizations; thus, the genesis of the "well-child visits." The issue has been confused by the resulting concentration on prevention and "wellness," obscuring the underlying need for continuity so vital in growing and developing children. The stodgy insurance industry objected to paying for well-child care, although some preventive services such as immunizations and car-seat advocacy have proven valuable from both monetary and health standpoints. However, a plethora of other valuable services have been added but not statistically proven to be cost-effective under present circumstances.

The insurance industry responded by avoiding or reducing payments, contending that parents should accept the responsibility for such low-cost services, pay cash (on the assumption that they had cash), and avoid the high cost of third-party administration. Employers, shopping for the cheapest care, frequently changed policies, which disrupted critical continuity of care. Practitioners responded to the various hamster-wheel demands in the only way they could: by reducing physician time with patients.2 What has been lost, aside from the damage to the soul of pediatrics, are those many "other things" to which Dr Shaw alluded and that those of us in practice well understood. The term "well-child care" is an anachronism that should be completely subsumed into the more accurate term, "child health supervision," which encompasses prevention and personal physician continuity of care and enables efficient illness care.

I take issue with Dr Schor's call for a single authoritative source of standards for well-child care. We should not attempt to deal with children and their families like we do with General Electric modular products. Many professors of yesterday, like Ashley Weech of Cincinnati, advocated that we approach and supervise the health of the whole child, recognizing that each child and family is unique, and required that they and their potential problems be considered not just as a member of the herd but as individuals. The pernicious tendency of ignoring individual personalities, needs, and responses is partially a result of overdependence of academicians, insurers, and policy makers on statistical proof, partially from attempting to artificially separate vital aspects of child health care such as continuity and prevention from illness care. Let’s look at the problems of primary child health care as a whole, recognizing the interdependency of the various parts while we eliminate the half-century-old shibboleth of well-child care and focus instead on health supervision with its vital and efficient component of personal physician continuity of care (which includes preventive services), an accurate term that has not lost its meaning.3–8

REFERENCES

  1. Schor EL. Rethinking well-child care. Pediatrics. 2004;114 :210 –216[Free Full Text]
  2. Morrison I, Smith R. Hamster health care. BMJ. 2000;321 :1541 –1542[Free Full Text]
  3. Inkelas M, Schuster MA, Olson LM, Park CH, Halfon N. Continuity of primary care clinicians in early childhood. Pediatrics. 2004;113 :1917 –1925[Abstract/Free Full Text]
  4. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients' trust in their physicians: effects of choice, continuity, and payment method. J Gen Intern Med. 1998;13 :681 –686[CrossRef][ISI][Medline]
  5. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1988;47 :213 –220
  6. Lambrew JM, DeFriese GH, Carey TS, Ricketts TC, Biddle AK. The effects of having a regular doctor on access to primary care. Med Care. 1996;34 :138 –151[CrossRef][ISI][Medline]
  7. Kearley KE, Freeman GK, Heath A. An exploration of the value of the personal doctor patient relationship in general practice. Br J Gen Pract. 2001;51 :712 –718[ISI][Medline]
  8. Becker MH, Drachman RH, Kirscht JP. Continuity of pediatrician: new support for an old shibboleth. J Pediatr. 1974;84 :599 –605[CrossRef][ISI][Medline]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics




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