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SPECIAL ARTICLE |
Department of Pediatrics, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio
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ABSTRACT |
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 TOP ABSTRACT THOUGHT 1: SPEND TIME...THOUGHT 2: MAKE EXPERIENTIAL...THOUGHT 3: LEARN FROM...REFERENCES |
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Key Words: anticipatory guidance • primary care • preventive services • preventive health care visits • learning
Abbreviations: AAP—American Academy of Pediatrics • NBAS—Newborn Behavioral Assessment Scale
The "new morbidity" is no longer new.1 The realization that psychosocial concerns need to occupy center stage in pediatric health supervision has been building over the past quarter century. The American Academy of Pediatrics (AAP) first published its schedule for preventive care in 1967.2 Since then, the recommendations have expanded steadily, like the average American's waistband, to the point that even the most optimistic clinician cannot hope to encompass them all within the bounds of a reasonable-length visit.3 Even so, most pediatricians manage to provide high-quality care, when quality is defined in terms of the number of topics covered.4,5
Covering topics, however, may be like covering acne: cosmetic but not healthy. Indeed, it often seems that the more we cover, the less we truly accomplish. When anticipatory guidance consists of the recitation of a long list of points (eg, eat vegetables, limit television, exercise, buckle up, wear a helmet, wear sunscreen, make time for homework, make time for play, look out for bullying, ask about drugs, ask about friends, brush every day, etc), both clinicians and parents tend to tune out.6 A variety of approaches can augment patient education, such as written handouts, videotapes, modeling, and role-playing,7 but teaching more effectively, in itself, does not solve the problem of there being too much to teach in too little time. Recognition of this dilemma has led to recent calls to "rethink pediatric primary."3,4,8 Here, in answer to the call, are 3 thoughts.
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THOUGHT 1: SPEND TIME RATIONALLY |
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TOPABSTRACTTHOUGHT 1: SPEND TIME...THOUGHT 2: MAKE EXPERIENTIAL...THOUGHT 3: LEARN FROM...REFERENCES |
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Current recommendations for well-child care are weighted down with topics that fail the twin tests of importance and responsiveness. For example, although most of us agree that children should help with chores, the health significance of chore-doing has not been well established, and the value of anticipatory guidance on the topic remains unknown. Other issues clearly are of great importance but may not be responsive to intervention within the well-child visit. Television addiction, handgun access, domestic violence, sexual abuse, sunburn, and permissive parenting all fall within this category. We simply do not know whether routinely covering these topics does any good. I do not mean to say that these topics should be dismissed, but until there is solid research to show how they can be addressed effectively in the context of primary care, we have only our personal experiences and preferences to guide us.
In contrast to the long list of issues that are important but not demonstrably affected, 2 recent reviews have identified a short list of issues on which we know we can make a difference.10,11 One example of an intervention that appears on both lists is promotion of reading aloud. Education experts agree that reading aloud is crucial for eventual school success, and there is substantial evidence that pediatric guidance about reading aloud positively affects parent behavior and child development in populations that are at high risk for school failure.12,13 Rational allocation of scarce face-to-face time would start with such proven interventions.
This strategy would not mean that we spend any less time with parents; it would mean that we spend the time better. Neither would this approach to routine guidance alter the general outline of well-child care. The visit still would begin by eliciting the parent's and the child's concerns, allowing them to define the first teachable moments of the encounter.14 The visit still would end with a wrap-up of the issues addressed and plans for interventions such as immunizations, blood tests, and future visits.
What about the multitude of problems for which we now screen or about which we provide routine advice (or would, if we could actually follow all of the recommendations)? Many, perhaps most, could be taken care of either before or after the face-to-face encounter, through questionnaires, handouts, recorded information, computers, the Internet, and other media.15 One necessary step is the creation of printed materials that are accessible to parents with limited literacy and that are effective for parents of all educational backgrounds.16 Billing and reimbursement would need to reflect the considerable effort expended. Problems that are uncovered through this process could trigger future problem-oriented visits. Just because a problem comes up during well-child care does not mean that its solution has to be confined within the same 20-minute time frame.
As we rethink how best to work within the well-child visit, we also have to work harder outside the visit, advocating for environmental standards, child protection, quality child care, equitable education, safety innovations, and other critical issues.17 We also have to continue to explore creative cross-disciplinary collaborations, such as the Healthy Steps program.18 Doing more outside the well-child visit frees us to "cover" less during the visit itself, while providing more—and more effective—care.
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THOUGHT 2: MAKE EXPERIENTIAL LEARNING THE FOCUS OF EACH VISIT |
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TOPABSTRACTTHOUGHT 1: SPEND TIME...THOUGHT 2: MAKE EXPERIENTIAL...THOUGHT 3: LEARN FROM...REFERENCES |
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The opportunity to create learning experiences begins at birth. In the Brazelton Newborn Behavioral Assessment Scale (NBAS), the clinician elicits an infant's competencies, including the abilities to habituate, to orient to visual and auditory stimuli, and to modulate arousal.23 Although the NBAS was developed as a research tool, studies have shown that when parents are invited to observe or participate in the NBAS with their own infants, the result is improved mother–infant interaction and child development, even months later.24
For older infants and children, picture books can readily provide the learning focus. For example, at a 6-month visit, I hold out a colorful board book, and say, "Let's see what Johnny will do with this." The mother and I watch how Johnny responds to the new object. We talk about what Johnny is learning, how he is learning, and how his mother can feed his growing curiosity. If all goes well, then Johnny leaves with the book, and his mother leaves with a new appreciation for Johnny's cognitive strengths and for her own parenting competence.
Used in this way, the picture book serves as a lens, focusing developmental assessment and teaching on issues that are relevant to the child's learning: receptive and expressive language, attention, social interaction, and cognitive/behavioral style. The book creates the opportunity to model developmentally appropriate teaching techniques, to observe first-hand how the child responds to such interactions, and to discuss the child's individual response with the parent in "real time."
The efficacy of clinic-based interventions using books has been documented repeatedly,13 but books are not essential. A wide range of toys and other objects could be used to elicit joint attention, playful interaction, and language.25 Whether the visit focuses on habituation, picture books, blocks, or dolls, the point is to help the parent engage the child in an act of learning. To inspire positive parenting behaviors, it may be best for pediatricians to do less telling and instead lead parents to come up with their own solutions to the challenge of supporting their children's development.26 In learning-focused primary care, the pediatrician creates a learning situation for the child, then provides encouragement and guidance to assist the parents' own process of discovery.
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THOUGHT 3: LEARN FROM COLLECTIVE EXPERIENCE |
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TOPABSTRACTTHOUGHT 1: SPEND TIME...THOUGHT 2: MAKE EXPERIENTIAL...THOUGHT 3: LEARN FROM...REFERENCES |
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I suggest a different approach. Instead of offering a solution, I would pose questions: Which forms of well-child care will provide the greatest benefits to which families? Do we need to create a 1-size-fits-all system, or can we devise different packages of care according to a particular child's and family's biological, psychological, and social assets and risks? Instead of a central standard-setting body, why not create an expert committee to generate protocols for primary care that will be subjected to clinical trials, just as the Children's Oncology Group creates protocols for cancer care?27 If we believe that well-child visits ought to be named rather than numbered, as Schor advocates, then let’s enroll a large number of families in a randomized trial to test that concept. If we think that the periodicity schedule needs revising, then let’s systematically compare a revised schedule with a traditional one. For that matter, let’s subject the idea of learning-focused care, as I’ve sketched it above, to empirical study.
A program of systematic assessment of primary care protocols would address a problem that has been skirted by most of the current research. Although many studies have evaluated interventions aimed at single issues, few have considering the effects of competition for time and attention from all of the other interventions that are provided during the same visit. For research to inform evidence-based practice, the unit of assessment has to be the visit or the series of visits rather than any single intervention in isolation.
Before we can meaningfully evaluate novel approaches to care, we will need to agree on a consistent set of clinically relevant outcome measures. Process measures, such as the percentage with complete immunizations, the number of anticipatory guidance topics covered, or parent satisfaction, already have been developed.8,28 Beyond these, we also need to assess hard clinical outcomes, such as visits to the emergency department and educational achievement. Conditions such as obesity, early reading delays, and referral for behavioral treatment are important enough, common enough, and readily enough gauged that it ought to be possible to detect differences in their incidence in response to different paradigms of primary care. Interventions that are directed at critical family issues such as domestic violence, parental smoking, and substance abuse also would benefit from a uniform set of measurement tools. The task of selecting a package of outcome measures to be applied across multiple studies could rightly fall to the panel of experts envisioned by Schor.
Regardless of how we end up "rethinking" primary care, the commitment to empiricism is fundamental. There are 60000 pediatricians in the AAP. If the fellows of the AAP took a more systematic approach to the study of primary care, then there would be no shortage of meaningful results. The AAP's Pediatric Research in Office Settings Network has demonstrated that such large-scale undertakings are feasible; undoubtedly, many lessons can be drawn from that effort.29 A commitment of research funding at the national level also would facilitate progress greatly in this area. Through a well-planned program of ongoing innovation and evaluation, the practice of providing well-child care would become, simultaneously, the process of improving it. Such a commitment to self-study would constitute the most important sense in which well-child care could and should become learning focused.
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FOOTNOTES |
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Address correspondence to Robert Needlman, MD, Department of Pediatrics, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109. E-mail: robert.needlman{at}case.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTTHOUGHT 1: SPEND TIME...THOUGHT 2: MAKE EXPERIENTIAL...THOUGHT 3: LEARN FROM...REFERENCES |
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