Published online July 2, 2007
PEDIATRICS Vol. 120 No. 1 July 2007, pp. 149-154 (doi:10.1542/peds.2007-0638)

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SPECIAL ARTICLE

2006 Job Lewis Smith Award Acceptance Address: Is There an OWA (Other Weird Arrangement) in Your Future?

Stanley I. Fisch, MD, FAAP

Harlingen Pediatrics Associates, Harlingen, Texas

Key Words: community pediatrics • medical education • medical home • chronic care

Abbreviations: OWA—other weird arrangement • COPC—community-oriented primary care • ACP—American College of Physicians • AAP—American Academy of Pediatrics • CCM—chronic care model • CPTI—Community Pediatrics Training Initiative

I am greatly honored to stand before you as the recipient of this award. To stand in the line of men and women who have been here before me and to stand before you, my colleagues, teachers and friends, is astonishing and gratifying, a truly wondrous moment. Please allow me to use this occasion to reconnect with our history and to look ahead at what lies before us.

I am particularly concerned about OWAs [other weird arrangements].

We have had many OWAs come and go. Like many attractive ideas, they have their day, then fade, with traces taken up by the next fad, the next iteration of the core idea. Here are a few:

	THE QUALITY MOVEMENT IN HEALTH CARE

TOP THE QUALITY MOVEMENT IN... RATIONALIZING THE SYSTEM IS COMMUNITY PEDIATRICS DESTINED... LINEAGE CONTEMPORARY OWAs: THE MEDICAL... AN AGENDA FOR REACHING... SUMMATION REFERENCES

 

• Quality assurance
  
• Quality improvement
  
• Performance improvement
  
• Six Sigma
  
• Patient safety
  
• Reducing errors
  

	RATIONALIZING THE SYSTEM

TOP THE QUALITY MOVEMENT IN... RATIONALIZING THE SYSTEM IS COMMUNITY PEDIATRICS DESTINED... LINEAGE CONTEMPORARY OWAs: THE MEDICAL... AN AGENDA FOR REACHING... SUMMATION REFERENCES

 

• Managed care
  
• Managed cost
  
• Integrated delivery systems
  
• Disease management
  
• Case management
  
• Pay for performance
  

	IS COMMUNITY PEDIATRICS DESTINED TO BE AN OWA WHOSE APPEAL WILL FADE?

TOP THE QUALITY MOVEMENT IN... RATIONALIZING THE SYSTEM IS COMMUNITY PEDIATRICS DESTINED... LINEAGE CONTEMPORARY OWAs: THE MEDICAL... AN AGENDA FOR REACHING... SUMMATION REFERENCES

 
We have had our share of OWAs in community pediatrics:

• Community medicine
  
• Community pediatrics
  
• Social medicine
  
• Family-centered care
  

In addition, several themes have entered the lexicon of community pediatrics:

• Social determinants of health
  
• Rights and equity
  
• Access to care
  
• Overcoming disparities
  
• New morbidity
  
• Millennial morbidity
  

But, I believe community pediatrics as a concept and as a discipline has a lot more durability than most OWAs because of its rich lineage, substantial content, and profound relevance to today's environment of pediatric practice.

	LINEAGE

TOP THE QUALITY MOVEMENT IN... RATIONALIZING THE SYSTEM IS COMMUNITY PEDIATRICS DESTINED... LINEAGE CONTEMPORARY OWAs: THE MEDICAL... AN AGENDA FOR REACHING... SUMMATION REFERENCES

 
We owe much to the work and legacies of many who have labored in the field of community pediatrics. To name a few who have influenced me, and by no means constituting an exhaustive list:

Martin Cherkasky, Victor Sidel, and Harold Wise made Montefiore Medical Center and the Albert Einstein College of Medicine [both in Bronx, NY] a fount of innovations in what was then called social medicine; from prepaid group practice to neighborhood health centers to community outreach, Montefiore was and remains an extraordinary place for practice, teaching, and research in social medicine.

George Silver, an internist like Cherkasky, Sidel, and Wise, was chief of social medicine at Montefiore from 1951 to 1965. He was very interested in the interface between public health and clinical practice. From Montefiore he moved on to the Department of Health, Education, and Welfare and had a profound influence on federal health programs for many years beyond his tenure as deputy assistant secretary. Our colleagues Fernando Guerra, Jeff Goldhagen, and Peter Simon expand the work of Dr Silver in their inspiring roles as public health officers, clinicians, and community advocates.

During 50 productive years, Robert Haggerty has done so much to set the research agenda for community pediatrics and model ways in which pediatricians can engage in their communities to bring about improvements in health for all children.¹

One figure of special importance to me was Sidney Kark [Fig 1], a family physician who, with his wife, Emily, developed models of community practice that still influence us today.

View larger version (141K): [in this window] [in a new window]   FIGURE 1 Sidney and Emily Kark. (Photo courtesy of Dr Jeremy Kark.)

 
Sidney and Emily Kark were South Africans. After completing their medical studies, they were sent to Durban, and in the early 1940s as part of an extraordinary social experiment established a network of primary-level clinics in the surrounding areas of the city. This work produced a stream of path-breaking innovations in the practice of social medicine. His notion of social medicine was expansive:

Social medicine may be regarded as a practice of medicine concerned with health and disease as a function of group living. It is interested in the health of people in relation to their behavior in social groups and as such is concerned with care of the individual patient as a member of a family and of other significant groups in his daily life. It is also concerned with the health of these groups as such and with that of the whole community as a community.²

Their practice was the Pholela Health Unit, a "neighborhood health center," which in the 1960s George Silver and others used as their model for the community health center initiative of the Office of Economic Opportunity. Sidney Kark understood the health problems of his patients as community health syndromes, which embodied the complex interactions of disease states, health conditions, family, and community life. Here is Kark's construct of a community syndrome of malnutrition, infections, and mental illness [Fig. 2].³

View larger version (21K): [in this window] [in a new window]   FIGURE 2 The determinants of a community syndrome of malnutrition, communicable diseases, and mental ill-health in a rural area in South Africa, 1940: the collapse of successful farming. (Reproduced with permission from Kark JD, Abramson JH. Sidney Kark's contributions to epidemiology and community medicine. Int J Epidemiol. 2003;32:882–884.)

 
He created teams of health care workers (a doctor, a nurse, and a health educator), and assigned each team to a particular neighborhood and list of families. The team was made responsible for the health of the families in that neighborhood and, indeed, for the health of the entire neighborhood. Teams were asked to do systematic assessments of health care needs in their assigned catchments and to use epidemiologic methods to catalog these needs and gauge the team's effectiveness.

Family care constituted a central point of interest in the clinical and public health practice of the [team]. ... Study of the patient's family life situation is very often essential in understanding ... his condition and in the consideration of the prognosis and the care program. This objective is one which is common to all doctors in clinical practice, whether in the preventive or curative field, general practitioners or specialists.²

In 1952, as chair of Social, Preventive, and Community Medicine of Natal University Medical School in Durban, Kark initiated a clerkship in social medicine for medical students. The clerkship required several unusual commitments from his students.² First, students should have a longitudinal experience, "a continuing relationship with individual patients and ... their families." Further, students were expected to make "a diagnosis of the state of health of a group, with particular stress on family diagnosis and on appraisal of a community's health." Finally, students were asked to give "consideration of the resources available for promotion of health and medical care within family and community as well as through various agencies." By the way, this course was spread over 3 years of the medical school's curriculum.

Over 200 community health centers, modeled after the Pholela unit, were planned for South Africa. However, with the imposition of apartheid in 1948, these plans were suspended, and eventually the 40 health centers already built were closed. The Karks left South Africa in 1958 and went briefly to the University of North Carolina. Sidney became founding chairman of the Department of Epidemiology in the School of Public Health at the University of North Carolina in Chapel Hill. After a year, the Karks and colleagues from South Africa went to Jerusalem, established the Department of Social Medicine of the Hebrew University, and resumed their work in developing and promoting social medicine.

In 1981 he published a foundational work on what he called community-oriented primary care (COPC).⁴ COPC was the conceptual link between primary care and public health. Community-oriented Karkian health care teams would utilize tools and concepts from epidemiology and behavioral and social sciences. Health promotion through education and special projects was an essential component of COPC. Appreciation for the families’ cultural identification and beliefs was emphasized. And, collaboration and coordination with other providers and agencies were essential for fulfilling these charges.

Already in the late 1940s Kark was developing methods for outcomes measurement. "Measurement of the progress of families," he wrote, "in a particular family practice and of the community's health as a whole was a feature of the service. ... A special group of health recorders was trained for the purpose and in this way it became possible to measure the changing state of health of the various communities and to evaluate the [practice's] programs."²

Pay for performance, anyone?

Kark left us many important insights. These include:

• Medicine is collaborative. The integration of curative, preventive, and promotive care requires many skills and many hands.
  
• The "social" is inherent in all medicine, not just primary care.
  
• "Cultural competence" is crucial.
  
• Epidemiology is an important tool in community practice: "What pathology and physiology have meant in the development of scientific diagnosis of the individual patient so epidemiology is coming to mean in the study of those processes determining the health of a group. As such, it is the foundation science of social medicine."²
  
• There is a vital link between community practice and public health, a theme addressed more recently by the current generation of COPC advocates.^5,6
  
• Teaching and research are essential components of the practice of social medicine.
  
• Medicine must hold firmly to an orientation toward equity and social justice.
  

	CONTEMPORARY OWAs: THE MEDICAL HOME

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The medical home represents a strong partnership between physicians and families to address the needs of children, especially children with special needs.⁷ It is interesting that our colleagues in internal medicine have become interested in the medical home.⁸ The American College of Physicians (ACP) acknowledges the work of Cal Sia and the [American Academy of Pediatrics] going back to the 1960s, laying the foundation for the medical-home concept. For the ACP, the advanced medical home may be a matter of survival of the discipline of general internal medicine.⁹ In a paper with the astonishing title of "The Impending Collapse of Primary Care Medicine [and Its Implications for the State of the Nation's Health Care],"¹⁰ the ACP sets out the stark terrain they see lying ahead for adults with chronic illness. There will not be anywhere near enough general internists to care for the boomers now approaching retirement. And, no one has given serious, systematic thought to how and by whom the needs of our obese teenagers will be met as they roll into their 20s and 30s with chronic metabolic disorders and their complications.

An important organizing principle, the architectural plan for the medical home, and yet another OWA is the chronic care model (CCM). This has been developed by another internist, Dr Ed Wagner of Seattle [Washington].¹¹ Dr Wagner has proposed a model that is universal in application: pediatricians, as well as internists and family docs, would find this a useful way to configure their practices as medical homes to meet the new morbidity (the millennial morbidity) heading our way.¹²

The CCM has these components [Fig 3]:

• a health care team which creates and manages a registry of patients and uses community resources and partners to serve the needs identified;
  
• an electronic health record to ensure complete data capture and access for all who need to know;
  
• office workflow which permits preparation for patients’ visits, making them purposeful events meeting needs of providers and patients alike, rather than random encounters; and
  
• informed and engaged patients and families, engaged with informed and prepared caregivers.
  

View larger version (39K): [in this window] [in a new window]   FIGURE 3 The CCM.

 
The CCM is distinctly not "disease management." Rather, it is an organization of practice (either primary or specialty care) with a much broader focus than disease management programs operated to reduce payors’ costs. The CCM may have benefits for all patients in such a practice, not only those with chronic illness. The CCM is a blueprint for the design of the medical home, an information-age neighborhood health center.

	AN AGENDA FOR REACHING THE NEXT STAGE: FROM [CURRENT PROCEDURAL TERMINOLOGY] 99214 TO SOMETHING BETTER ... BEGINNING WITH PRACTICAL MATTERS

TOP THE QUALITY MOVEMENT IN... RATIONALIZING THE SYSTEM IS COMMUNITY PEDIATRICS DESTINED... LINEAGE CONTEMPORARY OWAs: THE MEDICAL... AN AGENDA FOR REACHING... SUMMATION REFERENCES

 
The current third-party reimbursement system is built on patient encounters that are brief, with one clinician, and for an acute illness with little long-term impact. To deal effectively with the millennial morbidities, we must design new CPT [Current Procedural Terminology] codes and descriptors that match what we aspire to do. Codes 99214 and 99215 do not represent the work of a health care team performing medical home services:

• Clinical evaluation and management
  
• Education
  
• Care coordination (not disease management)
  
• Advocacy
  

Haggerty pointed out that without financial support for the practice of community pediatrics, many pediatricians would not be able to do it¹³: no margin, no mission. In advocating new arrangements in practice and reimbursement, the ACP wants to press the issue so that general internal medicine, which it sees evolving as the advanced medical home for adults, can distinguish itself and be accountable for its services. We must collaborate with our colleagues in internal medicine and family medicine to effect essential changes in the environment of community-based, community-oriented practice. Richard Pan makes the case in a wonderful commentary in the September Pediatrics.¹⁴ We have a common interest with the internists and family doctors in promoting these new OWAs.¹⁵

We must make certain that both generalists and subspecialists are engaged in these collaborative efforts.¹⁶ And, we must connect with advanced nurse practitioners, physician assistants, social workers, health educators, and outreach workers to develop mutual understanding of roles of team members.

We must press for changes in residency training.

The Task Force on the Future of Pediatric Education II in its 2000 report placed at the top of its list of recommendations the following: "Pediatric medical education at all levels must be based on the health needs of children in the context of the family and community."¹⁷

So how do we connect with context?

I believe Sidney Kark stated it correctly more than 40 years ago:

Medical and nursing education must include a basic understanding of sociology and psychology of the standard demanded in the biological sciences, such as physiology, if clinical experience in family practice is to be fully appreciated. Understanding and knowledge of the family-life situation in its relationship to family health are integral elements of social medicine and vital to the men and women who may become family physicians and family nurses. Not only is it of significance to those who become general practitioners, but also to many who specialize in other fields of medical practice.²

For residents, continuity experience must be placed at the center of their training, not left to the periphery. Well-organized and fully supported continuity experiences are essential for learning about context.

Program directors must have flexibility to be creative and distinctive in what they offer. There must be less focus on inputs and process [and] more focus on outcomes. We must press the Residency Review Committee and program directors to enhance and expand the Accreditation Council for Graduate Medical Education's general competencies with the Community Pediatrics Training Initiative's [CPTI] competencies [Table 1].¹⁸ And, fortunately, through the CPTI, we have excellent models of how this can be done.

View this table: [in this window] [in a new window]   TABLE 1 Competencies for Community Pediatrics

 
We can connect better with context by enlisting community pediatricians to partner with academic health centers and offer learning opportunities to students and residents. We will soon offer the Starter Kit for Community Preceptors to orient community pediatricians to their roles as teachers and mentors.

At the institutional level, the [AAP] and the Ambulatory Pediatric Association should expand their collaboration, particularly via the Community Pediatrics Education and Training Special Interest Group on the [AAP] side and the Community Based Teaching SIG [special interest group] on the APA [Ambulatory Pediatric Association] side. There are also unrealized opportunities for collaboration in informatics, curriculum, advocacy, and faculty development.

	SUMMATION

TOP THE QUALITY MOVEMENT IN... RATIONALIZING THE SYSTEM IS COMMUNITY PEDIATRICS DESTINED... LINEAGE CONTEMPORARY OWAs: THE MEDICAL... AN AGENDA FOR REACHING... SUMMATION REFERENCES

 
I have mentioned a number of OWAs:

• social medicine;
  
• community medicine;
  
• the medical home; and
  
• the CCM.
  

These OWAs are durable. They will not fade away like so many fads. They have real substance and rich legacies created in the lives and works of great teachers, clinicians, advocates for children, and colleagues.

Sidney Kark's life and work teach us one other lesson: innovation happens at the periphery, not only at the center. This has been proven many times over in the Medical Home Initiative, the CATCH [Community Access to Child Health] program, the Pediatric Research in Office Settings network, and the CPTI. It is to the [AAP's] credit that these initiatives are being sustained.

So, I submit to you the proposition that the OWA in the future of pediatrics is community pediatrics, or perhaps just pediatrics, if, like me, you find "community pediatrics" redundant.

Job Lewis Smith and Abraham Jacobi would have found "community pediatrics" redundant. They demonstrated that medicine is as much about science as it is about politics, the art and promise of making change. Even earlier in the 19th century, Rudolf Virchow stated it this way: "Medicine is a social science, and politics nothing but medicine on a grand scale."¹⁹

And, while we think about the social determinants of health as scientists and clinicians, our responses to the problems we perceive are fundamentally ethical. Community pediatrics, or just simply pediatrics, has at its core a commitment to social justice and equity. Bearing that commitment, we then stretch ourselves beyond our offices and clinics to regard all the children in our communities. We recognize and comprehend as best we can the forces acting for good or ill on their health. We join our insights from clinical practice with those from our colleagues in public health to formulate "best evidence" and create "best practices" for social change. And, we reach out to like-minded colleagues to harness the energy we will need to sustain our work.

May our efforts to improve the lives of all the children in the communities we serve succeed beyond our wildest dreams. Our shared legacy, and the talent and commitment in this room, assure me that we will do so.

	FOOTNOTES

 
Accepted Mar 6, 2007.

Address correspondence to Stanley I. Fisch, MD, FAAP, Harlingen Pediatrics Associates, 321 S 21st St, Harlingen, TX 78550. E-mail: sfisch{at}rgv.rr.com

The author has indicated he has no financial relationships relevant to this article to disclose.

	REFERENCES

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1. Haggerty RJ. Some steps needed to ensure the health of America's children: lessons learned from 50 years in pediatrics. Ambul Pediatr. 2006;6 :123 –129[CrossRef][Web of Science][Medline]
2. Kark S, Steuart G. A Practice of Social Medicine: A South African Team's Experiences in Different Communities. Edinburgh, Scotland: E & S Livingston Ltd; 1962
3. Kark JD, Abramson JH. Sidney Kark's contributions to epidemiology and community medicine. Int J Epidemiol. 2003;32 :882 –884[Free Full Text]
4. Kark SL. The Practice of Community-Oriented Primary Care. New York, NY: Appleton-Century-Crofts; 1981
5. Lasker RD; Committee on Medicine and Public Health. Medicine and Public Health: The Power of Collaboration. New York, NY: New York Academy of Medicine; 1997
6. Strelnick AH. Community-oriented primary care: the state of an art. Arch Fam Med. 1999;8 :550 –552[Free Full Text]
7. American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110 :184 –186[Abstract/Free Full Text]
8. American College of Physicians. Advanced medical home: a patient-centered, physician-guided model of health care. January 22, 2006. Available at: www.acponline.org/hpp/adv_med.pdf. Accessed September 17, 2006
9. Society of General Internal Medicine, Task Force on the Domain of General Internal Medicine. The future of general internal medicine. Available at: www.sgim.org/futureofGIMreport.pdf. Accessed September 23, 2006
10. American College of Physicians. The impending collapse of primary care medicine and its implications for the state of the nation's health care: a report from the American College of Physicians—January 30, 2006. Available at: www.acponline.org/hpp/statehc06.1.pdf. Accessed September 14, 2006
11. Wagner EH, Austin BT, Davis C, Hindmarsh M, Schaefer J, Bonomi A. Improving chronic illness care: translating evidence into action. Health Aff (Millwood). 2001;20 :64 –78[Abstract/Free Full Text]
12. Palfrey J, Tonniges TF, Green M, Richmond J. Addressing the millennial morbidity: the context of community pediatrics. Pediatrics. 2006;115(4 suppl) :1121 –1123
13. Haggerty RJ. Community pediatrics: can it be taught? Can it be practiced? Pediatrics. 1999;104 :111 –112[Free Full Text]
14. Pan RJ. A Jacobian future: can everyone have a medical home? Pediatrics. 2006;118 :1254 –1256[Free Full Text]
15. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005;20 :953 –957[CrossRef][Web of Science][Medline]
16. Maternal and Child Health Policy Research Center. Promising approaches for strengthening the interface between primary and specialty pediatric care. March 2006. Available at: www.mchpolicy.org/documents/InterfacePromisingPracticesReport.pdf. Accessed September 23, 2006
17. American Academy of Pediatrics, Task Force on the Future of Pediatric Education II. The Future of Pediatric Education II: organizing pediatric education to meet the needs of infants, children, adolescents, and young adults in the 21st century. Pediatrics. 2000;105(1 pt 2) :157 –212
18. Dyson Initiative Curriculum Committee. Competency in community pediatrics: consensus statement of the Dyson Initiative Curriculum Committee. Pediatrics. 2005;115(4 suppl) :1172 –1183
19. Bloch H. Rudolf Virchow, M.D. (1821–1902), builder of barricades. N Y State J Med. 1974;74 :1471 –1473[Web of Science][Medline]

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This Article Extract Full Text (PDF) Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via CrossRef Citing Articles via Google Scholar Google Scholar Articles by Fisch, S. I. Search for Related Content PubMed Articles by Fisch, S. I. Related Collections Office Practice Social Bookmarking                         What's this?