1. Enhanced understanding of psychosocial aspects of
pediatrics
2. Greater facility in dealing with developmental crises
3. More comprehensive approach to health supervision
4. Fuller appreciation of psychosocial implications of
chronic illness and handicap
5. Increased ability to help families
6. Expanded power to discriminate between transient
disturbances and more serious psychiatric disorders
7. More highly developed interviewing and counseling skills
8. Heightened awareness of the scope of one's competency in
the area of psychiatric disorders
9. Strengthened orientation to consult with or refer to child
psychiatrists or other mental health professionals as appropriate.
All the groups have had at least two child psychiatrists
involved as comoderator and back-up comoderator and several have had
more, with one COR group having an even mix of pediatricians and child
psychiatrists. The experience from those groups where child
psychiatrists participated in nonleader roles reinforces our belief
that the COR group can be a two-way street in which reciprocal gains
can be realized by both pediatricians and child psychiatrists.
The educational process in COR has varied considerably. One area of
variation relates to the role of case material in the process. All COR
groups make extensive use of work with patients, but they approach it
in a number of different ways. For instance, one group encourages
participants to bring in challenging/interesting cases that are matters
of the moment for the presenter. This group assumes that, over the
course of a year, a representative sample of case material will be
covered, and experience to date seems to support the assumption. Other
groups preselect topical foci and invite case reporting that will
illustrate the subject under consideration. Sometimes topics are
planned to follow developmental sequences; other times particularly
prevalent or challenging issues are selected, and the ostensibly
unremarkable health supervision visit has also been the object of
attention.
In some COR groups, structured didactic elements have been intertwined
with the consideration of clinical case material. Although relatively
formal teaching remains a feature in certain COR programs, if there has
been a trend in the life of COR, it would appear to be in the direction
of emphasizing clinical material and learning from the practical
challenges and opportunities that are presented when the group
considers cases. Nonetheless, other materials are routinely added,
usually in the form of supplementary reading, and sometimes through
other devices, such as videotaping and simulated interviewing. Visiting
experts, community workers, and families are among those who have been
invited on occasion to contribute to the discussion in one or more of
the groups.
Participation is open-ended for most groups, rather than rotating
participants after fixed time segments. This approach promotes a sense
of group identity and shared purpose that facilitates mutual trust and
open interchange. MCHB sees limiting the group size to 12 and striving
for meetings at least monthly, and preferably biweekly or more often,
as ways to reinforce the group process.
One half of the original grantees from the first generation of projects
have received support from the second generation COR program; they are
Case Western Reserve University, Dartmouth College, Duke University,
Vanderbilt University, and Yale University. They have been joined by
Children's Hospital of Cincinnati (University of Cincinnati),
Children's Hospital of Philadelphia (University of Pennsylvania),
Indiana University, and The University of Michigan. Also, COR groups
have been incorporated as an essential element in 11 behavioral
pediatrics projects supported by MCHB.
Behavioral pediatrics COR groups are, on the average, more involved
with trainee participants than the freestanding COR projects have been.
Many trainees are not able to make the same kind of continuing
commitment to the COR process that community practitioners can;
nonetheless, they have found purposefully time-limited COR exposure can
still be personally meaningful and practically useful.
Problems and Disorders
Health Supervision
Family and Community
Personal Challenges/Practical Complexities
Clinical Management
DEVELOPMENT OF THE COLLABORATIVE OFFICE ROUNDS (COR) PROGRAM 
As part of our ongoing concern with mind and body and our
continuing commitment to multidisciplinary approaches in child health care, the Health Resources and Services Administration's Maternal and
Child Health Bureau (MCHB) precursor office convened a meeting of
pediatricians and child psychiatristsa in the fall of 1988 to consider how to enhance collaboration in
education. The focus of the discussions was on the
psychosocial-developmental aspects of child health as they impact on
children, adolescents, and families.
The 1988 meeting led to a recommendation for the COR discussion group
approach. The centerpiece of the approach is a small group experience
that promotes the free exchange of ideas and provides for a continuing
relationship with the resource faculty and other group members.
Constancy in group composition and regularity in meeting frequency are
important features that contribute to a sense of collective group
identity and to sustained impact. The focus of attention is on clinical
situations.
The COR group addresses an increasingly recognized need for there
to be a greater focus on mental health issues in physical health care.
The groups can contribute to this objective by enhancing skills and
sensitivities that the present or future practitioner may have acquired
in training. Elements of COR are derived from the work of mental health
specialists, but its focus is very much on the unique opportunities and
challenges offered by the primary care setting. The COR program
provides modest funding as a stimulus to encourage collaborative
educational efforts by pediatrics and child psychiatry, and as a
vehicle for demonstrating the utility of the COR group experience.
COR PRECURSORS
In 1950, Michael and Enid Balint began to lead groups of British
general practitioners in discussion seminars that applied concepts from
psychoanalysis to the primary practice of
medicine.1 These seminars seem similar to COR
in providing an ongoing small group experience that addresses
psychosocial issues. However, the nature of their focus on
psychodynamics in doctor-patient interactions and on "limited but
considerable change of personality" in practitioners2
extends beyond the scope of COR program objectives. To a degree,
related differences appear to have also characterized the discussion
seminars when their attention was more limited in focus.3
Relatively recently, there has been an effort to formulate an approach
to Balint-type work that evidently involves a focus on change in
caretaking as distinguished from change in caretaker.1
In October 1964, Albert Solnit reported on experiences with pediatric
discussion groups in New Haven, CT that originated in 1957.4 He cited initiation of a mixed group of trainees
and more senior participants with a child psychiatrist serving as moderator. This evolved into a study group of pediatric practitioners with a child psychiatrist and pediatrician as cochairs. This model closely resembles a number of the current COR groups. Group activity of
this kind has continued in New Haven up to the present.
In April 1967, Sumpter and Friedman presented a report on a small group
of pediatricians who had started meeting in Rochester, NY in 1964 to
discuss cases from their practices that involved emotional/behavioral
problems.5 The group had no identified leader, but it did
call on outside experts for consultations at times. Although no
systematic evaluation of the group experience, referred to as a
workshop, was made, the impression was that it, "... meaningfully
altered some aspects of the practice of pediatrics for its members."
THE SPECTRUM OF COR PROJECTS
Initially, COR participants were expected to be primarily
practitioners, but COR has since shown promise with fellows and residents as well. Most of the participants in the groups to date have
been pediatricians. However, although the membership of these groups
has been more homogeneous than envisaged, other aspects of the
experience with these projects have been more variable. As a result,
these projects present a wide spectrum of COR experiences.
Ten first generation COR projects started in the fall of 1989. In
keeping with the program guidance, all 10 projects were jointly
sponsored by Pediatrics and Child Psychiatry medical school departments/sections. The grantees were: Case Western Reserve University, Dartmouth College, Duke University, Evanston Hospital (Northwestern University), Rhode Island Hospital (Brown University), The University of Chicago, The University of Connecticut, Vanderbilt University, Washington University
St. Louis, and Yale University. Because, as noted, most of the members were pediatricians, their objectives have been quite similar to objectives originally envisaged for pediatrician participants. These include the following:
PROGRAM CONTENT
The areas of interests covered by COR groups are wide ranging.
Essentially all the expected psychosocial/developmental problems and
disorders that the practitioner encounters, as well as some of the more
esoteric ones, are represented in the topics collectively addressed by
the COR projects. Health supervision, anticipatory guidance, and
counseling on developmental challenges and crises are frequently
addressed. The focus often extends to the family and community.
Personal challenges for the practitioner and practical issues for the
practice also draw considerable attention, as do issues in assessment,
treatment, consultation, referral, and follow-up. Examples of topics
are outlined below:
EVALUATION
All COR projects incorporate an evaluation component. These vary
considerably in their approach and extent. Among the methods used are
observation of how participants relate to patients and families;
detailed chronicling and review of group discussions; and use of
questionnaires, often for participants and sometimes for
moderators. The questionnaires inquire about a number of issues including psychosocial/developmental orientation, comfort with psychosocial aspects of clinical experience, practice patterns including use of referral and consultation, content and process of
individual sessions, and utility of what is derived from the sessions.
The findings from across the projects point to positive responses and
suggest significant impact.
In addition to individual COR group evaluation efforts, the groups
collectively provide information on an annual basis about their
experience during the past year, the responses of their participants to
the experience, and accomplishments/effects impacting others outside
the COR circle. These latter impacts are referred to as spinoffs.
Information from the past 4 years, incorporating input from the first
two generations of freestanding COR projects, paints a picture of
remarkable stability in the groups. Most groups have reported no change
in either of their two comoderators. The departure rate for
participants has also reflected a high degree of commitment, with the
great majority of participants remaining in COR over the duration of
the projects. In addition, participants have expressed universal
readiness to recommend the COR experience. Perhaps more revealing than
endorsement of COR is the pattern of attendance by participants. The
average attendance has remained in a range extending from approximately
two-thirds to about three-fourths of the group for each session. Also,
participant responses reflect a widely held conviction that COR is well
worth the investment of resources; MCHB support has recently averaged
$13 000 per project annually.
In evaluating their impact, COR groups document accomplishments beyond
those with direct value for their participants. These spinoffs include
the following: sponsorship of seminars and courses, influence on change
in existing curricula, institution of new faculty positions and new
teaching roles, additions to house officer training, development of
didactic materials, creation of new clinical programs/services, and
establishment of new linkages among medical faculty and between the
academic and local service communities.
In addition to specific spinoffs, the COR projects have extended their
influence beyond their group members through sharing of information and
ideas between participants and their colleagues. This form of
dissemination has been preplanned by some projects that recruit
participants from group practices so as to expand the area of impact.
Evaluative information supplied by the projects documents patterns of
sharing.
As suggested by the experience cited, evaluation efforts to date have
been encouraging; however, the COR projects have had to confront some
challenges during their formative years. Timing of meetings has been
one of the areas where adjustments have been necessary. Office hours
and parenting responsibilities are two major considerations. Different
groups have worked out different arrangements. Among the times set have
been early morning hours, evenings, and time slots juxtaposed to events
such as grand rounds.
Another issue is presented when some of the group members are
significantly more sophisticated than others regarding psychosocial aspects of clinical care. Problems might arise if this issue is not
addressed when there is a mix of experienced practitioners and
trainees. Sometimes, a problem occurs when a participant takes the part
of the expert in a way that is dominating or demeaning to others. If
such a situation is not dealt with, it can have a disruptive effect on
the process.
A variety of challenges can affect attendance. For instance, those who
are salaried employees, whether in the public or private sector, may
have difficulty getting their supervisors to support participation
unless they can convey effectively the usefulness of their involvement
with COR. Another factor that may affect attendance is the size of the
COR group. Information obtained from the projects suggests a trend in
the direction of groups somewhat larger than the 10 to 12 members
(including moderators) originally envisaged. This probably occurs for a
variety of reasons such as interest in being inclusive and desire to
offset inevitable absences of some members at certain times. Although
it appears as if the larger groups may have more peripheral
participants, they seem to have done well with them. Nonetheless, the
possibility of a dilution factor is something to keep in mind.
Evaluation information supports further development of the COR concept.
Nonetheless, it would seem worthwhile to obtain, through rigorous
study, outcome data that may further validate the approach and provide
insights to strengthen what one participant has characterized as,
"the best method of continuing medical education."
COMMENT
It is essential that attention to mental health be an integral
part of primary health care for children and adolescents, not only to
assist early identification of mental disorders and begin the process
of intervention, but also to provide a trusted wellness system that can
promote positive psychosocial development and serve as a key primary
prevention resource. These themes are reflected in Healthy
Children 2000: National Health Promotion and Disease Prevention
Objectives Related to Mothers, Infants, Children, Adolescents, and
Youth;6 in Bright Futures: Guidelines for
Health Supervision of Infants, Children, and
Adolescents;7 and in the new mental health
classification system geared particularly to the needs of primary care
providers who serve children, adolescents, and their
families.8
Experience to date points to the COR group as a useful tool for
addressing psychosocial issues in primary care. Its potential may be
more fully realized by applying this approach more widely, even as
further assessment is pursued. A natural extension would be to explore
the applicability of this approach in new situations and with different
group compositions. Hopefully, this could expand the contribution of
COR to the continuing education and training of health care
professionals who serve children, adolescents, and their families.
Reprint requests to (M.E.F.) Maternal and Child Health Bureau,
5600 Fishers Lane, Room 18A-30, Rockville, MD 20857.
ABSTRACT
