OBJECTIVE: To assess perspectives about the practice of well-child care among pediatric clinicians, especially in the areas of child development and behavior.
METHODS: Thirty-one focus groups (282 pediatricians and 41 pediatric nurse practitioners) in 13 cities addressed current practices, priorities used to determine content of well-child care visits, and changes to improve visit quality and outcomes.
RESULTS: Although most clinicians were positive about their practice of well-child care, they reported areas of concern and suggested ideas for improvements. Establishing a therapeutic relationship and individualizing care were viewed as significant contributions to quality of care. Participants agreed about the importance of eliciting parent concerns as the first priority for all well-child care visits. Community resources outside the office setting were seen as both a major influence on and, in some communities, a limitation to pediatric care. The challenges of early recognition of developmental and behavior problems through standardized questionnaires and effective interviewing were viewed as a priority to improve pediatric effectiveness in monitoring and treatment. To enhance primary care practices in developmental and behavioral pediatrics, participants suggested innovations in practice organization, community linkages, information technology, and integration of existing innovative programs. Education for pediatricians and enhanced resident training in developmental and behavioral pediatrics were endorsed.
CONCLUSIONS: Pediatric clinicians' support a vision of preventive care that is comprehensive, family centered, and developmentally relevant, both for children with greater risk to long-term healthy development and for families with more normative child-rearing concerns.
- well-child care
- pediatric primary care
- health supervision
- preventive care
- developmental care
- family-centered care
Well-child care is the foundation of preventive pediatrics. Visit structure has changed relatively little over several decades, whereas child health concerns and practice conditions have changed substantially.1,2 The earlier focus on acute illness has given way to growing concerns regarding chronic conditions, developmental disabilities, and psychosocial and environmental risks.3–6 Continuous and comprehensive care has been a cornerstone of model practice. Yet, disparities in access to care, shifting insurance coverage, parent work schedules, and part-time physician practices are challenging that goal.7–11 The “push-pull” on primary care clinicians to provide expanded services within limited opportunities for patient contact is of growing concern.12–14 Recognizing the gap between traditional well-child care and contemporary needs and pressures, Schor15 called on pediatricians to rethink well-child care.
What are pediatricians thinking about rethinking? Using a qualitative study design to provide a range of expression not possible with questionnaires, we examined the complexities of providing preventive care and elicited clinicians' visions of how to support developmental and adaptational needs of children and families. In this study, we addressed 2 core issues from the pediatrician's perspective: (1) What is most important about how you currently provide well-child care, including your priorities for the content of care? and (2) What, if any, changes are needed to provide high-quality, comprehensive well-child care?
Participant Recruitment and Site Selection
We conducted 31 focus groups between December 2005 and May 2007, with 282 pediatricians and 41 pediatric nurse practitioners. One of the authors (Drs Stein or Tanner) initiated recruitment with a professional at each site who advertised the meetings locally. These host clinicians were primary care pediatricians, general academic pediatricians, or nurse practitioners, and were selected for their known leadership roles and interest in well-child care. No incentives were offered beyond the invitation to participate and, in most cases, a meal or refreshments. The protocol was reviewed and approved by the institutional review boards of Children's Hospital & Research Center Oakland and the University of California at San Diego.
Sites were selected to ensure geographic and patient diversity and reflected a wide range of urban, suburban, and rural practice sites and income, racial, and cultural patient characteristics. Thirteen sites participated: Boston, Massachusetts; Burlington, Vermont; Cleveland, Ohio; Greensboro, North Carolina; Miami, Florida; Oakland, California; Portland, Oregon; rural New England; Salt Lake City, Utah; San Diego, California; San Francisco, California; Seattle, Washington; and Washington, DC. At most sites, 3 groups were held (2 with community-based practitioners and 1 with academic generalists). Groups ranged from 4 to 15 participants (mean: 7). A project synopsis and Schor's “rethinking well-child care” commentary15 were provided before the meeting.
Focus groups were moderated by Drs Stein and/or Tanner and lasted 60 to 120 minutes. Fifteen of 32 groups were audio-recorded and later transcribed. Group size and/or ambient noise made recording other groups more difficult; detailed notes were taken instead. Participants in 22 groups (n = 179) completed a demographic questionnaire. Constraints on time for meeting (eg, fitting the group discussion into a breakfast or lunch conference hour) was the main reason for the failure to complete questionnaires in the remaining 9 groups.
Adapting concepts from grounded theory,16,17 we used an inductive approach to create an understanding of how pediatricians might be viewing current issues in well-child care. Initial questions were developed on the basis of pilot interviews with selected pediatric professionals and parents, and tested in the first 3 focus groups. In the subsequent groups, participants were presented with the same series of open-ended questions (see Table 1) designed to stimulate open discussion between peers in areas of particular interest and concern to them. Transcripts or detailed notes were coded for recurrent themes. On the basis of participants' responses to the discussion guide questions, more specific concepts and categories generated from the participants were formed in the coding process. The initial categories were identified through joint discussion and coding by Drs Stein and Tanner for 3 transcripts. Drs Stein and Tanner then coded 3 additional transcripts independently to further consolidate themes. Agreement on revised themes was checked by independent coding and comparison of 4 additional transcripts. Drs Stein and Tanner independently coded the remaining transcripts.
Sample and practice characteristics are described in Table 2. More than 50% of participants were women. The mean age was 50.5 years (range: 30–86 years). Forty percent described their practice as a group setting. The majority (86%) provided well-child/adolescent care, reporting an average of 43 preventive care visits per week, with average visit duration ranging from 20 to 25 minutes of physician time per visit.
Overall, clinicians reported positive opinions regarding the value of well-child care to provide child-rearing information, support, and guidance, and the chance to get to know the child and parent during a nonillness encounter. They also noted areas of concern and ideas for potential improvements. Most were satisfied with the current recommended schedule for visits and approved of the 30-month visit and annual visits during middle childhood recently added to the AAP periodicity schedule.18
Major themes are reported below and are supported by quotes from clinicians.
Establishing a Therapeutic Relationship and Individualizing Care
In each group, clinicians emphasized the importance of the doctor-patient relationship. Asked to describe successful relationships (how they are developed and sustained), participants responded that such relationships develop over time through multiple visits with the same clinician. They emphasized the importance of trust between clinician and family. Both continuity of care, that is, an ongoing relationship between the patient/family and the individual doctor, and the ability to tailor care to the particular needs of the child and family were seen as prerequisites for strong relationships. Continuity was viewed as necessary in getting to know the family beyond immediate medical concerns, including family composition, history of concerns, child-rearing style, family support systems, and cultural values. Participants frequently tied continuity to their effectiveness in well-child care.
“The advantage of long-term care is that you don't have to deal with everything every time.”
Clinicians in all groups emphasized the importance of prioritizing family concerns.
“Focusing on the parent's agenda and concerns for the visit is important in developing a strong relationship. I do this by the rule of 3s: 1/3 my agenda and 2/3 the parent's agenda for each well-child care visit.”
“I always think about the importance of readiness of a parent to talk about a topic.”
Some clinicians used the terms “therapeutic relationship” or “therapeutic alliance” in describing their goal of building relationships with their patients marked by trust, mutual respect, and knowledge of the child and the family context over time. This theme was so prominent from group to group that we have gathered selected comments on important elements in developing such relationships in Table 3.
Some clinicians felt tension between inviting parents' concerns while simultaneously addressing recommended content outlined in professional guidelines. A young pediatrician commented:
“The parent's agenda is clearly a central focus and often precludes us from getting into the things we want to do. One of the problems is that we feel constrained by the periodicity schedule.”
A pediatrician with 30 years' experience stated:
“I've separated my thinking regarding health supervision visits into the MD's agenda and the parent's agenda. I've given up on checklists and just say, ‘What do you want to talk about today?’ I focus on the child's behavioral style, temperament, and talk about behavior and development as a main focus… I've given up on handouts… I always try to tell them they're doing a great job.”
“Tiered visits,” in which families assigned to a higher risk category on the basis of physical, behavioral, developmental, or family conditions receive longer or more frequent visits, were presented by the moderators as an idea for individualizing care. Reactions to tiered scheduling varied substantially. Some pediatricians saw value, discussing that a healthy third child may not need the same time as a first child. Others felt that they currently achieve the same end by informally adjusting visit time, or arranging need-based follow-up visits. Most were open to a tiered system if it was fluid, allowing risk categories to be adjusted over time to meet family need.
“There are 3 subpopulations that I think… have to be thought about in a more focused way: (1) chronically ill kids… ; (2) poor kids… ; and (3) children of immigrants. …”
Priorities for Well-Child Care Content
Participants agreed on the importance of eliciting parent concerns as the first priority for visits. Beyond that, they most often mentioned priorities consonant with existing AAP health supervision guidelines,19 but also expressed frustration with the overwhelming number of recommended health directives.
“One thing that I think is not helpful is the long list of things to be covered. Some practitioners feel that they're supposed to cover everything and end up covering little of anything. In particular, the lists have gotten in the way of establishing a dialogue… of being more intuitive.”
Regarding long-term goals for well-child care, clinicians described areas needing more attention, the majority of which centered on developmental and behavioral concerns and better support for families. Commonly discussed were themes relating to parental adjustment after the birth of the child, social development and school readiness in preschoolers, academic and social growth during middle childhood, and support for parents of adolescents.
Clinicians were asked to consider the idea of naming individual well-child care visits to reflect developmental themes and age-related priorities. Although some found this to be supportive of their intended goals for care, most worried that this might interfere with their ability to individualize care.
Table 4 provides ideas and innovative practices, according to patient age, generated by discussions on setting priorities and enhancing care.
Community Resources Linked With the Pediatric Office
To address challenging family and child needs, many participants suggested that pediatricians look beyond the current office-based model to create linkages with the community:
“Consider the community your examination room, an extension of the pediatric practice.”
Personal examples of connecting with community agencies to bring needed services to families included a pediatrician contracting with a Women, Infants, and Children program to provide nutritional counseling and food supplements during visits. Some described experiences with collaborative care models, in which other professionals (eg, psychologists, social workers, and nutritionists) practiced on-site with pediatricians. An enterprising New England pediatrician built a rural practice serving low-income children with 3 pediatric nurse practitioners, 3 social workers, and himself, focusing care equally on physical and mental health. Partnering with local and state public health agencies assured adequate funding.
Although co-location models were relatively rare, nearly every group discussed the need for better coordination between pediatric practices and community resources. With the exception of early intervention programs, participants rarely reported a community-based system of care for suspected problems in development, behavior, and mental health.
Some expressed concern that expectations have outstripped what is possible, and that other community resources should assume more responsibility.
“We need to ask what really can and should be done within the pediatrician's office. For instance, maybe accident and safety education should be given to the schools. On the other hand, problems such as attention-deficit/hyperactivity disorder and depression may be most appropriate for the primary care pediatrician to handle. Obesity is a great example that needs a systems approach—child, family, schools, community, MDs.”
Early Recognition of Developmental and Behavior Problems
All groups discussed the importance of developmental screening within early childhood visits, and most embraced standardized parent questionnaires to screen for developmental delays and behavior problems. Among those using standardized instruments, most reported benefits in screening for specific conditions and initiating parent discussions.
Although generally positive about standardized tools, clinicians also noted cautions. Some expressed doubts about the quality of parent responses in busy waiting rooms, or while caring for a child in an examination room. Participants using Web-based tools discussed benefits of screening instrument completion at home, including access to highlighted concerns or prescored screening questionnaires at the visit. Several pediatricians observed the value of computer-based screening with adolescent patients.
Some clinicians expressed concern that pervasive use of standardized instruments discourages dialogue between pediatricians, parents, and children. Others spoke of the value of direct observation of the child. There were wide variations in practice patterns regarding screening, with some using a parent questionnaire for all well-child visits and others using formal screens only at specific ages or when a problem was suspected. A frequent comment regarded the difficulty of selecting from the array of available assessment tools. Other concerns raised regarding developmental and behavioral screening included (1) identification of developmental or mental health risk or disorder without available referral sources, (2) lack of screening tools that clinicians know, like, or trust, and (3) additional time required for screening.
“One of the problems we have is that we're not quite sure what the treatment should be with most of this [developmental and behavioral] stuff—how to prioritize, how to put into the family's context, how to follow-up, how often, etc. The old adage, don't screen if you don't know what to do with the findings.”
Innovations to Enhance Well-Child Care
In addition to linkages with community agencies and professionals, participants described innovations in practice organization and patient scheduling, creative use of information technology, and integration into the practice of recent innovative programs (eg, Reach Out and Read20). Table 5 provides examples of participants' creative ideas to address developmental and behavioral challenges of well-child care.
Need for Educational Change
Participants frequently noted the importance of professional education to improve well-child care practices. Often cited as a deficiency of residency training, participants placed special emphasis on unmet educational needs in interviewing and communication skills, especially as needed to prepare them for well-child care concerns.
In this study of clinician perspectives on the current state of pediatric well-child care, participants were self-selected and may not represent the larger community of pediatricians. Although this may limit the ability to generalize the results of the study, their opinions are revealing.
Participants strongly endorsed the central role of therapeutic relationships, built on continuity and trust with children and families. This emphasis parallels the results from other studies30–34 and new focus groups with parents who described the importance of a trusting relationship with their child's doctor.35 It is a finding that is in contrast to the limited body of research examining the quality of the clinician-family relationship as a determinant of outcomes in well-child care.36
This study highlights the dilemma of prioritization, that is, deciding what to address within limited time, and balancing parent concerns with expanding preventive health directives. The number of recommended health directives for well-child care has far outstripped the time available,37,38 and participants described varied responses to coping with this challenge.
The degree of comfort in developmental surveillance and psychosocial counseling varied considerably, and seemed to reflect clinician interest, training, and experience more than specific practice conditions.14 Recommendations from participants included (1) stronger curricula in developmental and behavioral pediatrics during residency and beyond (outlines of which exist but remain underutilized),39,40 (2) practical tools for surveillance, screening, and patient/parent education, (3) practice infrastructure, including information technology to improve surveillance, referral, and patient education, and (4) workable referral links with community resources to allow clinicians to focus on problem identification rather than care decisions that exceed time and expertise.
There was widespread recognition of the importance of connecting practices and patients to community services when developmental or behavioral problems were significant, but clinicians only rarely reported being sufficiently linked to needed resources.
The capacity to tailor care to the specific needs of children and parents was described as a central need, beginning with the clinician's ability to elicit family priorities. Participants frequently endorsed the idea of reorganizing visits according to health and development risk by providing longer and/or more frequent visits for those with greater needs. Flexibility in time and reimbursement allocations, according to family needs, was seen as critical.41
The innovations outlined in Table 5 reflect both where we are now and where we might go in an expanded view of well-child care. Positive outcome studies are available for some; others await full evaluations. The range of ideas and the interest in innovative practices, as discussed by our study participants, was impressive. Some of these innovations, if applied to most pediatric practices, would represent a significant “retooling” of well-child care. Examples include co-location with mental health professionals, consultative relationships with community resources, length and frequency of visits tailored to need, school-based clinics, and electronic medical records systems that integrate previsit questionnaires with guidance for clinicians and educational materials for parents.
For many participants, challenges and obstacles to their notions of ideal well-child care existed in the interface between their own capabilities in the practice setting and the available resources within their communities. Focus group dialogues about the difficulties in accessing needed services beyond their offices led to discussion and speculation regarding what a more integrated system of care might look like. For instance, if more effective developmental and behavioral screening was provided in early child care settings, primary care pediatricians could then be available for those children and families who are at high risk and currently often get short shrift. In this format, care would be intensified, and an effective therapeutic relationship intentionally developed for those children and families who require more attention. A public-private collaboration could support a system of care that moves between the surveillance/screening component and the medical home, as well as from the medical home to targeted community resources.
From the responses of many of the focus group participants, achievement of these objectives would require change in pediatric training (during residency and after), including more opportunities to learn counseling skills, developmental appraisal, early treatment of behavioral conditions, and communication challenges between parent-child and between clinician-parent.
When the optimal care for children and youth in areas of development and behavior is our goal, there are opportunities both within current practice and in the context of community-based models. This exploratory study suggests the need, going forward, to pursue 2 available strategies:
More research in practical aspects of well-child care that can guide clinicians to greater effectiveness; examples include (1) delineating the characteristics of a therapeutic relationship and studying those components that can be taught successfully, (2) research that compares different practice formats (personnel, appointment systems, use of screening tools) with outcomes, and (3) studies that evaluate systems linking a pediatric office with community agencies.
Individual clinicians, groups of clinicians, and health care systems implementing innovations in care that may enhance, in particular, developmental and behavioral aspects of well-child care visits.
In this qualitative study, pediatric clinicians reflected on the most important elements of high-quality, comprehensive well-child care. Their experience and ideas support a vision of pediatric preventive care that is comprehensive, family-centered, and developmentally relevant, both for children with greater risks to long-term healthy development and for families with more normative child-rearing concerns. Recent parent focus group findings support these clinician-generated goals in many respects,35 and strengthen the argument for using in-depth explorations to frame future research questions and rethink the priorities for high-quality pediatric care.
This research was supported by the Commonwealth Fund.
We are grateful for the time and thoughtful contributions of our participant clinicians, project advisors, and others who provided consultation and review throughout the course of this study.
- Accepted March 22, 2009.
- Address correspondence to Martin T. Stein, MD, FAAP, University of California, Rady Children's Hospital, Division of Child Development and Community Health, San Diego, CA 92123. E-mail:
The views in this article are those of the authors and do not necessarily represent the views of the organizations for which they work.
Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.
What's Known on This Subject:
Schor has called on pediatricians to rethink well-child care. Gaps exist between traditional well-child care and contemporary needs and pressures. Little is known about pediatricians' thoughts regarding current well-child care delivery and ways in which these visits might be enhanced.
What This Study Adds:
What are pediatricians thinking about rethinking? Using a qualitative study design, we examined the complexities of providing preventive care in pediatric offices and elicited clinicians' visions of how to more effectively support developmental and adaptational needs of children and families.
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