Case Based Pediatrics For Medical Students and Residents
Department of Pediatrics, University of Hawaii John A. Burns School of Medicine
Chapter I.1. Pediatric Primary Care
Melinda J. Ashton, MD
May 2002

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A six year old male presents to your office for his annual well child visit. He is accompanied by his mother. You have cared for this child since his birth, and he has had regular well child care. You last saw him for his visit prior to entering kindergarten at age five years. Today his mother notes that she has been anxiously awaiting this visit as she has several concerns to discuss:

1. He is having some difficulty in school (now just finishing the first quarter of first grade). He is struggling to learn to read, and has some difficulty with arithmetic. His teacher called his mother yesterday to report that he hasn't been turning in his homework or completing his classroom assignments. His mother indicates that she was very surprised to hear this, as the previous teacher reports have indicated that he was doing adequate work.

2. He has frequent complaints of stomachache. He has a good appetite, but has always been a "picky eater". He enjoys drinking milk.

3. He has been having increasing nasal congestion over the last few months. He has had some sneezing attacks, and seems to clear his throat often. He does cough at night. The cough often sounds "wet" to his mother. He also joins in to tell you that he has a hard time breathing during PE. He has no other regular physical activity, but his mother reports that he is always "busy doing something". His mother reminds you that he was born prematurely at 34 weeks, and had difficulty with wheezing as a younger child, but he has done well in the last year or two and hasn't needed any medications for wheezing.

Exam: VS are normal. Weight 30 kg (66#) (> 95%ile), height 117 cm (46") (50%). In general, he appears to be an overweight, friendly child who is cooperative and who appears to be his stated age. He is active in the exam room, exploring the contents of the drawers and cabinets. He interrupts his mother repeatedly during the interview. He appears to be mouth breathing with significant nasal congestion. His tonsils are large but not inflamed. His heart is regular without murmurs. His pulses are normal. His lungs have clear breath sounds, with transmitted upper airway rhonchi. There are no wheezes, but the I:E ratio is prolonged. His abdominal and neurologic screening exams are normal.


The approach taken by a pediatrician when confronted with this patient with multiple complex complaints will vary considerably depending on factors such as training, availability of appropriate pediatric subspecialists, and past successes (or failures) when managing similar issues. As an example, the patient presented above could be referred to a psychologist for an educational assessment, a psychiatrist to manage possible ADHD, a gastroenterologist to manage his abdominal pain, an allergist, a pulmonologist, and possibly an otolaryngologist to evaluate his respiratory complaints, and a nutritionist or dietitian or weight management program to manage his obesity. It would be a daunting task to coordinate and manage all of these specialists, and it is likely that the parents would be thoroughly confused about how to improve his situation if they did receive input from all of these experts. On the other hand, a thoughtful pediatrician could successfully manage all of these issues without any consultations at all. Most pediatricians would probably develop a plan of care somewhere between these two extremes, using selected specialists to assist in the area of concern that they feel least comfortable managing.

The medical home is a concept in which a primary care provider is the ultimate source of all health care for a child. This would include acute care visits for illnesses and injuries, anticipatory guidance, immunizations, growth and development monitoring, preventive health maintenance, and especially for children with special health care needs; the coordination of care among other medical and nonmedical specialists (audiology, speech therapy, child development programs, school programs, etc.).

Although acute care office visits for illnesses and injuries are an important part of what pediatricians do, a significant component of pediatric primary care consists of anticipatory guidance, immunizations, growth and development monitoring, and preventive health maintenance (1). Coordination of care and providing after hours care are areas where there is a large amount of variation in approach. This variation is partly a result of personal style and choices, but it is also significantly influenced by location and type of practice. For example, a solo rural pediatrician would not be able to limit his/her availability after hours for emergencies in the same way that a pediatrician employed by a large group that provides full after hours coverage for emergencies, newborns and telephone triage would be able to. Even in urban areas with lots of coverage for emergency care and newborns, pediatricians vary in their accessibility to their patients. Some parents are told not to call their pediatrician after hours "unless it is an emergency", while others work with pediatricians who provide their home phone number and are easily accessible through an answering service for after hours concerns. Those pediatricians find that while many families feel comforted by the knowledge that they could reach their doctor easily if they needed to, not many families abuse the privilege.

Another area of after hours care with great variability is the use of the emergency room to manage illness when the office is closed. Some pediatricians are not available to their patients for after hours advice at all, with their answering machine directing parents with concerns to take the patient to the nearest emergency room. Most pediatricians will discuss concerns that a parent may have after hours; the difficulty then is that you must offer advice about whether to seek care in the emergency room or wait until the office is again open. Concern about liability may cause some physicians to send most patients to the emergency room, particularly if there is another physician there who will see the child (so that they do not have to go in themselves). That will then transfer the problem to someone else, and an exam will be performed so that you are no longer accepting the parental observations as your only source of information. Unfortunately this is a very expensive way to provide care, so many pediatricians try to refer only those patients who sound like they might benefit from emergency care. Determining which patients should go becomes even more difficult when covering for a colleague after hours. Part of the decision making often includes knowledge of prior interactions with the parents. When the parents are strangers, it is more likely that they will be sent to the ER if they call with concerns.

As primary care physicians, pediatricians are the first to be consulted by many parents for a wide range of concerns. It is useful to have a basic management plan (or algorithm) for the most common complaints that come in, including an assessment of when referral to a specialist might make sense. In developing such an algorithm, a primary consideration will be the local availability of pediatric subspecialists. For example, it is not useful to decide that any child presenting with a heart murmur will be evaluated by a pediatric cardiologist, if the nearest available pediatric cardiologist is hundreds of miles away. The varying availability of subspecialty care is one of the factors involved in the observed variability in the medical care provided in one locale compared to another.

If a pediatric subspecialist is not available locally, the choices for a general pediatrician then become: a) evaluate and manage yourself, b) use a specialist who does not have pediatric subspecialty training, or c) send the patient to the specialist regardless of the distance/expense/inconvenience involved. In some locations, you may also have the option of managing the patient using a specialist available to you by telemedicine, but this is not a widespread practice yet.

Certification is available from the American Board of Pediatrics in the following pediatric subspecialties: adolescent medicine, clinical and laboratory immunology, medical toxicology, pediatric cardiology, pediatric critical care medicine, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology/oncology, pediatric infectious diseases, pediatric nephrology, neonatal-perinatal medicine, pediatric pulmonology, pediatric rheumatology, developmental-behavioral pediatrics, neurodevelopmental disabilities and sports medicine (2).

Subspecialty certification (from other specialty Boards) is also available in: pediatric otolaryngology, child and adolescent psychiatry, pediatric radiology, pediatric surgery, and pediatric pathology (3). Other specialties may offer additional pediatric training to their fellows to allow them to be designated as subspecialists. For example, pediatric orthopedists and pediatric ophthalmologists have additional training and skills necessary for the appropriate care of children.

Under traditional fee for service payment arrangements (doctors are paid for services that they deliver), access to pediatric subspecialty care was primarily limited by geographic availability. "Capitation" refers to a system in which physicians are paid a fixed amount per patient per month regardless of whether the patient is seen 20 times during the month or not at all. Capitation is risky in that physicians will not be adequately reimbursed for severe or chronically ill patients, but on average, this is offset by healthy patients who do not use the service. With other insurance payment arrangements covered under the umbrella of "managed care" (which may be pure capitation or a combination of capitation and fee for service), the access to pediatric subspecialty care may also be limited by the network of physicians who participate with (or are employed by) the health maintenance organization. A pediatrician who is deciding whether to contract with, or become employed by, a health maintenance organization may want to consider what degree of access to pediatric subspecialty care his/her patients will be able to count on. As access to subspecialists becomes more difficult, the primary care pediatrician will need to be able to provide more complex care for at least some of the patients in his/her panel.

The American Academy of Pediatrics has addressed these issues in several policy statements. For example, in "Guiding Principles for Managed Care Arrangements for the Health Care of Newborns, Infants, Children and Young Adults" (4), some major principles were outlined including:

1. Access to Appropriate Primary Care Pediatricians:
. . . . a. Choice of primary care clinicians for children must include pediatricians.
. . . . b. Primary care pediatricians (PCPs) should serve as the child's medical home and ensure the delivery of comprehensive preventive, acute, and chronic care services. They should be accessible 24 hours a day, 7 days a week, or have appropriate coverage arrangements.
. . . . c. The PCP should assume the role of the care coordinator (i.e., the physician who ensures that all referrals are medically necessary). The function of the PCP might be transferred to a pediatric medical subspecialist for certain children with complex physical and/or mental health problems (e.g., those with special health care needs, such as children with cystic fibrosis, juvenile rheumatoid arthritis) if the specialist assumes responsibility and financial risk for primary and specialty care. For certain physical, developmental, mental health, and social problems, the PCP may seek the assistance of a multidisciplinary team with participation by appropriate public programs (e.g., Title V Program for Children with Special Health Care Needs).
. . . . d. Families should receive education at the time of enrollment to help them understand fully how managed care arrangements work for their individual policies.

2. Access to Pediatric Specialty Services:
. . . . a. When children need the services of a physician specialist or other health care professionals, plans should use clinicians with appropriate pediatric training and expertise. Pediatric-trained physician specialists, including pediatric medical subspecialists and pediatric surgical specialists, should have completed an appropriate fellowship in their area of expertise and be certified by specialty boards in a timely fashion if certification is available. These physicians and other health care practitioners should be engaged actively in the ongoing practice of their pediatric specialty and should participate in continuing medical education in this area.
. . . . b. There should be no financial barriers to access for pediatric specialty care above and beyond customary plan requirements for specialty care.
. . . . c. Plans should contract with the appropriate number and mix of geographically accessible pediatric-trained physician specialists and tertiary care centers for children.
. . . . d. Referral criteria for pediatric specialty clinicians should be developed. These criteria may include age of the patient, specific diagnoses, severity of conditions, and logistic considerations (e.g., geographical access and cultural competence).
. . . . e. Processes for approving referrals to pediatric medical subspecialists and pediatric surgical specialists should be developed by health plans working collaboratively with PCPs and pediatric medical subspecialists and pediatric surgical specialists.

There is particular concern about pediatric specialty care for children with special health care needs. As stated in the AAP policy statement "Managed Care and Children with Special Health Care Needs: A Review" (5): Children with disabilities differ from adults with disabilities in a managed care environment in a variety of ways. Three major differences include the following: 1) The changing dynamics of child development affect the needs of these children at different developmental stages and alter their expected outcomes. Illness and disability can delay, sometimes irreversibly, a child's normal development. 2) The epidemiology and prevalence of childhood disabilities, with many rare or low incidence conditions and few common ones, differ markedly from that of adults, in which there are few rare conditions and several common ones. 3) Because of children's need for adult protection and guidance, their health and development depend greatly on their families' health and socioeconomic status.

This policy also states, "Children with disabilities and other chronic conditions that may lead to disability require the services of pediatric subspecialists in addition to primary care pediatricians. Access and availability of pediatric subspecialty services must not be significantly impeded by managed care arrangements. Although it is ideal for the primary care physician to manage and coordinate the care for a child's health needs, the complex or rare nature of a particular child's condition may make it difficult for the primary care physician to meet all of the needs of the child and family adequately without additional expertise" (5).

A good pediatric primary care physician should also work with non-physician partners. Interactions with school personnel, public health nurses, social workers, various therapists (such as speech/language therapists, occupational therapists, physical therapists), early childhood educators or daycare providers are a common part of pediatric practice today. Learning to interact appropriately with these individuals, and to gain from their expertise, is an important part of pediatric training.

Primary care pediatrics can be very challenging. Although there is a perception that office based pediatrics is largely limited to runny noses and ear infections, in fact there is a wide realm of issues and problems that a pediatrician may become involved in. The nature of the practice will depend to some extent on the ease of availability of subspeciality care, but will also depend on personal characteristics of the pediatrician that determine the practice style he or she is most comfortable wit rtable with.


Questions

1. True/False: When caring for pediatric patients, it is always more appropriate to use pediatric subspecialists than specialists who may be primarily trained to work with adults.

2. True/False: There is a standard for after hours accessibility that all pediatricians adhere to.

3. True/False: There is variability in the use of pediatric subspecialty care that results from factors other than availability of specialists.

4. If a pediatric subspecialist is not available, the pediatrician has the following choices:
. . . . a. Evaluate and manage the patient without referral.
. . . . b. Use a specialist who does not have pediatric subspecialty training.
. . . . c. Send the patient to a pediatric subspecialist regardless of cost and inconvenience.
. . . . d. All of the above.

5. Pediatricians may be concerned about giving after hours telephone advice to parents who call. This concern may be dealt with by:
. . . . a. Refusing to talk with parents after hours.
. . . . b. Referring all parents who call to take their child to the ER.
. . . . c. Only giving advice to parents who are familiar and reliable.
. . . . d. Ignoring concerns and giving advice to any parent who calls.
. . . . e. All of the above may be considered appropriate.


References

1. "What is Pediatrics?" Statement by the American Board of Pediatrics http://www.abp.org/pedsinfo/peds.htm

2. "Pediatric Subspecialties" http://www.abp.org/STATS/WRKFRC/SUBS.HTM

3. "ABMS Member Boards: Subspecialty Certificates Issued" http://www.abms.org/approved.asp

4. AAP Committee on Child Health Financing. Guiding Principles for Managed Care Arrangements for the Health Care of Newborns, Infants, Children, Adolescents, and Young Adults (RE9932). Pediatrics 2000;105(1):132-135.

5. AAP Committee on Children with Disabilities. Managed Care and Children With Special Health Care Needs: A Subject Review (RE9814). Pediatrics 1998;102(3):657-660.


Answers to questions

1. False. Proximity to the patient is also an important factor. A general surgeon practicing in a small town might be the best person to handle a suspected case of appendicitis, for example.

2. False. Although some third party payors have standards written into their contracts with physicians, and the American Academy of Pediatrics has created a standard, not all pediatricians adhere to these standards.

3. True. Many factors are involved, including the training of the primary care pediatrician and past experience with similar cases.

4.d

5.e


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