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 her yesterday to report that he hasn't been turning in his homework or completing his classroom assignments. She was very surprised to hear this, since his previous teacher reports had 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 physical education. 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 pounds) (> 95%ile), height 117 cm (46") (50%ile). BMI is 21.9 (>99%ile). In general, he appears to be an overweight, friendly child who is cooperative. He 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. Whatever the approach, the primary care pediatrician is expected to coordinate all of the care this patient needs and to serve as the patient’s medical home.
The medical home is a concept in which a primary care provider is the ultimate coordinator of all health care for a patient. In pediatrics, this includes performing acute care visits for illnesses and injuries, and providing anticipatory guidance, administering 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.).
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 there is wide variation in the availability of subspecialty telemedicine.
Certification is available from the American Board of Pediatrics (ABP) in the following pediatric subspecialties: adolescent medicine, pediatric cardiology, child abuse pediatrics, pediatric critical care medicine, developmental-behavioral pediatrics, pediatric emergency medicine, pediatric endocrinology, pediatric gastroenterology, pediatric hematology/oncology, pediatric infectious diseases, neonatal-perinatal medicine, pediatric nephrology, pediatric pulmonology, and pediatric rheumatology. Certificates for the following subspecialties are co-sponsored by the ABP with other American Board of Medical Specialties (ABMS) boards: hospice and palliative medicine, medical toxicology, sleep medicine, sports medicine and pediatric transplant hepatology. (1)
Subspecialty certification (from other specialty Boards) is also available in pediatric anesthesiology, pediatric dermatology, pediatric emergency medicine, adolescent medicine, pediatric otolaryngology, pediatric pathology, pediatric rehabilitation medicine, child and adolescent psychiatry, neurodevelopmental disabilities, pediatric radiology, and pediatric surgery. (2) 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.
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, and 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.
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. (3) 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, for newborn and pediatric inpatient care and for 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 phone number and are easily accessible 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. Often, pediatricians will join together to share and rotate after-hours call responsibilities, even when they do not belong to a formal group. There are also practices that employ nurses or mid-level practitioners to manage telephone advice, and these services may also be marketed to other unaffiliated physicians for their patients too.
Another area of after-hours care with great variability is the use of the emergency department (ED) or an urgent care center to manage illness when the office is closed. Some pediatricians direct parents with any after-hours concerns to take the patient to the nearest emergency department. As discussed above it is common to provide some mechanism for after-hours advice; the difficulty then is that you must sometimes determine whether the patient should seek care immediately or wait until the office is again open. Concern about liability may cause some physicians to send most patients for urgent or emergency care, 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 the pediatrician is no longer accepting the parental observations as the only source of information. Unfortunately this is a very expensive and often inefficient way to provide care, so many pediatricians try to refer only those patients who sound like they need physician evaluation before that can be provided in the usual office setting. Determining which patients should go becomes even more difficult when covering for a colleague after hours. Nurse advice lines often use standard protocols to assist in the decision making regarding immediate versus delayed care, but no matter who is providing telephone advice part of the decision making often includes an assessment of the caretaker capabilities. When the parents are strangers there is a higher likelihood that they will be sent to the ED if they call with concerns.
In addition to interactions with subspecialty physicians and others, a pediatrician must also understand the financial structures that impact the ability to provide care that is affordable for the families they see. Many children in the US are covered by Medicaid (or the various individual state plans that serve the Medicaid population), and although there may not be out of pocket expenses for these children, there are still rules, restrictions, and requirements that must be followed for the desired care to be provided.
For patients with 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. The fee for service payment approach also commonly allows patients (or their parents) to seek care wherever they think it is appropriate. They can refer themselves for specialty care, without consulting their primary care physician. Although this is an ability that many people enjoy, it may result in overuse of specialists, seeking care from inappropriate specialists, lack of coordination among multiple physicians all providing care for the same patient, etc. In part, it is this confusion and waste that is pushing the adoption of different payment models.
In addition to fee for service, there are a number of variations in payment methodologies that may be encountered. This is currently an area of significant change as accountable care organizations (ACO’s) and other strategies to improve coordination of care and to reduce costs are being developed and implemented. In addition to ACO’s, health maintenance organizations (HMO’s) continue to be popular in parts of the United States. Kaiser is the best known HMO example for most physicians. In an HMO, instead of fee for service, the organization receives a fixed fee for caring for each enrollee for a period of time. Commonly the fee is an amount for each member for each month of enrollment, commonly referred to as "PMPM” (per member, per month). All medically necessary care must be paid for within this fixed fee. This is also known as "capitation". This leads to careful management of resources within a successful HMO, and may mean reduced access to some pediatric subspecialty care unless the HMO enrollment is very large. The network of physicians and rules about how that network is managed impacts the work of the pediatrician who participates and needs to be considered carefully when joining such an organization.
There is also variation in the coverage policies for various health insurance policies. With the adoption of the Affordable Care Act, an expansion of coverage for preventive services has been required, but families are not always aware of what will be covered and what may not be, and they often assume that the pediatrician will know what is covered and won’t initiate care that won’t be covered. This can create friction so it is best to engage in clear communication about this issue with parents or others who are responsible for paying the bills.
There are many stakeholders and interested organizations involved in promoting the best interests of pediatric patients in the evolving organizational and payment structures. The American Academy of Pediatrics is one such organization. They create and release policy statements about issues of coverage, and they also represent pediatricians and children as national policies are formulated. Current policies are available at www.aap.org.
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 range of issues and problems that a pediatrician may become involved in. The nature of the practice will depend to some extent on the payment arrangement(s) that provide the income for the pediatrician. These payment arrangements then influence the ease of availability of subspecialty care and the ability of the pediatrician to participate in a coordinated patient centered medical home. Ultimately the nature of the practice will also depend on personal characteristics of the pediatrician that determine the practice style he or she is most comfortable with.
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 choice(s):
. . . . 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. Give advice to any parent who calls.
. . . . e. All of the above may be considered appropriate.
1. Subspecialty Certifications & Admission Requirements. (n.d.) From the American Board of Pediatrics. Retrieved from https://www.abp.org/content/subspecialty-certifications-admission-requirements on March 13, 2015.
2. Specialty and Subspecialty Certificates. (n.d.) From the American Board of Medical Specialties. Retrieved from http://www.abms.org/member-boards/specialty-subspecialty-certificates/ on March 13, 2015.
3. Hagan JF, Duncan PM. Chapter 5: Maximizing Children’s Health: Screening, Anticipatory Guidance, and Counseling. In: Kliegman RM, et al (eds). Nelson Textbook of Pediatrics. 2011, Philadelphia: Elsevier Saunders, 13-25 e2.
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. Pediatrics 2013;132: e1452-1462.
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.