The Frontiers of Pediatrics

COVID highlights both the fragility of pediatrics and its promise, leading me to think about the frontiers of pediatrics—where we were, are and should be going. It is often said that in crisis there is opportunity—COVID has been so disruptive on so many fronts that we may have opportunities, with thought and planning, to go where we ought to and ensure that each and every child achieves their optimal outcome.



While COVID lays bare the disparities in access to healthcare and health outcomes rooted in discrimination and poverty, it also reminds us that we are all one people traveling together on satellite Earth. On the frontiers of the future, COVID makes crystal clear that equitable universal health insurance is both a fundamental human right and a necessity; that the family-centered pediatric medical home (FCPMH), with its emphasis on accessibility, care coordination, quality improvement, engagement and communication, cultural humility, and continuity of care is vital to optimal outcomes; and, that a well-funded public health system at all levels is vital for and beyond pandemics, epidemics and crisis readiness.


This is far from an exhaustive list. There are many other frontiers within subspecialties, both medical and surgical, within general pediatrics, and in research, education, and clinical care. A wonderful thing about science is the constant acquisition of new knowledge that challenges or affirms old assumptions. But, these are a few I am thinking about: the emerging and evolving pediatric disciplines, transforming systems of care, and technologies that help pediatricians, families, and children.


Pediatric Disciplines


We have many disciplines in pediatrics that are in early developmental stages or undergoing transformation as the science in their disciplines evolves. These include, but are not limited to: Pediatric Emergency Medicine (PEM), Pediatric Hospital Medicine (PHM), Complex Care, Palliative Care, Social Pediatrics and life-course health, Pediatric Informatics, Global Health, Transplant Medicine, and Transition Care/Medicine-Pediatrics. All of these disciplines have emerged during my career in response to and to better serve the needs of children and improve their outcomes.

I see several challenges that are common to these burgeoning disciplines. These include the need for:

  • Mentorship around career development

  • Appropriate financing and payment

  • Academic credentialing

  • Development of a solid research, educational, and QI portfolio

  • Prevention of burn-out

The AAP has the opportunity to provide a professional home and work with other organizations such as the Academic Pediatric Association (APA) and discipline-specific organizations (such as Pediatric Hospital Medicine), to provide mentorship, leadership training, networking, and professional development. For example, opportunities exist to provide PHM with training in quality improvement, patient safety, transforming health systems, care coordination and population health. Pediatric hospitalists, intensivists, pediatric emergency medicine physicians, and many pediatric subspecialists are at high risk for secondary traumatic stress because they bear witness to the suffering of children and often have to make children uncomfortable to promote healing. Hospitals and health organizations must provide environments that are trauma-informed, psychologically safe, support team-based care, and in which physicians, staff and families have a meaningful voice.


The central question for all these new disciplines is- how can we do the best for children?


Systems of Care


Our pediatric healthcare system is overall working well for most children. But we can do even better.


The Family-Centered Pediatric Medical Home is the core of pediatric primary care. It is something every child should have. Family-Centered Pediatric Medical Homes provide vital preventive health care in the context of family strengths and needs despite slim financial margins. Family-Centered Pediatric Medical Homes are engaged in re-designing WCC to align with Bright Futures guidance to:

  • Identify and manage social risk factors

  • Implement and sustain trauma-informed and resilience promoting care

  • Provide comprehensive, coordinated care to children with complex conditions

  • Manage populations with specific health conditions (e.g., asthma, obesity, ADHD) both in the health care setting and the community in which they live, learn and play

But there are many challenges to family-centered medical homes. These challenges include:

  • The need for more research to improve the evidence-base for optimizing pediatric primary care. This is essential in many areas but especially behavioral and mental health, childhood trauma, obesity, and other prevalent conditions

  • Appropriate payment for essential services such as care-coordination, preventive care, trauma-informed care, telehealth and phone management

  • Developing a child-focused value-based care system so that payment is tied to what children need and not visit number

  • Pediatric well-child care visits that are tiered to patient and family needs identified through assessment and evaluation of child and family needs and strengths

  • Integrating community services with primary care practices

  • Optimal management of social risks such as financial hardships, ACEs, food insecurity

  • Lack of providers and resources in rural communities and some urban centers

  • Educating the next generation of pediatricians in the best way

Challenges create opportunities and pediatricians can lead the way:

  • We can work with our AAP chapters and state leadership and respond with the AAP at national and state levels to advocate for appropriate payment

  • Those in academic pediatrics can conduct the research, including translational research with community partners, to identify interventions that work and can be disseminated and sustained

  • The AAP is the leading pediatric educational resource in the world. In addition to continued excellence in education of practicing pediatricians, whether primary care or subspecialty, we need to work with our training programs to ensure the next generation understand systems of care, preventive care, trauma-informed care, patient engagement, population health, care of medically complex children and children with chronic conditions etc.

There are many other pediatric systems of care beyond medical homes—subspecialty systems, hospital systems, urgent care systems, public health systems—all serving children and families. In addition, children and pediatricians are increasingly clustered within broad health systems or ACOs that are understandably focused primarily on adult health care. Pediatric departments often exist within academic medical centers that focus mostly on adult care. While each of these systems has their own specific needs, many of the challenges and opportunities outlined above apply to these other systems of care.



And we have opportunities to shape the frontiers of pediatrics through these broader systems.

  • Within academics, we can develop new educational programs and models to train pediatricians to help transform health systems to become even more child-focused. This will involve rigorous training in quality measurement, quality improvement, safety, and high/low value care

  • We can increase our focus on leadership training. My dream is that pediatricians will “infiltrate” key systems of care in leadership positions- this includes health systems, academics, public health, professional organizations, and government. We can lead the way for children

  • We can work closely with our colleagues in adult medicine, surgery, social sciences, business, and administration to ensure that children’s needs are met

The central questions of every pediatric system of care and every health system that includes children are simple–what is best for children and families and how do we get there?


Technology


Newer technologies carry with them both benefits and burdens. We must optimize the potential benefits (e.g., communication, care coordination, accessible health record, etc.) to augment our care of children and families while reducing the burdens that interfere with that care and lead to burn-out (e.g., checklists that reduce physician-patient interactions, the documentation demands etc.).


The electronic health record should assist with clinical decision support and communication with patients through the patient portal. COVID -19 highlighted the potential benefits of telehealth and telephone care, which support the connection between the pediatrician and the family and reach families where they live and work especially where distances are long and resources limited, as in rural areas. Virtual care that keeps families connected to the FCPMH can prevent incorrect care because of the pediatrician’s familiarity with the patient and family. Other major technological advances include the home computer, tablet, and smartphone which together have transformed children’s lives. We need to harness these technologies to best help children while protecting them from harm.

Older children and teens use social media for communication and we need to capitalize on the possibilities of social media while maintaining the value of good old-fashioned personal human interactions.

Challenges of newer technologies are fairly easy to identify:

  • Electronic health record design reflects the domination of adult medicine and is not always adaptable to pediatric care. EHRs can be rigid. While designed for billing, they are not as useful for care coordination, tracking, population health and patient education. After-visit summaries are often long but lacking important health information and guidance for patients and parents

  • Prior to the COVID-19 pandemic, Tele-Health and Telephone Care were seldom paid for or supported to enhance the connection between the FCPMH and the families they care for. Temporary regulatory changes during COVID-19 have improved this but are designed to lapse as the pandemic abates

  • Pediatricians need to keep up with and learn new technologies and applications in the midst of multiple other demands

  • Technology is often addicting for children, leads to poor self-concept in comparison to others, and isolates them from, rather than engaging them in relationships

Opportunities also exist with new technologies.

  • Informatics is an area of post-graduate training enabling pediatricians to become experts within their practice setting and to educate others

  • New technologies create new opportunities for QI, research, leadership, patient education, and improved communication and care coordination

  • And, ultimately (through population health, QI, patient education and care coordination, etc.) they provide opportunities to improve child health and outcomes

Imagine the day when technology will…

  • Reduce pediatricians’ workload

  • Help clinicians with decision support and rapid access to useful information

  • Provide substantial support to patients outside of office or hospital visits (e.g., improve patient self-monitoring especially for patients with chronic disease; link results of such monitoring to the EHR, etc.)

  • Help parents and older children engage in and manage their health care

  • Result in appropriate payment for care

  • Enable us to provide valuable education and information to children and adolescents via their communication device of choice

  • Enable easier access to evidence-based information (such as the value of vaccines) in preference to incorrect and unhealthy information on social media

I believe that day will come.


A final thought...


As we travel forward together, our evolution should be strategic in taking what we know and will learn about child and family health and well-being, systems of care and technology and integrating them so that every child reaches their optimal potential. In planning, we have to continue to address and fix what harms children (disparities, poverty, ACEs, etc.) and to promote what builds resilience (inclusion, diversity, safe communities, quality schools and childcare, parenting skills etc.). None of us can do this alone.

We can only do this by working together, listening to and learning from each other and keeping what is best for children at the center of all that we do.

Dr. Moira Szilagyi

Child and Family Advocate

Moira Szilagyi, MD, PhD, FAAP

mszilagyi@mednet.ucla.edu

© 2020 by Moira Szilagyi, MD, PhD