Finding unique value in the medical home model

Ari Brown, MD, FAAP

By Ari Brown, MD, FAAP. Dr. Brown is a pediatrician, author of the Baby 411 book series and has offered her expertise to several media outlets including the Today show, CNN and the Wall Street Journal. Dr. Brown completed her residency at Children’s Hospital Boston in 1995 and will be joining her peers at an upcoming alumni reception at the Institute of Contemporary Arts on October 15. For more information visit, Children’s event website.

You are as old as you feel, right? Most days, I feel like I’m still a kid—probably because I hang out with kids all day long. But the other day, I received an invitation to my 20-year medical school reunion. Admittedly, I felt just a little old…and a bit reflective.

The last time I saw many of my med school classmates was when I was 26, and heading off to my pediatrics residency at Children’s Hospital Boston. So much has happened since then. Marriage. Kids. Career. But unlike some of my peers, I wouldn’t change a thing.

I’ve loved pediatrics for twenty years. I am truly happy going to work every day. I have a special relationship with my patients and their families—a relationship that they will never have with the practitioner working in the minute clinic around the corner. I am the one who examines my patients when they are first born. I perform the well child visits, encourage breastfeeding, answer the worried parent phone calls, identify developmental delays, offer parenting advice, and diagnose the colds, flus, ear infections and occasionally things a bit more serious. And I love every minute of it (okay, almost every minute of it). I love it because I can help future generations develop healthy lifestyles and I genuinely enjoy watching my patients grow up.

But, the current trends in healthcare—particularly in pediatrics—are troubling to me. More parents are heading to that minute clinic around the corner to get their child a quick Strep test after school and work, choosing convenience over quality and continuity of a medical home. Are pediatricians going to become the next Borders or Netflix? Are we being shoved out of the marketplace because we haven’t kept up with consumer demand?

One office visit that can’t be replicated at the neighborhood pharmacy is the well child visit. The cornerstone of child health has always been check-ups, scheduled at regular intervals, to ensure that a child is growing and developing properly. Do pediatricians make the grade when it comes to appointments that we consider pivotal to child healthcare?

Minute clinics offer quick service, but can the level of care compare to the quality and continuity found in a medical home?

A recent study published in Pediatrics looked at how much face-to-face time a pediatrician spent in a well child visit and inquired about parental satisfaction. The study has some serious flaws: it was done a long time ago (2000) and time with the doctor was based only on parent recall, sometimes up to a whole year later. (I can’t even remember how long I waited in line at Costco last week!) But regardless of the study’s limitations, it brings up some important points.

Office visits are shorter. About 1/3 of parents surveyed by phone said they spent less than 10 minutes talking to the doctor in their child’s recent well child visit. Half of those surveyed reported visits of 11-20 minutes duration. Only 20% had visits lasting over 20 minutes. Not totally surprising. It’s a simple math equation. The costs of running a medical practice are rising and the reimbursements for healthcare are shrinking. So, doctors have to see more patients to stay afloat. That means less time in Exam Room 1.

But here’s the important question: has the “condensed” well child visit sacrificed the quality of care or parent satisfaction?

No. Regardless of the duration of the visit, 4 out of 5 parents surveyed felt satisfied with the well child visit. The more time that was spent in the visit, the more developmental and healthcare prevention tips were discussed. But, truthfully, having the parent fill out a pre-visit developmental questionnaire form and offering a handout with tips at the end of the check up could provide this additional information.

I asked longtime mentor and fellow Children’s Hospital Boston alum, Dr. Lewis First, who is now Chairman of Pediatrics at the University of Vermont and Editor-in-Chief of the journal, Pediatrics, about his perspective. “The bottom line is that it is not about the quantity of time spent, but the quality of that time—and as pediatricians, we strive to maximize that quality in every encounter by personalizing and coordinating the care to each and every child and family who views being a part of our practice as their unique medical home. That’s what being a pediatrician is all about!”

So, what’s a parent to do in this age of the shorter well check? Do your homework and speak up! Your child’s doctor can tailor the office visit to discuss the issues you want advice about—take advantage of your time together. And know that you can always follow-up by phone (or email, if your practice communicates this way) if you have additional questions after the visit. That is the beauty of having a medical home and a doctor that knows your child and your family.

And, what’s a pediatrician to do? There is a still a role for the pediatrician and there always will be. We have a unique skill set—a combination of medical acumen and developmental, behavioral and parenting expertise. Pharmacy-based care clinics and non-physician providers cannot compete with that. But, healthcare and information technology are rapidly changing—and like other professions, we need to adapt to the needs of our patients and their families. Offering evening and weekend appointments and keeping communication lines open via social networks may be the solution for today’s busy families to stay connected to their child’s medical home.

2 thoughts on “Finding unique value in the medical home model

  1. As a manager for a pediatric practice, I’m fully aware of
    the challenges you describe.

     

    I do, however, understand why a parent would choose a retail
    based clinic over a physician’s office; especially when the perception from the
    parent is that they will get the same care (quality wise) as they would in a
    pediatrician’s office.

     

    Although those of us in this field know that the quality of
    care can be substantially different between a physician and a mid-level
    provider, to the untrained eye, the services appear equal; not to mention less
    expensive and convenient.

     

    The job of pediatricians is to demonstrate value.
    Otherwise, parents will not justify paying more and will continue to forgo a what they perceive as “a little less quality” for the convenience of going in and out

    @Pediatricinc:twitter 

  2. By dismissing the minute clinic “practitioner” (are we to assume you mean nurse practitioner?” and only focusing on the pediatric physician, you are neglecting the role of the NP in primary care in general, and specifically the medical home. Families are increasingly likely to see an NP for primary care, for both urgent care and well child visits. The NP’s role as a PCP is frequently undervalued or ignored by physicians in the way that this article manages to do (unless the MD actually works in collaboration with – and values the contributions of- PNPs.)

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