SPECIAL ARTICLE
Thoughts on Health Supervision: Learning-Focused
Primary Care
Robert Needlman, MD
Department of Pediatrics, Case Western Reserve University, MetroHealth Medical Center, Cleveland, Ohio
The authors have indicated they have no financial relationships relevant to this article to disclose.
ABSTRACT
Primary care clinicians confront a long list of topics that are supposed to be covered during well-child visits, but evidence for the effectiveness of preventive counseling for most issues is limited, and it is doubtful that covering more topics confers correspondingly enhanced clinical benefits. Amid growing professional interest in rethinking primary care, 3 ideas that would facilitate constructive change are proposed. First, face-to-face time between doctors and parents should be allocated as a scarce resource, with priority given to topics that are both important and uniquely responsive to in-office intervention. Second, to maximize the educa-tional value of anticipatory guidance, visits could focus on experiential, as opposed to merely didactic, learning. Finally, recommendations for primary care should be based on evidence, rather than expert opinion. Competing protocols for preven-tive care ought to be subjected to large-scale, coordinated research. The unit of analysis should be the visit or series of visits, rather than a single intervention. A crucial first step would be the definition of universal outcome measures.
www.pediatrics.org/cgi/doi/10.1542/ peds.2005-1826
doi:10.1542/peds.2005-1826
Key Words
anticipatory guidance, primary care, preventive services, preventive health care visits, learning
Abbreviations
AAP—American Academy of Pediatrics NBAS—Newborn Behavioral Assessment Scale
Accepted for publication Dec 21, 2005 Address correspondence to Robert Needlman, MD, Department of Pediatrics, MetroHealth Medical Center, 2500 MetroHealth Dr, Cleveland, OH 44109. E-mail: robert. needlman@case.edu
T
HE “NEW MORBIDITY”is no longer new.1Therealiza-tion that psychosocial concerns need to occupy cen-ter stage in pediatric health supervision has been build-ing over the past quarter century. The American Academy of Pediatrics (AAP) first published its schedule for preventive care in 1967.2Since then, the
recommen-dations have expanded steadily, like the average Amer-ican’s waistband, to the point that even the most opti-mistic clinician cannot hope to encompass them all within the bounds of a reasonable-length visit.3Even so,
most pediatricians manage to provide high-quality care, when quality is defined in terms of the number of topics covered.4,5
Covering topics, however, may be like covering acne: cosmetic but not healthy. Indeed, it often seems that the more we cover, the less we truly accomplish. When anticipatory guidance consists of the recitation of a long list of points (eg, eat vegetables, limit television, exercise, buckle up, wear a helmet, wear sunscreen, make time for homework, make time for play, look out for bullying, ask about drugs, ask about friends, brush every day, etc), both clinicians and parents tend to tune out.6A variety
of approaches can augment patient education, such as written handouts, videotapes, modeling, and role-play-ing,7 but teaching more effectively, in itself, does not
solve the problem of there being too much to teach in too little time. Recognition of this dilemma has led to recent calls to “rethink pediatric primary.”3,4,8 Here, in
answer to the call, are 3 thoughts.
THOUGHT 1: SPEND TIME RATIONALLY
The inescapable reality of primary care is that time is limited. The precise number of minutes per visit varies, but 20 to 30 represents a practical upper limit, and most encounters are shorter.9 Adding minutes or visits
can-not change the fact that the time that a pediatrician has face to face with a parent and a child is a scarce resource. To maximize the benefit to patients, this resource needs to be allocated rationally, with priority given to issues that are both clinically important and uniquely respon-sive to the personal intervention of the pediatrician. Issues that can be dealt with effectively outside the face-to-face encounter ought not take up valuable encounter time.
Current recommendations for well-child care are weighted down with topics that fail the twin tests of importance and responsiveness. For example, although most of us agree that children should help with chores, the health significance of chore-doing has not been well established, and the value of anticipatory guidance on the topic remains unknown. Other issues clearly are of great importance but may not be responsive to inter-vention within the well-child visit. Television addic-tion, handgun access, domestic violence, sexual abuse, sunburn, and permissive parenting all fall within this category. We simply do not know whether routinely
covering these topics does any good. I do not mean to say that these topics should be dismissed, but until there is solid research to show how they can be ad-dressed effectively in the context of primary care, we have only our personal experiences and preferences to guide us.
In contrast to the long list of issues that are important but not demonstrably affected, 2 recent reviews have identified a short list of issues on which we know we can make a difference.10,11One example of an intervention
that appears on both lists is promotion of reading aloud. Education experts agree that reading aloud is crucial for eventual school success, and there is substantial evi-dence that pediatric guidance about reading aloud pos-itively affects parent behavior and child development in populations that are at high risk for school failure.12,13
Rational allocation of scarce face-to-face time would start with such proven interventions.
This strategy would not mean that we spend any less time with parents; it would mean that we spend the time better. Neither would this approach to routine guidance alter the general outline of well-child care. The visit still would begin by eliciting the parent’s and the child’s concerns, allowing them to define the first teachable moments of the encounter.14 The visit still would end
with a wrap-up of the issues addressed and plans for interventions such as immunizations, blood tests, and future visits.
What about the multitude of problems for which we now screen or about which we provide routine advice (or would, if we could actually follow all of the recom-mendations)? Many, perhaps most, could be taken care of either before or after the face-to-face encounter, through questionnaires, handouts, recorded informa-tion, computers, the Internet, and other media.15 One
necessary step is the creation of printed materials that are accessible to parents with limited literacy and that are effective for parents of all educational backgrounds.16
Billing and reimbursement would need to reflect the considerable effort expended. Problems that are uncov-ered through this process could trigger future problem-oriented visits. Just because a problem comes up during well-child care does not mean that its solution has to be confined within the same 20-minute time frame.
As we rethink how best to work within the well-child visit, we also have to work harder outside the visit, advocating for environmental standards, child protec-tion, quality child care, equitable educaprotec-tion, safety in-novations, and other critical issues.17 We also have to
continue to explore creative cross-disciplinary collabo-rations, such as the Healthy Steps program.18 Doing
more outside the well-child visit frees us to “cover” less during the visit itself, while providing more—and more effective— care.
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THOUGHT 2: MAKE EXPERIENTIAL LEARNING THE FOCUS OF EACH VISIT
One way to get the most out of limited face-to-face time is to arrange each visit around a brief interaction in which the child learns something while the parent par-ticipates in the learning experience. The topic is highly salient. Surveys repeatedly show that parents value guidance about children’s learning and want more of it.19–21 The emphasis on experiential learning follows
from current theories of adult learning. Adults, like chil-dren, learn best when they are actively engaged rather than passively listening.22
The opportunity to create learning experiences begins at birth. In the Brazelton Newborn Behavioral Assess-ment Scale (NBAS), the clinician elicits an infant’s com-petencies, including the abilities to habituate, to orient to visual and auditory stimuli, and to modulate arousal.23
Although the NBAS was developed as a research tool, studies have shown that when parents are invited to observe or participate in the NBAS with their own in-fants, the result is improved mother–infant interaction and child development, even months later.24
For older infants and children, picture books can readily provide the learning focus. For example, at a 6-month visit, I hold out a colorful board book, and say, “Let’s see what Johnny will do with this.” The mother and I watch how Johnny responds to the new object. We talk about what Johnny is learning, how he is learning, and how his mother can feed his growing curiosity. If all goes well, then Johnny leaves with the book, and his mother leaves with a new appreciation for Johnny’s cognitive strengths and for her own parenting compe-tence.
Used in this way, the picture book serves as a lens, focusing developmental assessment and teaching on is-sues that are relevant to the child’s learning: receptive and expressive language, attention, social interaction, and cognitive/behavioral style. The book creates the op-portunity to model developmentally appropriate teach-ing techniques, to observe first-hand how the child re-sponds to such interactions, and to discuss the child’s individual response with the parent in “real time.”
The efficacy of clinic-based interventions using books has been documented repeatedly,13 but books are not
essential. A wide range of toys and other objects could be used to elicit joint attention, playful interaction, and language.25 Whether the visit focuses on habituation,
picture books, blocks, or dolls, the point is to help the parent engage the child in an act of learning. To inspire positive parenting behaviors, it may be best for pediatri-cians to do less telling and instead lead parents to come up with their own solutions to the challenge of support-ing their children’s development.26 In learning-focused
primary care, the pediatrician creates a learning situa-tion for the child, then provides encouragement and guidance to assist the parents’ own process of discovery.
THOUGHT 3: LEARN FROM COLLECTIVE EXPERIENCE
Schor3 detailed the evolution of the AAP’s periodicity
schedule, noting that it always has been based on expert opinion rather than scientific evidence. He acknowl-edges that operating without benefit of data poses some risks: How can we be sure that we are not wasting our effort, or even causing harm? That consideration, how-ever, does not prevent him from calling for an expert panel to set “standards of practice” for the whole profes-sion.
I suggest a different approach. Instead of offering a solution, I would pose questions: Which forms of well-child care will provide the greatest benefits to which families? Do we need to create a 1-size-fits-all system, or can we devise different packages of care according to a particular child’s and family’s biological, psychological, and social assets and risks? Instead of a central standard-setting body, why not create an expert committee to generate protocols for primary care that will be subjected to clinical trials, just as the Children’s Oncology Group creates protocols for cancer care?27 If we believe that
well-child visits ought to be named rather than bered, as Schor advocates, then let’s enroll a large num-ber of families in a randomized trial to test that concept. If we think that the periodicity schedule needs revising, then let’s systematically compare a revised schedule with a traditional one. For that matter, let’s subject the idea of learning-focused care, as I’ve sketched it above, to empirical study.
A program of systematic assessment of primary care protocols would address a problem that has been skirted by most of the current research. Although many studies have evaluated interventions aimed at single issues, few have considering the effects of competition for time and attention from all of the other interventions that are provided during the same visit. For research to inform evidence-based practice, the unit of assessment has to be the visit or the series of visits rather than any single intervention in isolation.
Before we can meaningfully evaluate novel ap-proaches to care, we will need to agree on a consistent set of clinically relevant outcome measures. Process measures, such as the percentage with complete immu-nizations, the number of anticipatory guidance topics covered, or parent satisfaction, already have been devel-oped.8,28Beyond these, we also need to assess hard
task of selecting a package of outcome measures to be applied across multiple studies could rightly fall to the panel of experts envisioned by Schor.
Regardless of how we end up “rethinking” primary care, the commitment to empiricism is fundamental. There are 60 000 pediatricians in the AAP. If the fellows of the AAP took a more systematic approach to the study of primary care, then there would be no shortage of meaningful results. The AAP’s Pediatric Research in Of-fice Settings Network has demonstrated that such large-scale undertakings are feasible; undoubtedly, many les-sons can be drawn from that effort.29A commitment of
research funding at the national level also would facili-tate progress greatly in this area. Through a well-planned program of ongoing innovation and evaluation, the practice of providing well-child care would become, simultaneously, the process of improving it. Such a com-mitment to self-study would constitute the most impor-tant sense in which well-child care could and should become learning focused.
REFERENCES
1. Haggerty RJ, Roghmann KJ, Pless IB. Child Health and the Community.New York, NY: John Wiley and Sons; 1975 2. American Academy of Pediatrics, Council on Pediatric Practice.
Standards of Child Health Care. Evanston, IL: American Academy of Pediatrics; 1967
3. Schor EL. Rethinking well-child care. Pediatrics. 2004;114: 210 –216
4. Zuckerman B, Stevens GD, Inkelas M, Halfon N. Prevalence and correlates of high-quality basic pediatric preventive care.
Pediatrics.2004;114:1522–1529
5. Olson LM, Inkelas M, Halfon N, Schuster MA, O’Connor KG, Mistry R. Overview of the content of health supervision for young children: reports from parents and pediatricians. Pediat-rics.2004;113(suppl):1907–1916
6. Barkin SL, Scheindlin B, Brown C, Ip E, Finch S, Wasserman RC. Anticipatory guidance topics: are more better?Ambul Pe-diatr.2005;5:372–376
7. Glascoe FP, Oberklaid F, Dworkin PH, Trimm F. Brief ap-proaches to educating patients and parents in primary care.
Pediatrics.1998;101(6). Available at: pediatrics.org/cgi/content/ full/101/6/e10
8. Bethell C, Reuland CH, Halfon N, Schor EL. Measuring the quality of preventive and developmental services for young children: national estimates and patterns of clinicians’ perfor-mance.Pediatrics.2004;113(suppl):1973–1983
9. LeBaron CW, Rodewald L, Humiston S. How much time is spent on well-child care and vaccinations?Arch Pediatr Adolesc Med.1999;153:1154 –1159
10. Nelson CS, Wissow LS, Cheng TL. Effectiveness of anticipatory
guidance: recent developments. Curr Opin Pediatr. 2003;15: 630 – 635
11. Regalado M, Halfon N. Primary care services promoting opti-mal child development from birth to age 3 years: review of the literature.Arch Pediatr Adolesc Med.2001;155:1311–1322 12. Mendelsohn AL. Promoting language and literacy through
reading aloud: the role of the pediatrician.Curr Probl Pediatr Adolesc Health Care.2002;32:188 –202
13. Needlman R, Silverstein M. Pediatric interventions to support reading aloud: how good is the evidence?J Dev Behav Pediatr.
2004;25:352–363
14. Nutting PA. Health promotion in primary medical care: prob-lems and potential.Prev Med.1986;15:537–548
15. Sturner RA. Parent questionnaires: basic office equipment?
J Dev Behav Pediatr.1991;12:51–54
16. Davis TC, Crouch MA, Wills G, Miller S, Abdehou DM. The gap between patient reading comprehension and the readability of patient education materials.J Fam Pract.1990;31:533–538 17. Palfrey JS, Tonniges TF, Green M, Richmond J. Introduction:
addressing the millennial morbidity—the context of commu-nity pediatrics.Pediatrics.2005;115(suppl):1121–1123 18. Zuckerman B, Parker S, Kaplan-Sanoff M, Augustyn M, Barth
MC. Healthy steps: a case study of innovation in pediatric practice.Pediatrics.2004;114:820 – 826
19. Busey S, Schum TR, Meurer JR. Parental perceptions of well-child care visits in an inner-city clinic.Arch Pediatr Adolesc Med.
2002;156:62– 66
20. Young KT, Davis K, Schoen C, Parker S. Listening to parents. A national survey of parents with young children.Arch Pediatr Adolesc Med.1998;152:255–262
21. Kuo AA, Franke TM, Regalado M, Halfon N. Parent report of reading to young children. Pediatrics. 2004;113(suppl): 1944 –1951
22. Merriam SB. Andragogy and self-directed learning: pillars of adult learning theory.New Dir Adult Contin Educ.2001;89:3–13 23. Brazelton TB. The Brazelton Neonatal Behavior Assessment
Scale: introduction.Monogr Soc Res Child Dev.1978;43:1–13 24. Nugent JK, Brazelton TB. Preventive intervention with infants
and families: the NBAS model.Infant Mental Health J.1989;10: 84 – 89
25. Mendelsohn AL, Dreyer BP, Flynn V, et al. Use of videotaped interactions during pediatric well-child care to promote child development: a randomized, controlled trial.J Dev Behav Pedi-atr.2005;26:34 – 41
26. Miller W, Rollnick S. Motivational Interviewing. 2nd ed. New York, NY: Guilford; 2002
27. Reaman GH. Pediatric cancer research from past successes through collaboration to future transdisciplinary research.J Pe-diatr Oncol Nurs.2004;21:123–127
28. Minkovitz CS, Hughart N, Strobino D, et al. A practice-based intervention to enhance quality of care in the first 3 years of life: the Healthy Steps for Young Children Program.JAMA.
2003;290:3081–3091
29. Wasserman RC, Slora EJ, Bocian AB, et al. Pediatric Research in Office Settings (PROS): a national practice-based research network to improve children’s health care.Pediatrics.1998;102: 1350 –1357
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