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research-article2014

CPJXXX10.1177/0009922814533408Clinical PediatricsMote et al

Article

Clinical Excellence in Pediatrics

Clinical Pediatrics 2014, Vol. 53(9) 879­–884 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922814533408 cpj.sagepub.com

Phillip C. Mote, BS1, Barry S. Solomon, MD, MPH1, Scott M. Wright, MD1, and Michael Crocetti, MD, MPH1

Abstract The 7 core domains of clinical excellence in academic medicine, as defined by the Miller-Coulson Academy of Clinical Excellence at Johns Hopkins, are applicable to the field of pediatrics. The authors use published case reports and teaching models from the pediatric literature to illustrate how thoughtful clinicians have realized distinction in each of the 7 clinical excellence domains, recognizing excellent pediatric patient care serves to strengthen all 3 arms of the tripartite academic mission. Clinicians who feel valued by their institution may be more likely to remain in an academic clinical setting, where they promote the health and well-being of their patients, provide support to families and caregivers, serve as role models for pediatric trainees, and integrate research into their practice with the overall aim of improving patient outcomes. Keywords pediatrics, clinical competence, academic medical centers, standard of care

Introduction In an attempt to more concretely define a clinically excellent physician in the academic setting, 24 “exceptional” academic physicians were studied using qualitative methods. From this work, 7 domains of clinical excellence were identified in the broad practice of medicine: (1) communication and interpersonal skills, (2) professionalism and humanism, (3) diagnostic acumen, (4) skillful negotiation of the health care system, (5) knowledge, (6) scholarly approach to clinical practice, and (7) exhibiting a passion for patient care.1 The MillerCoulson Academy of Clinical Excellence (MCACE) at Johns Hopkins University School of Medicine works to perpetuate these ideals by inducting “members” annually who are chosen using rigorous selection criteria with input from an external review board, akin to a study section. Members join this “working” academy and promote such ideals through innovative programs that raise the visibility of clinically excellent patient care within academic institutions.2,3 Clinical excellence articles in the fields of psychiatry and cardiology using the 7 domains have been published.4,5 With this framework in mind, the aim of this article is to characterize clinical excellence in the field of pediatrics. The practice of pediatrics varies across the spectrum of health care delivery settings: ambulatory primary and subspecialty care, the emergency department, inpatient, and intensive care environment. Nevertheless, there are common unifying threads in the clinical work

of the pediatrician. Unlike other types of physicians, the pediatrician has unique demands in oft seeing more than one person at a time (families) with particular attention needed for assessing caregiver perspectives while employing shared decision making. The pediatrician must balance immediate care and long-term health and development. The pediatrician also fills a trusted role in the community. Keeping this broad spectrum in mind, we seek to provide examples and insight into each of these aforementioned domains using materials from existing literature highlighting the unique roles of pediatricians. Potential articles/reports were found by searching keywords pertaining to each domain through PubMed. Those selected were deemed to be most illustrative and applicable by the authors based on content, relevance to the domain, number of times cited, inclusion of case reports, and journal published in.

Communication and Interpersonal Skills Janine was a 13-year-old female brought to her pediatrician by her mother for an annual checkup. The mother had not 1

Johns Hopkins University School of Medicine, Baltimore, MD, USA

Corresponding Author: Phillip C. Mote, Johns Hopkins University, David M. Rubenstein Child Health Building, 200 N Wolfe Street Room 2074, Baltimore, MD 21287, USA. Email: [email protected]

880 planned to address behavioral concerns during the visit. The pediatrician, however, asked to privately interview the child. After talking with the daughter, the pediatrician obtained consent from the daughter to bring the mother in the room and talk about these peer pressure and anger issues she had brought up. After having gained confidence by talking privately with the pediatrician, the daughter then revealed in the mother’s presence that she had wanted to kill herself for the last 6 months as a result of self-blame for her father’s recent fatal car accident. The mother and daughter had been having a lot of problems for over a year; consequently the mother expresses gratitude for the daughter’s ability to confide in the doctor about what was bothering her. Although ongoing work was required for this family, the pediatrician visit was a major step forward in addressing and managing the daughter’s behavioral issues.6

This process of “family truth discovery” plays an important and crucial role in the dynamics of a family. Interpersonal communication skills may be the strongest attribute of seasoned pediatricians; the mere act of involving a growing child serves as a therapeutic and confidence-building tool. Focus on such engagement is merited, as currently only 10% of communication involves the pediatric patient during routine visits.7 Specific techniques have been shown to engage and retain participation from younger patients (3-8 years old) during the interview: (1) asking social questions early on in the visit, (2) phrasing questions in yes/no format, and (3) directing a nonjudgmental gaze at children with each question.8,9 This “common factors” approach emphasizes building genuine, trusting relationships with patients and their families. By acknowledging shared goals and embracing affective engagement, this therapeutic alliance increases sharing of psychosocial information and adherence to care plans. Furthermore, by focusing as much on the process of care as on the diagnostic and management aspect, pediatricians can find increased fulfillment in their work.10 A large aspect of working with children is alleviating fears of the medical environment. Great strides have been made through small changes such as promoting attachment instead of separation for parent and child in clinical settings. Certain professions have arisen specializing in the practice of child-centered care, such as Child Life specialists who work in hospitals to provide support, guidance, and help for families coping with chronic illness and loss. Pediatricians have learned from the Child Life specialists, as well as from behavioral, developmental, and mental health professionals, about the importance of using simple language of what to expect, and creating a sense of autonomy for the child by offering choices.11

Clinical Pediatrics 53(9)

Professionalism and Humanism Shortly after his birth, Ryan Milton Wills was diagnosed with pulmonary hypoplasia. Early on during Ryan’s illness, Anne and Jeff were committed to doing everything they could to “cure” him. Yet, when he was around 4 months old, they realized that his condition was life threatening and that a “cure” might not be possible. They continued to focus on providing Ryan with the best care possible so that he might have a chance to live. At the same time, with the help of the clinical team, Anne and Jeff broadened their vision for their family. They focused on two additional priorities: assuring that Ryan knew he was loved and cared for, and resolving not to lose a sense of family during Ryan’s illness. This clarity of focus enabled them to have the strength, in Jeff’s words, “to do what was important, no matter what it took.” In Anne’s words, “our primary care physician called us every day for 9 weeks in the ICU. He was always my litmus test. I wish he knew how much I appreciate his patience and humility.” Ryan received the best of care both at home and during his many hospitalizations. Nonetheless, he died of complications related to the disease on November 29, 2001, at 9 months and 6 days of age.12

Professionalism and humanism are guiding and necessary principles for the practice of pediatrics. In the words of Jordan Cohen, “Humanism is the passion that animates professionalism.”13 Cultivating compassion, altruism and other deep convictions about service to others helps propel observable behaviors (honesty, competence, respect) toward patients. Sometimes such compassionate care must be checked by the professional obligations of the pediatrician. Many families of seriously ill children hold onto hope even in the face of slim odds for sustained viability; families often describe their role as the “bearer of hope.” As illustrated in the above case, a communication strategy among the clinicians and families could be to focus on specific care goals (time to cradle the child, visits from grandparents). The duty of the pediatrician is to ensure the family understands the prognosis related to their child’s condition; beyond this, families are able to choose realistic care goals and to maintain hope in their own way.14 Humanism requires a presence of awareness, acknowledging the different perspectives of each person involved in an encounter and a conscious effort to act in the patient’s best interest. Recent effort has been made to expose the need to cultivate honest self-reflection: a type of self-care that enables the pediatrician to care better for the patient.15 Such habits begin in training. One such example is an annual resident workshop on the grief process and breaking bad news; in fact, Anne and Jeff Willis attend this workshop each year to help pediatricians-in-training

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Mote et al understand that no death is routine. As stated in former Academic Pediatric Association President Dr Janet Serwint’s words: “Although understanding and communicating the intellectual components of disease, physiology, and treatment are important, understanding and connecting at an emotional level demonstrates we respect the values and beliefs of our patients.”16 Clearly, this intricate dance of professional obligation and humanistic idealism is not simple; however, the fusion of these guiding principles lies at the heart of what it means to be an excellent pediatrician.

Diagnostic Acumen A 12-year-old boy complained of pain at the umbilicus, beginning just after he started to urinate and lasting around 30 seconds post-voiding. There was no radiation of the pain, and he did not complain of dysuria. Though the patient noted painless retraction of umbilicus during urination for as long as he could remember, discomfort and pain had onset 3 days earlier. No suprapubic tenderness or abdominal masses were palpable; urine studies came back normal. An ultrasound examination of the abdomen revealed no evidence of a urachal cyst and neither did a voiding cystourethrogram. Nonetheless, Pediatrician Dr. Peter Rowe and Pediatric Urologist Dr. John Gearhart both had persistent suspicions for the diagnosis and agreed that the child needed a cystoscopy. The study revealed a small opening at the dome of the bladder; this prompted surgical exploration to find a urachal remnant which reproduced symptoms of retraction.17

The above case illustrates the important element of diagnostic thinking. Heretofore, such retraction of the umbilicus was a previously unknown sign of a urachal remnant; further, classic signs of a urachal anomaly such as discharge, enlargement of umbilical cord, or fever were not present in the case described above. In true fashion of leaving no stone unturned, these astute pediatric clinicians went to great lengths to verify the patientreported pain by taking photographs of the umbilicus during urination, something not done by the previous physicians involved in his care. Excellence, then, understands that each child is a unique case; work-up is aided by, but not confined to, classical patterns of presentation or previously reported clinical manifestations. Though “classical” cases follow “Ockham’s razor,” each patient demands a holistic view that may not be solved by the simplest explanation.18 The father of this art in pediatrics, Dr Frank Oski, referred to this as hypothesis generation: “Allowing a certain hypothesis that integrates information to guide further diagnostic testing.” He added that veteran physicians begin this process of hypothesis generation on hearing the chief complaint and continue to refine these throughout the process of gathering or hearing additional details. Armed with other tools such as pattern recognition and clinical

algorithms, Oski described useful steps such as recognizing inherent bias, risk/benefit of testing, fearing the most serious possible disease, and fostering patience in the process.19

Skillful Navigation “I think a lot has to do with instilling an attitude of selfconfidence with the kids early on and just expecting them to do things for themselves,” commented the family. “The pediatric specialist was a very firm believer in the children taking responsibility for their own health care. And so when Bobby was 2½ years old, he started answering his own questions when we came to clinic, and as a family we started rehearsing those questions and answers on the way to clinic.”20

In this encouraging description of a family’s experience with a pediatrician, the theme of self-responsibility and transitioning of care emerges. A pediatrician helps transition care from parent-dependent to child-independence with milestones such as active participation (confidence building) in the visit, alone time without the parent when nearing adolescence (self-autonomy), and eventually transitioning into the adult care paradigm.21 In each of these steps, seasoned pediatricians facilitate the patient role by setting healthy expectations and boundaries, thus instilling a sense of “graduation” when moving onto the next level of care. Within the realm of making transitions out of pediatrics, it seems rather obvious that it becomes harder the closer the relationship is; thus, many patients with frequent specialist visits (like a childhood cancer survivor) find parting with their pediatrician particularly taxing.22 The increasing survivorship of childhood conditions demands vigilance on the part of practitioners. Educating survivors about their expected disease progression, recurrence risk, and coping mechanisms is vital to optimizing lifelong health and well-being. Further awareness of childhood survivorship is needed, given that only one third of adult “childhood cancer survivors” receive appropriate care adjusted for these risks.23 In an effort to navigate transitions in pediatrics, the concept of the medical home was introduced in 1967 by the American Academy of Pediatrics. In its debut, the emphasis relied heavily on the hallmark question: “Where is this child’s medical home?” so as to ensure that all information would be sent “there.” Over the years, this concept has taken a role in discussions of managed care and in noble aspirations such as a whole person orientation, quality and safety, and enhanced access to care.24 In the current era, this paradigm has molded into “life course theory,” helping care for patients from preconception through young adulthood.25 As well, transition to the electronic medical record presents a challenge to wholepatient care and attentiveness but it also aids in compiling

882 information along a patient’s life course. Hence, even with the ever-changing face of health care, staples of pediatric quality care remain paramount.

Knowledge A 3-year old child and family enter a standard well-child visit with their pediatrician. In the past year, the child has had a simple viral upper respiratory infection (URI) about every two months. Since there was some wheezing and nighttime cough that only came about periodically, a shortacting B-agonist had already been given to the family to use for these episodes. The child did not consistently need the inhaler more than once a week on average. The mother, with him today is herself asthmatic, is on long-term controller therapy. After consideration of the recent Expert Panel Report 3 asthma guidelines, the pediatrician starts the child on a low-dose daily inhaled corticosteroid. Close monitoring, including a follow-up in a month to see if symptoms have been controlled, is instituted.26

Pediatrics, as in any other area of medicine, demands a commitment to lifelong learning. For, as illustrated above, the evidence-based appropriate management of illness changes over time. Outlined here, the Expert Panel Report–3 guidelines emphasize components of current illness severity and validated risk for future lung disease progression.27 In order to keep pace with these updates, connection to the best information available is crucial. Professional guidelines, such Bright Futures launched by the Maternal and Child Health Bureau is now implemented through the American Academy of Pediatrics and, serves as the primary resource for pediatricians to deliver evidence-driven, developmentally focused, health supervision practices. Research suggests that most physicians do not properly utilize widely available guidelines; this could stem from an attitude of mistrust in the evidence, lack of awareness, or self-confidence in optimal care.28 In this age of mobile medicine, clinical knowledge is no longer as hard to access but rather still requires skill to interpret and apply to the patient. Yet gestalt remains invaluable in clinical practice. Often, it is equally important to have the knowledge base of identifying when to be worried as it is to eventually arrive at the final assessment and plan; this is colloquially referred to as the “can’t miss diagnosis.” While clinicians must continually build their knowledge base, clinical experience helps translate this knowledge into action. Similarly, pediatricians sit at a crux of information from various sources (family, teacher, community, etc) and are charged with sifting through these inputs to obtain an accurate picture of the patient’s life; this is made more complicated when these sources disagree, which some studies show happens 50% of the time.29 Clearly, clinically excellent pediatricians must not only be knowledgeable

Clinical Pediatrics 53(9) but also have the skill to balance information from various individuals to optimally manage their patients.

Scholarly Approach In the words of pediatrician and geneticist, Dr Barton Childs, “the thoughts of today are always compounded on those of the past.” When one thinks of melding academic pursuit and the practice of pediatrics, Dr Childs must be considered among the foremost sage. Throughout his career, he found himself among a genetic revolution of sorts, aided in part by the discovery of the DNA helix. He focused on the gene in developing and advocating the use of evidence-based medicine. In his words, It is the genes, however, that bind the individual to the species and to all life; through their powers, both permissive and constraining, they initiate a trajectory of development, maturation, and aging, which although subject to modification by experiences along the way, preserves the identity of the individual throughout life.30

Even posthumous, his influence continues to propel modern medical thinking, such as inspiring the current medical school curriculum entitled “Genes to Society” at his home institution, Johns Hopkins.31 Adopting a scholarly approach to pediatrics includes widely adopted ideals such as evidenced-based medicine. A unique situation that is not uncommonly encountered involves the interpretation of results from landmark clinical or drug trials that were performed in adults. The reason for the frequency of this scenario can be attributed to many factors such as increased ethical dilemmas when dealing with studying children. This generates an inherent level of uncertainty with many therapeutic options, requiring pediatricians to best reason appropriate conclusions for their unique patient. Fortunately, recent incentives have been passed through legislation to try and correct this relative dearth of pediatric studies. For instance, the Pediatric Exclusivity Provision of the BPCA (Best Pharmaceuticals for Children Act) give pharmaceutical companies an additional 6 months of exclusivity for its drug patent if it adheres to testing rules established for pediatric populations. As well, the PREA (Pediatric Research Equity Act) gives power to the Food and Drug Administration to require pediatric testing on a new drug application.32 Hopefully, these advances help generate a larger evidence-base for pediatric practice. Overall, the clinically excellent Pediatrician in academia may be trying to generate new insights and discovery independently or in collaboration with investigators, and all clinically excellent pediatricians are thoughtful about how they integrate new research findings into the care of their patients.

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Passion for Patient Care Dapper and gentle, Dr. Jordan S. Ruboy cared for generations of children at his private pediatrics practice in Concord and at Massachusetts General Hospital, where he was on staff for 50 years. He went on house calls, soothed the anxieties of generations of parents, and wept openly when a child died. He typified the best of the era of old-fashioned medicine; he was part of the community. He was very involved with not just the children but also their families. He would sometimes go to children’s school conferences, and even attend court appearances if children were in trouble. Work hours were less of an issue and he was always available to his patients. A parent described: “He was always incredibly supportive and helpful, he just had a way of making you feel confident as a parent. He would give advice in such a way you hardly knew you were getting advice. He understood being a parent was not always easy or automatic. He would oftentimes put on the top of an appointment bill, ‘No charge.’ He did a lot of that.”33

Caring for children—whether younger or older—is extremely satisfying for clinically excellent pediatricians. Dr Ruboy embodies the many pediatricians who genuinely care for their patients and go to great lengths to provide them with the best possible care. This work is not always easy and can often seem never-ending. Such passion for clinical care comes from a genuine desire to authentically engage with patients and families, framing oneself as their advocate and supporter. A practice grounded in the extrinsic reward of working with patients and the intrinsic reward of playing a role in their stories and continually learning on many dimensions helps fuel the dedicated pediatrician. Being passionate about pediatrics is essential if one truly wants to achieve clinical excellence consistently over time.

Community Involvement An additional domain felt to be an important component of pediatric excellence is involvement in the community. Realizing that only a miniscule portion of the child’s life is spent at the clinic/practice, the clinically excellent pediatrician is aware of and may even help to create more healthy living spaces in the surrounding neighborhoods. Each pediatrician is encouraged to seize this opportunity, as outlined by the American Academy of Pediatrics to “synthesize clinical practice and public health principles to promote health of all children within the context of family, school, and community.”34 This process involves looking at the natural and built environments where children spend time, as well as partnering with other advocates in the community: school districts, environmental agencies, and so on. The dynamics of engagement in the community are always changing, and no 2 patients present with the same

social milieu. Homelessness provides one example of such a challenge affecting 1 out of 45 American children. These patients face challenges such as family separation issues based on certain shelter policies, inconsistent care, and general health deficiencies. Pediatricians can serve as advocates by working to make quicker permanent housing an option instead of multiple short-term housing options.35 Children of immigrant families, 25% of American children, also present unique considerations. Efforts that advance the health and insurance rights of children promote the health of the entire country.36 With continually evolving social circumstances, certain adaptable skills are needed to approach each issue and strategically work to solve it. With the American Academy of Pediatrics’ Community Pediatrics Training Initiative (CPTI), there is an ongoing opportunity for education in learning and applying community-based methods at many levels of training.37 One model, Health Leads, uses the medical home setting and the pediatrician as a partner to link children and their families to available social service agencies and community resources.38

Conclusion In this article, we highlighted examples from the literature of individual pediatricians and teams of providers delivering excellent care to patients and their families. Whether in a community-based or an academic pediatrics setting, rural or urban environment, small or larger community, clinical excellence will always be valued by patients and their family members. Now more than ever in our rapidly changing, complex health care system, pediatricians must strive for clinical excellence consistently because medicine is a public trust and all children deserve only the best from their physician. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Dr Wright is a Miller-Coulson Family Scholar and is supported through the Johns Hopkins Center for Innovative Medicine.

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