Implementation: Continuity Clinic Perspective
The physical health of children continues to improve dramatically. However, the primary health care system has been less able to comprehensively respond to the pervasive changes occurring in many families and communities. New morbidities, such as substance use, early sexual activity, violence, and child abuse, threaten the health of today’s children. In response to these challenges, primary care physicians must expand their knowledge base of, and boundaries for, comprehensive solutions to complex medical and social problems.
Are the newer “basic sciences” of health promotion, medical decision-making and community-based medicine being adequately incorporated into residency training programs? Medical education must incorporate training in the delivery of “family-centered” and “community-based” care. Many would agree that the ideal setting for residents to learn these newer “basic sciences” is in a continuity clinic setting, the “medical home” for children. It is here that residents can deliver personalized care and develop patient-professional partnerships.
Resident training in behavior, growth, development, and adolescent medicine must emphasize far-reaching needs assessments, screenings, health promotion, and disease prevention. Residency programs recognize that these subject matters are an important part of child health training, but also acknowledge that it has been traditionally difficult to teach these skills, particularly in medical centers where life threatening illnesses and complex medical problems sometimes overshadow the community aspects of child health.
Family-based problems are seen today as the “new hidden morbidities” because of the difficulty in recognizing the problem(s). Specific aspects of interviewing, such as asking questions about psychosocial issues, making supportive statements, and listening attentively can increase disclosure of sensitive information. A goal of resident training in health supervision should be to provide the necessary information, guidance, and action for managing family-based problems. Residents must learn to effectively screen for psychosocial issues, by using specific interviewing skills. This should include obtaining sensitive information and identifying parental risks and family strengths, providing linkages to community resources, and supporting and advocating for families.
In order to provide “family-centered” care, primary care clinicians need to form partnerships with patient families and interdisciplinary professionals to foster patient involvement in medical decisions and put health promotion into practice. Residents need training on how to counsel families about medical and psychosocial problems that they uncover. Effective communication between the health care provider and family enables a patient-professional partnership to develop and increases patient satisfaction and adherence to a medical regimen. Today’s physicians are seeing more and sicker patients. Residents must be trained how to efficiently and cost effectively incorporate health promotion into an already time sensitive office visit.
Behavioral pediatrics, growth, development, and adolescent medicine have not been easily taught until this case-based curriculum came along. The learner is thrust into the exam room, experiencing real problems that need answers. As each case unfolds, there is active discussion and learning between the teacher and learners. By implementing this case-based Bright Futures curriculum into Pediatric Residency Training Programs, residents learn to become “family-centered” physicians, enabling them to create effective patient/family and professional partnerships. This case-based teaching curriculum serves as part of the solution for training residents in the focused delivery of “family-centered” and “community-based” care.
Henry Bernstein, D.O.