Monday, July 23, 2018

Pediatrics -- The Persistent Problem of Connecting Academia to Practice

Many of my readers are medical types.  This might be of interest to you people, especially the pediatricians.  50 years ago, Robert Haggerty and a colleague published one of his most important articles in the Journal of Pediatrics.  As a professor, Haggerty took the unusual step of investigating practitioners in his area, to see what their perspective was, what their problems were, how well they felt prepared for practice by their teaching programs, and how they handled what he had labelled the "new morbidities."  He had postulated that as acute disease became less of a problem, chronic diseases and social concerns would come to constitute more of pediatric practice, and that training programs should concentrate more on these issues.

Michael was asked to comment on this paper and he brought me in as his colleague, since I am older and remember that era personally, and since I have been in practice and Michael has been an academic so we can cover both sides of the ledger.  What we found -- and comments are yet to come in, and I will not be surprised to hear from lots of academics telling us that we don't understand how much things have changed -- was that the article largely describes the world today as much as it described it 50 years ago.  The emphasis of training program is still largely on science and in-patient services, hi-tech and rare diseases, and primary care is still neglected.  50 years ago practice was largely organized in quite small groups, and training programs didn't do much to help their residents learn how to run such practices.  Today, with practice largely organized into larger groups and hospital owned and other owned practices, there is still precious little teaching of how a pediatrician can exert leadership in such a group, and if one is not to be a leader, at least how one can understand the workings of organizations.  The unhappy consequence of this lack of preparation might be that leadership passes to non-clinical hands, to administrators, who will inevitably have different approaches and different understandings about practice, not to mention different ethics.

With that as introduction, here is what we wrote:

50 Years Ago
50 Years Ago in The Journal of Pediatrics: General Pediatrics: A Study of Practice in the Mid-1960's

Hessel SJ, Haggerty RJ. J Pediatr 1968;73:271-9

Fifty years ago, Hessel and Haggerty bridged the town-and-gown divide by surveying their surrounding primary care practices. Unlike today, 50 years ago male pediatricians predominated, most practices were small, and house calls were common. Most impressive, however, is what has not changed in 50 years.

The article describes a busy primary care enterprise that was gradually seeing fewer acute problems, leaving the chronic problems for hospital clinics, concentrating more on preventive visits, and struggling to deal with the so-called “new pediatrics,” which featured psychosocial, behavioral, and learning problems. The practitioners felt unprepared to handle these issues and ill-prepared for office management. The authors called for improved training to meet the challenges of the new morbidities, to run offices efficiently, to incorporate paraprofessionals, and to help practitioners get involved with community programs, especially for the underserved.

The continuation of these trends today underscores the prescience of Hessel and Haggerty, especially as vaccines reduce once-common acute conditions. Prevention is more advanced but is still a challenge. The “new” morbidities still plague primary care, with obesity and anxiety as additional components. Residency programs still undereducate on these problems and neglect administrative training. The primary care system struggles with population health.

The researchers hoped that “planning” would bring progress. That hope was not fulfilled. Instead of planning, the 2 major influences on primary care practice are what residency programs inculcate during training and the priorities enforced by third-party payment policies. Residency training is important: young pediatricians look for what they know, and fix what they know how to fix. But even with training reform, new skills will not bear fruit until payers find ways to redress the inequities of a payment system that underpays cognition and prevention. An organization needs to get paid for what it does.

Knowledge has always guided action. The more that academic pediatricians involve themselves in practice-based research similar to this classic study, the more they can identify ways for pediatricians to be effective in everyday modern practice, find effective measures of value to guide activities and payment, impact primary care outcomes, and promote needed primary care change.

Budd Shenkin

1 comment:

  1. My gut reaction to this is to further solidify my belief that the relationship between hospitals and preventive care is antagonistic at best. Every human institution, once it gets large enough, focuses on its own preservation over those whom it serves - that we apparently haven't moved the needle much in 50y just makes me more cynical.