Berkowitz's Pediatrics

A Primary Care Approach

Carol D. Berkowitz

• Publisher: American Academy of Pediatrics
• Year: 2020
• ISBN:
  9781610024105
• Edition: 6
• Topic: Medicine
• Subtopic: Pediatric Medicine

The reference of choice for pediatricians, residents and medical students, the newly revised and expanded 6th edition provides clear, practice-oriented guidance on the core knowledge in pediatrics. Edited by a leading primary care authority with more than one hundred contributors, the 6th edition provides comprehensive coverage of hundreds of topics ranging from temper tantrums and toilet training to adolescent depression and suicide.
 
More than 155 ( including 5 brand new ) clinical chapters review pertinent epidemiology and pathophysiology, then give concise guidelines on what symptoms to look for, what alternative diagnoses to consider, what tests to order, and how to treat your patient.
 
New in the 6th edition

• All chapters have been reviewed and updated to address current issues.
• Five new chapters are included on the following:
  • Health Systems Science
  • Population Health for Pediatricians
  • Social Determinants of Health: Principles
  • Adverse Childhood Experiences: Trauma Informed Care
  • Commercially Exploited Children and Human Trafficking
• Student worksheets corresponding to each chapter’s case study questions will be posted online in a user-friendly format so that they can be completed in preparation of discussions.
• Case study questions have been enhanced and resources have been revised.
• This edition is completely reorganized into 15 sections using a systems-based approach.
   

 

PART 1

Primary Care: Skills and Concepts

1. Primary Care: Introduction

2. Talking With Parents

3. Talking With Children

4. Talking With Adolescents

5. Telephone Management and E-medicine

6. Informatics

7. Counseling Families About Internet Use

8. Cultural Competency Issues in Pediatrics

9. Global Child Health

10. Child Advocacy

CHAPTER 1

Primary Care: Introduction

Niloufar Tehrani, MD

CASE STUDY

As a primary care physician, you evaluate a 2-year-old boy who is presenting to the office for the first time. The mother states he has always been small; he was born at term but weighed only 2,272 g (5 lb). She is a single mother, and he is her only child. He speaks only 5 words and is quite active. The physical examination is normal, but the boy’s height and weight are less than the fifth percentile. The mother reports her son is immunized, but she does not have his immunization records with her at this visit.

Questions

1. What are the 4 components of primary care?

2. What are the main characteristics of a medical home? What are the eligibility criteria for designating a practice as a medical home?

3. What is the difference between a consultation and a referral?

4. Why are laboratory tests done during a routine health maintenance visit?

Primary care is defined as the comprehensive health care a patient receives from the same health professional over a longitudinal period. The term was first used in the 1960s to designate the role of the primary care physician in response to the abundance of subspecialists and lack of generalists among practicing physicians. It is generally accepted that primary care physicians include pediatricians, family physicians, and internists. In 1966, The Graduate Education of Physicians: The Report of the Citizens Commission on Graduate Medical Education (the Millis Committee Report) to the American Medical Association recognized the importance of primary care and recommended a national commitment to educating primary care physicians. Primary care was further defined in 1974 by Charney and Alpert, who separated it into component parts: first contact, longitudinal care, family orientation, and integration of comprehensive care. To comprehend the depth of primary care, it is necessary to understand its component parts.

First contact occurs when a patient arrives for medical care at the office of a primary care physician. The visit includes an intake history, complete physical examination, screenings appropriate for age, and an assessment of problems with treatment, if indicated. Of great importance is the establishment of the physician-patient relationship. Physicians become the primary medical resource and counselors to these patients and their families and the first contacts when successive medical problems arise.

Longitudinal care, the second component of primary care, implies continuity of care over time. Physicians assume responsibility for issues concerning health and illness. In pediatrics, such care involves monitoring growth and development, following school progress, screening for commonly found disorders, conducting psychosocial assessments, promoting health, preventing illness with immunizations, and providing safety counseling programs.

Family orientation, the third component of primary care, is a recognition that the provision of adequate care is dependent on viewing patients in the context of their environment and family. In pediatrics, a child’s problems become the family’s, and the family’s problems become the child’s. This has become increasingly apparent with the recognition that the social determinants of health (eg, problems of poverty, drug use, obesity, teenage pregnancy, and gang involvement), directly affect a child’s health and quality of life (see Chapter 141). The psychosocial forces in a particular child’s life are intricately interwoven into that child’s health care, and the assessment of these forces is an essential component of the primary care of that child. Environmental exposures (eg, lead contamination of the water supply) have a direct effect on a child’s health, and the primary care physician must have knowledge of those environmental threats.

The fourth component of primary care, integration of comprehensive care, involves the use of health and educational resources in the community to supplement care as a means of addressing the increased complexity of pediatric medical problems. Primary care physicians integrate and coordinate these services in the best interest of patients. Working with social service agencies, home care providers, educational agencies, and government agencies, physicians can use multiple resources for the benefit of patients. Understanding the available community resources is an important part of a primary care physician’s education.

Medical Home

When patients select a primary care physician, they have identified a medical home. The medical home incorporates the physical, psychological, and social aspects of individual patients into comprehensive health care services, thus meeting the needs of the whole person. This concept of the medical home was first documented by the American Academy of Pediatrics (AAP) in 1967 in the book Standards of Child Health Care, which noted that a medical home should be a central source of all the child’s medical records. The idea of a medical home developed into a method of providing comprehensive primary care and was successfully implemented in the 1980s by Calvin Sia, MD, FAAP, in Hawaii. He is considered to be the “father” of the medical home. In policy statements published in 1992 and 2002 (the latter reaffirmed in 2008), the AAP defined the characteristics of a medical home to be “accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective.” Geographic and financial accessibility are key elements in making that home work for patients. The most important aspect of a home, however, is that it be a place in which patients feel cared for.

Since its implementation in pediatrics in 2004, the medical home model was adopted by the American Academy of Family Physicians and the American College of Physicians. The definition of the medical home was expanded to include use of electronic information services, population-based management of chronic illness, and continuous quality improvement. The concept has been accepted as a form of high-quality health care. Cost and quality of benefits have been well documented. Recognizing these benefits, large corporations in collaboration with health professionals formed the Patient-Centered Primary Care Collaborative to promote the idea of designated medical homes. As part of that collaborative, the National Committee for Quality Assurance adopted eligibility criteria for a practice to define itself as a medical home. Requirements for the designation include the adoption of health information technology and decision-support systems, modification of clinical practice patterns, and ensuring continuity of care.

With the advent of health care reform in the United States, as part of the effort to control the rising cost of health care, the federal government has endorsed the concept of the medical home model. The Academic Pediatric Association has defined the family-centered medical home to delineate the dependency of the child to the family and community in the medical home model. This principle was highlighted in a consensus statement that was developed and jointly endorsed by the AAP, American College of Physicians, American Academy of Family Physicians, and the American Osteopathic Association.

Role of the Primary Care Pediatrician

As a primary care physician, the pediatrician has a role that has included not only the management of acute illness and injury but also the preventive aspects of well-child care with its focus on immunizations, tracking growth and development, and anticipatory guidance. Currently, there exists a renewed emphasis on the importance of the role of the pediatric primary care physician in assessing the psychosocial aspects of pediatric patients. Evaluation of social issues such as family dysfunction, developmental problems (including learning disabilities) and behavioral problems (including emotional disorders), termed the new morbidity by Robert Haggerty, MD, in the 1970s, has become a significant part of the role of the physician. In 1993, the AAP stated that pediatricians are obliged to have knowledge of physical and environmental factors and behaviors affecting health, normal variations of behavior and emotional development, risk factors and behaviors affecting physical health, and behavior problems. The focus of the pediatrician should be detection, evaluation, and management, with referrals if necessary. Newer morbidities secondary to the increasing complexity of our society were outlined in 2001 by the AAP. These include school problems, mood and anxiety disorders, adolescent suicide and homicide, firearms, school violence, drug and alcohol abuse, HIV, obesity, and the effects of the media on children. Other psychosocial factors, such as poverty, homelessness, single-parent families, divorce, working parents, and child care, necessitate that pediatricians work with social service agencies to deliver appropriate care to their patients. The role of the primary care physician is continually expanding in an effort to deliver comprehensive care to each patient in a medical home. This care is often rendered by physician-led teams that include other health professionals.

Subspecialist Care

Considerable advancement has been made in medical knowledge and technology in the past several decades. Total knowledge of all fields is impossible for any individual physician. As a result, the role of the subspecialist physician has developed as an adjunct to that of the primary care physician. New fields of subspecialties, such as child abuse pediatrics, have arisen as a response to increased knowledge. The primary care physician should seek subspecialist consultation when the suspected or known disease process is unusual or complicated, in cases that require the use of specialized technology, and in situations in which the primary care physician has little experience with the disease. Generally, subspecialists evaluate patients and concentrate on the organ system or disease process in their area of expertise.

Use of a subspecialist is termed secondary care. The primary care physician can elicit the help of a subspecialist in the form of a consultation or a referral. When initiating a consultation, the primary care physician seeks advice from the consultant on workup or management of the patient. The consulting physician assesses the patient with a history and physical examination, focusing on the particular specialty. The consultant recommends possible additional laboratory tests and offers a diagnosis and treatment plan, after which the patient returns to the primary care physician for coordination of further care.

Electronic, abbreviate...