Philosophy of Pediatric Primary Care

Carol Green-Hernandez PhD, FNP-C

Daniel Z. Aronzon MD, FAAP

Joanne K. Singleton PhD, RN, CS, FNP

INTRODUCTION

Pediatric primary care practitioners are specialists; they specialize in primary care. They specialize in health maintenance and disease prevention. They specialize in the education of new parents, the development of parenting skills, and the identification of intrafamilial stress and conflict resolution. They specialize in the care of primary complaints in children such as colds, fevers, earaches, sore throats, coughs, rashes, and minor injuries. They are specialists in managing the child with chronic disease, coordinating multispecialty and multidisciplinary treatment regimens, and preserving the family unit as the ultimate support group. Children are not little adults. Well informed pediatric primary care specialists know more about the causes, microbiology, presentation, diagnosis, intricacies of management, and prognosis of middle ear disease in children than the ear, nose, and throat “specialist.”

Today’s pediatric primary care practitioners come from various educational disciplines, backgrounds, ethnic groups, and cultures. The field still includes traditional medical practitioners in pediatrics, family practice, general practice, emergency medicine, and (for adolescents) obstetrics and gynecology. Over the last 35 years, individuals from the nursing profession also have joined pediatric primary care, so the field now includes certified pediatric, family, and neonatal nurse practitioners. Allied health professionals include physician assistants in various disciplines, psychologists, licensed social workers, audiologists, nutritionists, and physical, occupational, speech, and language therapists. Even more recently, practitioners of alternative and complementary medicine have become active in primary care. The settings for pediatric primary care are varied as well. Solo practices, single and multispecialty groups, public and private clinics, academic teaching centers, regional centers and small community hospitals, and rural and inner city facilities create a panorama of locales in which children receive primary care.

All pediatric primary care specialists realize that successes and failures in outcomes ultimately depend on the child’s environment. On a “macro” level, society must do more to value its most important yet most vulnerable citizens. On a “micro” level, children must receive treatment within the context of their families. By creating a caring environment in which they clearly and effectively communicate health messages and where they support children and families in developing care-of-self skills, pediatric specialists may find that such practice yields positive outcomes. This chapter outlines methods for creating an environment that focuses on caring, communication, and care-of-self as tools for successful pediatric primary care.

CARING

The principle of caring in primary care is family focused, wherein the family and the primary care provider work in partnership to the greatest extent possible. This vision allows family members to be coparticipants in selecting and testing their health care plans, helping to ensure their continued involvement. The deliberate use of caring as an intentional therapeutic model can increase positive health outcomes. The clinician needs to use a holistic perspective, focusing on what the child and parents need not just physically, but also psychologically, spiritually, and emotionally.

Culturally Sensitive Caring

Because the intentionality is holistic, primary care based on professional caring necessitates a culturally sensitive approach, starting from the first moment of each family encounter. Most westernized countries are becoming increasingly diverse; so, too, are the populations that pediatric primary care is serving. This fact requires all practitioners to be culturally aware about what assessment and intervention strategies will work best to meet health care needs across cultural boundaries. Deliberate, culturally sensitive caring is especially important because western society is time-obsessed. For primary care providers, the time-driven demands of managed care further compound personal and professional demands. Issues of time are less troublesome when the clinician and family share a common language and customs, such as the handshake as a greeting, use of direct eye contact, and open discussion of “sensitive” topics, such as sexuality. When cultural norms and expectations differ, providers can quickly express caring through a simple touch on the arm, eye contact, and sitting kitty-corner rather than across from the family or separated by a barrier (eg, a desk or an examining table). Similarly, providers maintain professional caring when they do not break communication (both verbal and nonverbal) with the child and parents even when they are using a translator. All these measures can convey that the clinician is aware of and present for the family.

For the family whose culture would consider “getting right to the point” as rude or for whom language is a barrier, providers can express caring in other ways. For example, when working with Latino patients, Fontes (2000) suggests that professionals try to be helpful as soon as possible. The author asserts that providers should demonstrate caring and allow more time to build relationships with Latino clients. Providers can enhance these measures by increasing their knowledge of Latino cultures. Such involvement, however, requires time. Providers can simply and efficiently reconfigure the ongoing need for time—to acknowledge the humanity of the child and family, to build relationships, to be caring—through a calm and caring presence.

Coparticipative Relationships

The giving and receiving of caring require both provider and family to communicate their needs openly and honestly. The goal is a coparticipative relationship, in which both practitioner and family are equal members, with equal voices and
equal responsibilities. This situation is the ideal, but sometimes the reality of developing and nurturing an open, coparticipative relationship with a child and family is impossible if they are unable to share this vision with the provider. The clinician must strive to support the family’s participation in making and following the prescribed therapeutic regimen to the extent that circumstances allow. When efforts to support family functioning are successful, both provider and family are coactualized. That is, the very fact of giving and receiving caring inevitably changes both parties. Caring as a mutual experience helps both family and clinician to evolve as human beings.

The growth that derives from a caring, coparticipative practice means that the clinician collaborates with rather than controls the child and parents. Achieving this vision is a special challenge within the managed-care model and its accompanying constraints (eg, 10-minute office visits). The organized, formalized practice of primary care framed by the professional caring model requires that the clinician learn both how and how best to practice caring as a generic professional skill (Green-Hernandez, 1991a; 1991b; 1992; 1996; 1997; 1999).

Really listening to what families say and do not say is an important means of expressing caring. Doing so validates the importance of what the child and parent think is wrong or is needed. Taking a brief moment to inquire about how things are going at home, school, and with friends is not only important to history taking, but also helps to build a relationship. The provider can further these efforts by remembering to follow up at the next visit about what families previously shared. This work helps to forge links and build relationships between practitioner and family members.

Validation

Caring requires time and energy. Intentional, professional, therapeutic caring mandates that the provider be involved with the other person. The giving of caring, however, cannot be a one-sided effort. It must be reciprocal. The ability to continue to give professional caring depends on receiving caring in return, which validates the clinician as a human and as a professional who is deliberately trying to improve primary care through caring practice.

The continued ability to give caring depends on the provider’s caring energy level. Validation is key to perpetuating this level. Receiving caring from people other than children and their parents can help providers to replenish the necessary energy reserves. Personal and collegial relationships that are marked by mutual caring and respect reinforce this cycle. Professional caring partnerships with colleagues provide a source for constant renewal. The support derived from collegial caring can fuel the sheer energy needed to practice primary care, with professional caring as the foundation for its delivery.

COMMUNICATION

Patients cannot perceive caring if it is not communicated to them in a way that they can understand. Communication is key to effective primary care, whether in taking a history or providing anticipatory guidance. However, communication is not a simple process. The provider must be aware of several important concepts to communicate effectively with children of differing ages and their parents. The health care practitioner with good communication skills and techniques will enjoy improved outcomes, enhanced satisfaction, and a greater likelihood of financial viability and success. This section provides a framework for understanding and practicing effective communication in primary care pediatrics.

Communication, Quality, and Success

Mrs. H., a harried mother of four, has spent 30 minutes in a crowded waiting room, supervising her children, before a pleasant but uninterested LPN ushers her family into the examining room. Alex, her youngest child, has had a fever for 2 days. Dr. X enters the examining room, asks about the history, examines the child completely (albeit quickly), pronounces, “It’s just a virus,” and exits.

Was this care appropriate? From a strictly scientific viewpoint, the answer is yes. A history and physical were performed, and the correct diagnosis was established. Does this care represent quality? What are the possible results of such an encounter?

Upon returning home, Mrs. H. realizes that she did not understand what was wrong with Alex. She phones the practitioner. The explanation still is lacking. When Alex begins to run another temperature, Mrs. H. rushes him to the emergency room. Once there, after another long wait, the health care team evaluates Alex, draws blood, and obtains a chest x-ray. Results come back normal. The emergency room physician makes the diagnosis of upper respiratory infection and prescribes amoxicillin “to be safe.”

What is the cost of this encounter to Mrs. H., to society, and to Alex, who has had an x-ray and blood work and is now taking an unnecessary antibiotic for 10 days? What is the likelihood of Mrs. H. returning to Dr. X’s office? What is the likelihood of Dr. X surviving in practice? These questions are all obviously rhetorical. Clearly, however, the lack of effective communication during the initial primary care encounter adversely affected the family in this fictional scenario. More effective communication between clinician and family can and will result in better care, as defined by improved outcomes and higher satisfaction rates for both patients and providers.

Traditional View of Quality

Communication that improves outcomes enhances the traditional view of quality, defined by such things as accurate and prompt diagnoses and safe and effective treatments. Effective communicators will be more likely to ensure the patient’s participation in designing a therapeutic plan, cooperating with treatment regimens, and returning for necessary follow-up. Providers practicing in the public sector, whose patients may represent a “captive audience,” will reap the rewards of improved outcomes but equally important, will derive greater professional satisfaction. Similarly, clinicians whose practice is in the private sector will likely see improved outcomes linked to a stable base of patients. When people feel that their providers listen and treat them with care, they are more apt to choose to continue with such clinicians despite the vagaries of managed care.

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