What does a perfect pediatrics practice look like?

I had a phenomenal day in clinic yesterday. Imperfect for sure but inspiring, connected, and busy. I felt useful and like anybody else, that feels so good to me. Productivity can be defined in various ways and yesterday I fulfilled my personal definition. I wrote an email to a friend and cardiologist this morning where I said, “But I must say, it’s a sincere fortune to be a doctor some days. Yesterday was one of those …”

It was typical day in the sense that my schedule was crammed full of well child check-ups, newborn visits, and a few scattered visits for acute care–colds, depression, and belly pain. As is typical, I arrived in the morning with absolutely no open spots on my schedule. I saw 25 patients, squeezed in 2 patients to “double book” who needed to be seen by a pediatrician more urgently, and we provided vaccination updates for over 1/2 the patients. The “productive” feeling washed over me a number of times. At one point a mom said, “I knew that but I just needed you to guide me to know that I was right.” Another moment when I confirmed the correct diagnosis for a patient who’d been into doctor’s offices twice where the diagnosis had been missed. It’s exhilarating to help people understand health, highlight their understanding of science, and calm them down. Parenthood can be extraordinary (understatement of the century). The best part of my job is when I can help clear off the windshield of doubt. I do want parents to see the road …

But the day wasn’t perfect.

  • I ran behind at a few points due to complexities in care and conversations that extended past the allotted time.
  • The computer had to be restarted in exam room #4 three times, once because I hit the wrong button at login, another 2 times for reasons beyond me.
  • For another patient, the handout I’d printed out at the end of the visit was for a 2 month-old while the baby was 4 months-old. Wanting the family to have the correct information and links, the entire note needed to be regenerated in the EMR. Another few minutes delay and likely a sense of patient distrust.
  • I’m also certain that I didn’t answer every single question from every single parent. I would suggest it’s impossible to do so when you see over 20 patients in a day, all the while answering phone calls, speaking and coordinating care for patients not in the office with outside specialists, filling out school forms for taking Benadryl or playing sports, and assisting the medical team to triage and communicate with families.

Meanwhile, my email inboxes piled up. Twitter (of course) sat silent, the blog was ignored, and my stomach growled. Regardless, it was a day in pediatrics that filled me up (I felt helpful).

Today, I’m reminded how much better this can be. In my heart, I want to be available to my patients all of the time, but for reasons of practicality and self-preservation, I’m not. Social media helps by allowing me to share and listen out of the exam room, but it isn’t a cure-all for obvious reasons. Social media just isn’t set up for personalized health care–that precious partnership with a clinician we all want. I believe a more perfect practice is coming.

Perfect pediatrics looks something like this:

  • Availability. I have open appointments in my schedule every single day for acute medical issues for patients that consider me their pediatrician. I imagine perfect availability boosted by easy access to scheduling (no sitting on hold for 20 minutes). I see it like this: a parent can wake up, realize that they need their child to be seen, go online to book an appointment or chat with a nurse, and come in to see me (or my nurse partner) the same/next day.
  • Online advice and content. I have an up-to-date online repository of health information for families to browse and review pediatric health information when necessary. This would include videos and written content on every single vaccine we give, developmental milestones for every wellness check we do, information on every medication I prescribe, links to AAP, CDC, or leading health institutions’ health guidelines, and parenting content that helps families navigate the web intelligently. There would be directions to credible websites on buying car seats or finding coupons to do so, buying diaper cream, using and dosing anti-fever medications, and stories from wise families detailing how they made decisions raising their children. We’d highlight disease-specific groups where families can connect with other families challenged by similar circumstances or similar medical conditions. And there would be stories from my practice panel that could be shared: we all want parent “pearls”–clips from families looking back at the things they would do if they did it all again–so those would be there, too. Instead of sharing this content over and over and over again each day, it would be produced over a series of months to fill the need for families and avoid redundancy for clinicians.
  • Team. My patients would be cared for by a team committed to them. Nurses, schedulers, lab technicians, and medical assistants who know them, care for them at each visit, and coordinate their care between visits or with specialists. Many visits for preventative pediatrics can be completed by someone other than me, and my patients would have access to the same set of of team when they needed a nurse visit, a school form completed, a growth check, or a reminder to return for a booster shot. The team would all have access to the family’s email or cell phone so they could reach families in opted to be contacted. This team would galvanize sincere partnerships between health care and family.
  • E-visits, video-visits and two-way communication. A practice where all of my patients have access to me at reasonable intervals of time from the comfort of their home. I imagine functionality where families can stream 1-minute question videos asking for guidance or diagnoses, and where I can respond with 1-2 minute video answers. Further, I imagine a practice where follow-up care is completed online or by phone or Skype-type encounters. Where teens can follow-up on their depression from their smart phone and where they can get their HIV results by text. I imagine visits where we value each others’ time and geography appropriately.
  • Payment. A perfect practice has payers and insurers valuing what is most precious in a medical home–expertise, personal care, time, and follow-up. Perfect includes support for content online–where advice for prevention is paid for upon completion or in global billing charges, where a visit that takes 15 minutes by phone is reimbursed at the same rate as one that takes 15 minutes in the office. More generically, a payment structure where as a physician I’m incentivized to provide professional, efficient care at the highest quality. And where I’m not incentivized to bring patients into the clinic when unnecessary. Where I am incentivized to reach my patients in ways they prefer. Even more perfect, a system that values the time it takes to communicate and utilizes the technologies of our time to make it happen rapidly.

I’ll work to make this happen. You tell me what problems you see as a parent, patient, or clinician with my schema. Imperfect on course toward perfect. Watch and see …

Wendy Sue Swanson is a pediatrician who blogs at Seattle Mama Doc.

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