Riding Shotgun

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.

Research that agrees with my anecdotal observations and supports my nonconforming practices always warms my heart, so the lead article in the December issue of Pediatrics really got my old cockles cooking.

After carefully evaluating 42 preventive interventions recommended by at least two national organizations concerned with child health, the investigators concluded that “limited direct evidence was found to support” these recommendations. So many interventions have been recommended and mandated, they also observed, that implementation of an unsupported recommendation by pediatricians could actually be harmful because it may displace “other beneficial activities” (Pediatrics 2004;114:1511–21).

What a bold and long overdue observation. Over the past 30 years, well-meaning groups from every nook and cranny of the child-oriented world have recommended that we pediatricians invest our hard-earned reputations and precious time promoting their pet ventures. It's time for us to say, “Whoa! Let's see if what you're asking us to do works.”

Even if the majority of these recommendations were well supported, their overwhelming volume would make implementation impossible even by the most efficient practitioner. When unproven interventions become mandated by state laws and regulations, those of us who dare to ignore them are vulnerable to financial penalties and, even worse, professional censure.

Obviously, this situation represents a serious challenge to our profession. We must demand that, regardless how valid they sound, all recommended interventions be evidence based.

Good research takes time, though, particularly when some of the outcomes may not be measurable until our patients reach adulthood. So what should we front-liners do for the next few decades while the researchers are gathering the evidence?

We must change our attitude toward well-child care. Health maintenance visits should be parent- and patient-driven. For too long, we and the committees that coach us have been writing the agendas for these visits.

This paternalistic attitude ignores the basic truth that our patients and their parents know best what is troubling them. Occasionally, we may need to help them articulate and focus their concerns, but it is the families and not the committees that should be writing the script for well-child visits. It's time for us to slide out from behind the steering wheel and begin riding shotgun. From our new seat on the passenger's side, we must keep our eyes on the road ahead and be prepared to warn parents when we see potholes in the path they have chosen.

We must replace our committee-driven interventions with open-ended questions that signal to parents that we are concerned about what concerns them. Then we must patiently wait for their answers. Instead of asking every family if they keep a gun in the house, we must become experts at reading body language and listening to the answers of simple questions like, “How are things going? Is your baby happy? Are you happy?” Dialogues that build on these open-ended questions will create the framework of a more valuable well-child visit.

If the parent is experienced and voices no concerns when offered the opportunity to express them, the visit may last just long enough for a good exam (though we may even find that part unnecessary) and some immunizations.

On the other hand, our apparent willingness to listen may encourage the depressed mother of a toddler to share her secret that she has been abusing the child. A well-child visit cannot be a one-size-fits-all event fabricated from a collection of committee-made parts.

We must acknowledge that the most important component of well-child care doesn't occur during the health maintenance visit. The three critical elements in keeping a child healthy are availability, availability, and availability. Parents already believe that pediatricians know a lot about children. Our challenge is to demonstrate that we care about their concerns and are eager to answer their questions not just at well-child visits, but at any time. An illness can be an excellent opportunity to get to know more about the patient and his family and to make it clear that we are good and concerned listeners.

It sounds like the medical home is the answer again.