The Family Tree of “General Pediatrics” Where is it Going? Thomas F. Boat, MD Professor of Pulmonary Medicine Cincinnati Children’s Hospital Medical Center Executive Associate Dean for Clinical Affairs University of Cincinnati College of Medicine

General/Community Pediatrics Evolution Differentiation Cohesion Leadership

J 1980sUNC History Tree 1990s 2000s 1960s 1970s Iowa Minnesota Rainbow CCHMC

Connecting Science and Service Innovation Translation Basic Science

Basic Science 1.Psychology health-related behaviors motivation prevention 2.Sociology cultural barriers poverty 3.Engineering systems redesign standardization information systems

Basic Science (continued) 4.Economics cost : benefit affordability 5.Law/political science/government regulatory milieu legislation advocacy 6.Business business plans marketing human capital outcomes

Basic Science (continued) 7.Epidemiology magnitude of health problems longitudinal tracking 8.Biology human genetics environmental pathobiology

Connecting Science and Service Innovation Translation Basic Science

Prediction Translation/Practice Innovation

Prevention Elements 1.Defining problems 1.Identifying risks 1.Reducing risks 1.Intervening early

Prevention 1.Universal 2.Selective 3.Indicated

Emotional And Behavioral Problems 1.25% of pediatric visits 2.20% of 0-18 year olds (cross-sectional) 3.40% of 0-18 year olds (longitudinal) 4.Enormous cost 5.No systematic response

Screening Sites For Risks 1.Primary care 2.Schools/day care Risk Reduction

Risks For Emotional And Behavioral Problems (Evidence-based) 1.Parental mental disorders 2.Exposure to violence; neglect 3.Divorce 4.Death of parent 5.Harsh parenting 6.Bullying 7.Foster care 8.Catastrophic events 9.Poverty 10.Chronic disease

Screening and Early Interventions 1.Tools 2.Model programs 3.Can this approach be incorporated into practice?

Barriers to Screening 1.Time 2.Unreimbursed cost 3.Inability to assess, intervene How do we surmount barriers?

Prediction Translation/Practice Innovation

Prediction 1.Genetic factors 2.Environmental exposures 3.Psychosocial experiences

Adverse Childhood Experiences (ACE) Study (Felliti, Am. J Prevent Med 14:245, 1998) Cohort: 17,421 adults in the San Diego Kaiser Permanente system (68% of eligible adults) Measures: A. Recall of 8 adverse childhood experiences 1) recurrent physical abuse 2) recurrent emotional abuse 3) sexual abuse 4) family member who was alcoholic or a drug abuser 5) imprisoned family member 6) depressed family member 7) mother who was the target of violence 8) separated or divorced parents B. Health assessment (average age = 57)

Adverse Childhood Experiences (ACE) Study (Felliti, Am. J Prevent Med 14:245, 1998) fold increased risk of alcoholism drug abuse depression suicide Adults who reported 4 or more types of ACE had:

Adverse Childhood Experiences (ACE) Study (Felliti, Am. J Prevent Med 14:245, 1998) fold increased risk of smoking poor self-related health sexually transmitted diseases 3.An increased risk of obesity ischemic heart disease cancer COPD skeletal fractures liver disease

Prediction Translation/Practice Innovation

Pre-emptive Health Plans 1.Individually tailored 2.Risk-specific interventions education modification of health behaviors self-management support systems - action plans - monitoring

Prediction Translation/Practice Innovation

Health Services Delivery 1.Shortfalls in safety, effectiveness, efficiency, equity, access, family/patient centeredness 2.Opportunity for leadership Intervention design Outcomes measurement Implementation - community practice - home Defining and enhancing value Influencing public policy Redesigning payment systems

QI Research Methodology 1.QI methods 2.Application and interpretation of quasi-experimental designs 3.Systematic reviews and meta analyses 4.Implementation of RCTs

Connecting Science and Service Innovation Translation Basic Science

Should General Pediatrics Continue To Differentiate? 1.It’s inevitable 2.Heterogeneity is desirable 3.Foster collaborative efforts 4.Be the conduit, cohesion factor for child health programs that span discovery to implementation

Leadership Not empire building Creating shared vision Enabling an array of stellar contributions

Visualize the Whole Tree Add branches (leadership) Sprout many leaves (training) Reach toward the sky