CEHL:

Introduction and Overview

... for those who want to know more.

Mastering Pediatric Care in the Age of Healthcare Reform: Thriving in a Patient-Centered Model


An open letter to potential participants

Dear colleague:

We invite pediatricians, family practitioners, medical-pediatric physicians and pediatric nurse practitioners to participate in an educational program “Mastering Pediatric Care in the Age of Healthcare Reform: Thriving in a Patient-Centered Model.” Our goal is to enhance pediatric practitioners' confidence in providing psychosocial assessment, management, and referral for children and families.

This is the fourth year we have offered the program, and most past participants have found it very useful; some have found it transformative. For each monthly meeting, we invite an expert to discuss topics related to psychosocial pediatrics. Topics will include: utilizing reflective listening and empathic interviewing skills; understanding the role of family systems; the diagnosis and management of childhood depression; the art of the therapy referral; professional boundaries, and other issues specifically related to building a comprehensive psychosocial skill base.

In an effort to utilize these skills, each participant will present a case from their practice. In preparation for the case presentations, participants will receive consultation and clinical supervision from course leaders. Course participants will discuss these cases, and consider ways to help parents and patients to address the issues that arise. Course participants will also participate in a day-long training, "Difficult Conversations in Primary Care Pediatrics," co-sponsored by the Institute for Professionalism and Ethical Practice at Boston Children's Hospital. This training uses the PERCS (Program to Enhance Relational and Communication Skills) collaborative relational learning model.

When parents express worry that their child or adolescent may have an emotional or psychosocial problem, or when pediatricians/practitioners identify such problems, we will encourage course participants to invite their patient and/or family members to return and meet with them for a fifty-minute interview and to present information from that interview with the CEHL group. As a result of such an interview, we anticipate course participants will come to more clearly understand how the patient's problem came to be and how to develop a plan for management and support.


What have we learned from our earlier courses?

  • When we provide parents with sufficient time, a sense of curiosity, and significant empathy, parents can be great storytellers and can teach us much about how the problem arose.
  • Our work in psychosocial pediatrics requires more than just skillful interviewing. It also requires significant self-awareness, a sense of caring, and good boundaries.
  • Through skillful interviewing, we gain a better understanding as to "who is the real patient." The real patient might turn out to be another family member.
  • When taking a three-generational history, we may discover the presence of a family secret, such as alcoholism in one or more family members.
  • As parents develop a sense of trust in their pediatrician, they may then be able to share their personal histories.
  • We try to help parents not only solve present problems but also prevent future problems. Parents may also be able to ask for help earlier than in the past, not only of us but also of the wider community.
  • We may also be able to help parents overcome their fear of stigma resulting from asking for help with an emotional problem, either in their child or within the family.

From data gathered in our previous CEHL courses, we have worked to show insurers and health systems that, in the best kind of medical care, mental/psychosocial/behavioral healthcare deserves parity and reimbursement equal to the physical healthcare we provide. We continue to work to help insurers and health systems to acknowledge that psychosocial stressors are a contributor to physical symptoms and overall health care outcomes.


Impact of Rosie D legislation on the need for Massachusetts pediatricians to screen for emotional problems

As a result of the Rosie D legislation, every Massachusetts pediatrician who is a Medicaid (MassHealth) provider must screen for psychosocial problems in children. Many insurance companies and other third-party payers now require such screening. If pediatricians check out the Rosie D website, they will obtain further details.

Identification of behavioral problems on a checklist may be one approach for pediatric practitioners in terms of identification of areas of concern. But is there an alternative, more comprehensive approach, beyond identification only. The approach utilized will depend on the motivation of the physician/practitioner--i.e., assess and refer or become a skilled patient advocate.


The CEHL (Children's Emotional HealthLink) approach

Consider the benefits some pediatricians (and the families with whom they work) might derive by being willing to ask a family to return when the pediatrician identifies subtle concerns in the context of a well-child visit. Such benefits might include:

  • Diagnosing emotional problems in children at the earliest possible time.
  • Focusing on the entire family and not just the child
  • Reflecting as pediatricians, "Who is the real patient in this family?"
  • Asking parents, "What are your worst fears? Whom does he remind you of?"
  • Pediatricians thinking about how their own issues may facilitate (or interfere with) understanding the family dynamics more clearly
  • By understanding family functioning better, we may be able to reduce our dependence on medicating some of the children we see.
  • Improving parents' capacity as decision-makers, including esteeming them as our teachers, in their role as storytellers
  • Always being mindful of how family secrets, including mental illness, domestic violence, and the addictions, may be passed on from one generation to another.
  • Appreciating the role of the routine office visit as having the potential of becoming a corrective emotional experience.
  • Becoming aware that "spending time" can actually save time and increase our efficiency
  • Knowing that not every parent is psychologically-minded and that it takes time to build trust
  • Offering support, understanding and empathy as a valuable intervention
  • Finally, understanding that "half of therapy is preparation for therapy" and that pediatricians should value their strategic role in helping patients and their families follow through with mental health referrals


Conclusion

The above discussion represents some of the core beliefs which the leaders of this course intend to encourage among our participants.

Not every physician/practitioner desires to learn more about the emotional development of the children and the families for whom they provide care. Accordingly, they may not choose to enroll in this course. And, even among those who do, they may not wish to embrace all of these core values. We accept that there are variances in skill level, experience and motivations to participate.

However, the leaders of this course wish to share with those who are interested what we plan to convey during the twelve months of this course. For those who review the preceding comments, we will do everything we can to incorporate these concepts into the hearts and minds of all of our participants.

For additional perspectives, we invite you to look at the comments from previous course participants on this website.

Sincerely,
Howard S. King, MD, MPH, FAAP
Elizabeth A. Rider, MSW, MD, FAAP
Julia Swartz, SW, LICSW, CEIS

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Support

I would like to thank the following for their generous support, without whom this web site and training program would not exist: The Sidney R. Baer, Jr. Foundation, The Alden Trust, the Commonwealth of Massachusetts Department of Mental Health, Project INTERFACE (Newton Public Schools and the U.S. Department of Education), the Locke Educational Fund at Newton- Wellesley Hospital, Aetna Health Plan, the Kenneth B. Schwartz Center,  and the families of my medical practice. 

I hope you find this site useful and encourage any comments.


- Dr. Howard King, M.D.