Medical News: Looking past on the last year, how has the healthcare system changed and what is the physician community doing to adapt?

Julia Richerson, MD: In the field of pediatrics, the biggest change has been an evolving recognition of the contributing factors to child health, and the implications of this for children and families in Kentucky. As pediatricians we must articulate, in an adult dominated healthcare delivery system, priorities for healthcare delivery and access for children.

The evidence is clear. One in four of Kentucky’s children have a chronic illness or special healthcare need. Children have asthma, ADHD, developmental delays, congenital heart disease, autism spectrum disorders, obesity, long term complications related to prematurity and other very common situations that challenge the healthcare system’s capacity. These children and families need and deserve a system of care that respects them and provides and pays for care that this family centered and comprehensive, and leads to optimal health outcomes.

In the last year the healthcare system is starting to understand that we can no longer continue as we always have, because we now know about the impact of childhood adversity and resilience. We cannot continue to deliver healthcare in a way that ignores the role in children’s lives of poverty, food insecurity, childhood abuse and trauma, housing instability, health inequity and the challenges that many children and families face. And we can no longer ignore the critical importance of resilience and building family’s strengths and our role in this as the healthcare system, and how crucial it is for the health and resilience of a family to have adults insured with secure access to healthcare.

In our role as pediatricians, we are speaking up for children and families and telling their stories, with hope that, as a healthcare community of providers and payers, that we can create a better system. We continue to try to provide the highest quality of care we can in our offices, and navigate the complex and inadequate system of care for children.

MN: What is the role of the Community Health Center in the healthcare system? How do you (and your physicians) approach the delivery of healthcare?

JR: Across the country Community Health Centers (Federally Qualified Health Centers/FQHC’s) are the healthcare safety net for primary care. More than 26 million people receive care at health centers across the country and Kentucky has outstanding centers all over the state, serving urban and rural communities including programs providing healthcare for the homeless, school based health centers, refugees and immigrants.

We provide primary care for people of all ages and also dental, behavioral health, health education, pharmacy services and other services that support people in their health and wellness. Our role in the healthcare system is first and foremost to provide high quality care to people who live in medically underserved communities, and to make sure that people without the ability to pay have access to care. Community Health Centers nationally and locally have led the profession of primary care for many years in our dedication to quality of care efforts, including tracking key health data and using quality improvement efforts to continuously improve in our health outcome measures. These are key elements of value based payment as well, and we have played active role for many years in partnership with payers to try to build payment mechanisms for the interventions that we know improve health outcomes.

As a pediatrician in a Community Health Center, I approach the delivery of care with a heightened awareness of the challenges that the children and families may face to be healthy and well. I and my colleagues always strive to provide patient and family centered care, partnering with people to help them achieve health and well-being. We try to understand the unique barriers and challenges and recognize strengths that each person may have in achieving health and wellness and strive as best we can to weave in the supports that they need to be successful. We value the relationships we are privileged to develop with our patients and their families.

MN: How do you address the social determinants of health with the patients you serve? How would you like to see the community address these?

JR: The issues that can impact health are almost endless. For people with adequate financial and social resources, achieving health and wellness can be very challenging. For families facing adversity and living with economic instability, the challenges to achieving health and wellness can be overwhelming. In my experience, partnering with children and families to create a trusting relationship is a key element in addressing social influencers of health. In the context of a trusting relationship I work in partnership with families to identify strengths and needs, prioritize and together come up with steps to meet current needs. Maybe linking family with food resources might be a priority one visit but the next the family may mention educational advocacy needs for their child. In between visits the family might contact the office asking about how to access a medication they cannot afford. Identifying and prioritizing needs is important, and learning how to help people address those needs can be very difficult as a busy pediatrician. I rely on several key community resources, like the Community Ministries, Centerstone, the WIC program, the Center for Women and Families and the Neighborhood Place services to refer families to, just to name a few.

However, I know that the families I work with have many more unmet needs than I can help with. Community services are important but housing, financial and employment security are vitally needed in Louisville and across Kentucky for everyone. This requires policy and leadership across the community at all levels, in all facets of our community. If you ask any community agency, they would like to be put out of business, with no members of our communities needing emergency food assistance or emergency housing, for example. As helpful as it may be for me to refer families to community services, it often makes just a small impact in the bigger context of their struggles. Our community must continue work in the areas such as affordable housing, safe and healthy neighborhoods, better schools and livable wages that keep families and children strong.

MN: How has the practice of medicine changed over your career? How would you like to see it continue to change?

JR: I often discuss with my contemporaries, who have been in practice for 20-30 years, about the changes we have seen. Technology changes in the last 5 years in the office with electronic health records is a big change. In medical school I had no interaction with computers and in residency we were introduced to email within the training program. Now, of course, I am on the computer documenting notes, reviewing outside reports, submitting lab and consultation requests and creating patient problem lists and other documentation that captures what I do in the office, then submit charges electronically to our billing staff. I use electronic resources to find patient education, to look up current treatments and research complicated diagnosis.

These changes in the use of technology have had both positive and negative impact on my ability to practice and fell effective I do not believe, however, that this is the most profound change I have seen in the practice of medicine since I started. Cellphones allow me to make call from anywhere, without having to find a payphone. Hospitalists care for my patients in the hospital now, allowing me more time to be with patients in the office. Fifteen years ago, I rounded on my patients before I went to the office and I was able to provide comfort and ease to families that I already knew well during a stressful time for their child in the hospital. I was up to date on aspects of medical care that I have since lost. Over the last few years I have also heard from pre-professional and professional students that they are being told by family and friends that medicine is no longer a rewarding career. They are being told that the headaches of practice aren’t worth the rewards of practicing medicine. I rarely or never heard that when I was looking at a career in medicine. Another difference is that when I trained, our expectations of the work in primary care were maybe different from today. We knew that we would be working way more than 40 hours a week, nights and weekends to be available to our patients. I was trained that practicing medicine is a lifelong commitment to service, learning and advocacy.

MN: What are the biggest challenges to practicing medicine in KY? What are the benefits?

JR: I view the challenges and rewards in practicing medicine in two big categories–practicing medicine and the practice of medicine. Practicing medicine to me is the science and art of promoting health and wellness with individual children and their families. I enjoy exploring complicated diagnoses and physical findings. As a pediatrician, meeting parents of a newborn and seeing them every few months and watching them grow as parents is amazing. In Kentucky, as in many states, we have high child poverty rates and high rates of obesity and behavioral health conditions. Helping families be strong and children be healthy has very little to do with what I do in the office.

The practice of medicine- or the healthcare delivery system for children in Kentucky also is stressed because of those same issues. How does a system that depends on office visits, hospitalizations and hospital based procedures achieve good health results when the biggest things that determine child health are separate from the delivery system?

The biggest challenges also lead to the biggest rewards for me. To be able to help children and families who may be in need is a great honor. And in Kentucky, there are many families who are in need of help, respect and a compassion.

MN: What can Kentucky do to create a better environment for physicians?

JR: In Kentucky, the more we work together toward a patient and family centered, safe healthcare delivery system the closer we move to a good environment for physicians. I can provide better, higher quality of care in a health system that functions well, with well-educated and well-trained professionals, working in a work environment that is respectful, fun and rewarding. Health system owners and administrators, leaders in payment systems, health career professional education and training programs, and medical providers are in a chaotic environment that is changing every day, responding to external priorities and influences such as value based payment and electronic health record vendors to name just two. In Kentucky, it is time to take a few steps back and identify priorities that are best for the patient experience and the experiences of the medical professional and redefine what the delivery of healthcare should look and feel like, on our terms.