Residential Lead-Hazard Interventions, Childhood Anxiety, and Cognitive Impairment

Abstract

In Reply We thank Loud and Shipman for their insightful response to our Viewpoint, "Consumerism, Innovation, and the Future of Pediatric Primary Care." 1 In our piece, we argued that our system of pediatric primary care must innovate to avoid decline, a possible future suggested by 2 complementary theories from the business literature, creative destruction, and the innovator's dilemma. 2,3 As a starting point, we suggested that supporting team-based care, improving access and efficiency for consumers, and implementing telehealth as a part of the medical home would provide 3 ways to begin to reshape practice.Loud and Shipman present an alternate perspective, arguing that pediatricians should primarily serve children with medical complexity, acting as consultants to nurses, advanced practice clinicians, and family physicians. This vision is one piece of the future, but incomplete. First, based on the innovator's dilemma, ceding routine child health care to nonpediatricians outside medical homes would only build the expertise and financial resources of groups that compete with the medical home, potentially hastening its decline. The expertise of the pediatrician to manage complex care should complement the work of other professionals, including nurse practitioners, while keeping care and revenue within the medical home. Second, from a patient perspective, families with all levels of medical complexity highly value their relationships with pediatricians. In an unpublished survey we completed during the past year with nearly 1000 parents in our region, we found that pediatricians remain the most influential source of health information. We should leverage that trust in building a primary care system inclusive of community and crossprofessional partnerships. Third, we found in our survey that the most salient parenting challenges today include behavior problems, diet and nutrition, sleep, social media overuse, peer relationships, and stress. These findings and the confidence that families have in pediatricians suggest that the primary care medical home should grow its capability to address these wellness concerns, not retreat to a narrower focus on complex illness. Pediatrician collaboration with nonphysicians, including psychologists, social workers, nutritionists, and others, will be key to a future that builds a medical home proactively supportive of wellness.Loud and Shipman also stress the importance of primary care pediatricians increasingly covering for the predicted subspecialist shortage and the need to creatively train the pediatric workforce for that role. We agree with their vision. However, we believe that not only training but also changes in practice structure are needed to realize this vision while avoiding burnout of the health care team. In our network, the development of practice pathways and the provision of electronic health record-based tools with the support of specialists but without further system change often has been inadequate to improve primary care's capacity to address specialized concern...