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Pediatrics and the Medical Home

By Carol Duh-Leong

During my first week on a pediatric outpatient clinic as a third year medical student, I spent an average of 140 minutes caring for each patient. Looking back at that first week, the amount of time I spent with each patient ranged from a “brief” 79-minute visit to one whopper 188-minute visit where I reviewed several journals in the workroom and sought two attending physician opinions to be completely sure. After this ordeal, I pronounced that the baby most likely had a URI or the common cold, and would get better in a few days with fluids and rest.

As training for my upcoming third year clerkships, I took a physical diagnosis course that taught me a thorough history and physical should take a physician close to two hours. The third year bridge between what’s taught and what’s real reassures students that “First you do it right, then you do it fast.” Sure enough, as I gained experience through the rotation, my patient visits shortened as I became more confident that the kids I sent home with the sniffles were not secretly harboring a life-threatening meningitis and I could relax.

However, the most pronounced distinction became clear when I began to see patients in the office for the second time. The amount of time I spent dispensing care that second time dramatically cut to half or even a third of the patient's original visit; my familiarity with the child’s past medical history allowed me to skillfully direct my questions and physical exam. Everything from my prior understanding of when mom likes to dispense medication to which ear the child likes to be examined first allowed me to not only be a better provider but a faster one.

The chief principle of a medical home is to build a system around continuity and coordination. The American Academy of Pediatrics first introduced the concept of the medical home in 1967, and the definition is simple. It is an approach to comprehensive primary care that facilitates partnerships between patients and personal providers. One study cites that if we were to implement this model, “health care costs would decrease by 5.6%, resulting in national savings of 67 billion dollars per year.” 

The benefits are not only financial, but also for quality. A CDC study from 2007 found that continuous primary care in a medical home was associated with higher rates of vaccinations. Improving preventative care measures will save more money and more lives than any surgical miracle we can devise.

As we walk through the stages of health care reform, we must establish and honor the principles that we value as we implement these new systems. The value of continuity of care is priceless. Continuity between doctors and patients facilitates everything from patient comfort to provider efficiency. Strong relationships allow providers to quickly integrate new information and recommend decisions based on a more sophisticated understanding of the patient’s perspective. 

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