In the ever-changing fields of pediatrics and obstetrics, physicians must adapt constantly to political and economic pressures, which produce innovations in how patients receive care as well as new challenges in how physicians care for patients.
Several Mid-South medical professionals say they are faced with challenges resulting from new federal government mandates as well a shortage of pediatric subspecialists. In contrast, they affirm that there has been a shift for hospitals to offer more choices in the delivery room for women and more team-based care and health initiatives for children, which in some cases lower costs and hospitalization rates.
“There has been a shift in how we care for children,” said Jon McCullers, MD, pediatrician in chief at Le Bonheur Children’s Hospital and chair of the department of pediatrics at the University of Tennessee Health Science Center. “Pediatric residents are faced with different challenges than when I was a resident 20 years ago.”
According to McCullers, pediatric residents are spending less time with patients and more time entering data in electronic medical records (EMRs).
“There is so much documentation that is required now and residents are acting as scribes when they should be spending more time with patients,” McCullers said.
As part of the American Recovery and Reinvestment Act, all public and private healthcare providers were required to adopt the use of EMRs by Jan. 1, 2014 in order to maintain their existing Medicaid and Medicare reimbursement levels. Since then, the use of electronic medical records has spread.
According to Mark Heulitt, MD, medical director of the pediatric intensive care unit at the Spence and Becky Wilson Baptist Children’s Hospital, it can be cumbersome to collect and enter the data required, and the data aren't always shared easily across hospital systems.
“EMRs have forced medical staff to become more task-oriented than patient-oriented,” Heulitt said. “In theory it seems it would make processes more efficient, and they do provide a lot of data that physicians can access quickly, but the medical staff is overburdened to collect data and the data isn’t always available if the patient comes from another hospital system. This may result in repeating tests that may have already been done and can increase costs in the long run.”
On a more positive note, McCullers says pediatric residents are paying more attention to social determinants of health when treating a patient.
“Traditionally, we looked at determinants like genetics and family history to determine a child’s health,” he said. “Now we are looking at a child’s family environment and socioeconomic status.”
McCullers says another trend he sees is many residents opting to work part time out of residency.
The American Medical Association says 75 percent of pediatric residents are female, and according to the American Academy of Pediatrics, four out of 10 pediatric residents seek part-time employment after graduation.
“The majority of new pediatricians are female, and many choose to work part time during their child’s early years until their child goes to school and then they work full time,” McCullers said.
McCullers says that an additional trend on the rise is that 20 percent of graduating residents are becoming general hospitalists. A general hospitalist is a physician who cares for patients specifically while they are in the hospital.
“This area didn’t even exist 20 years ago, and we have seen an explosion during the past decade due to the shortage of subspecialists,” McCullers said.
McCullers and Heulitt agree there is a shortage of pediatric subspecialists, and there are various reasons even though all residents are exposed to a variety of subspecialty areas when training.
“Some subspecialty areas pay less than others, but I see a correlation between a resident and a strong role model,” McCullers said. “For instance, we recruited a renowned nephrologist at Le Bonheur, and in the past five years we have had six residents who want to specialize in nephrology. I feel a strong mentor and role model must be present for the resident to be interested in a subspecialty area.”
“There has been a growing shortage of doctors overall in the last 10 years,” Heulitt said. “This is due to the limited number of programs for residents which need to be increased to meet consumer demand. Pediatrics is underserved.”
With a shortage of subspecialists and advancements in technology, there has been a shift to more team-based care in hospitals, according to both McCullers and Heulitt.
“It’s become more common for physicians to group together to treat a patient, and technology is making it quicker and easier for physicians to communicate than ever,” Heulitt said. “I can consult with another physician through video or text very easily. A decade ago you had to wait for a physician to schedule to see a patient. Now, the physician can consult electronically.”
In addition to centralized care, McCullers has seen a trend in the decline of hospitalization rates in some cases due to various community health initiatives. One example is the Changing High-Risk Asthma in Memphis through Partnership (CHAMP) program at Le Bonheur.
According to Le Bonheur’s website, asthma is the cause of more than 3,500 visits to its hospital each year. Le Bonheur developed a healthcare coordination team to oversee pediatric asthma patients who are enrolled in the CHAMP programs. These community healthcare workers work to improve coordination of care between providers, teach better asthma self-management to families and engage the community in caring for high-risk patients.
“We want kids to be healthier and stay healthy, so they don’t have to go to the emergency room or hospital,” McCullers said. “We have seen a 70 percent reduction in hospital visits with the children who participated in the program.”
Also, Le Bonheur’s website says there has been a 56 percent reduction in asthma-related costs per child.
Additionally, new trends have been emerging in the Mid-South in obstetrics and gynecology. One recent trend is the addition of certified nurse midwives (CNMs) to community clinics and the hospital delivery room.
There are four CNMs at Regional One Health. According to Breia Loft, a certified nurse midwife there, she sees both obstetrics and gynecological patients who are low-risk with non-surgical issues.
“We can perform breast exams, deliver babies and consult with patients on hormone replacement therapy and general contraception management,” she said. “We offer another option for women. We can spend more time with the patient and help keep healthcare costs low.”
According to the American College of Nurse-Midwives, the professional organization for certified nurse-midwives, CNMs are registered nurses who have graduated from a nurse-midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME) and have passed a national certification examination to receive the professional designation of certified nurse-midwife.
“Regional One wanted to give women a choice to deliver how they want to deliver, and we wanted to provide patients with that option because it wasn’t available in the Memphis area,” said Angie Golding, director of corporate strategic communications at Regional One Health.
Aric Giddens, MD, OB/GYN, chair of the department at Baptist Women’s Hospital, says physicians now have access to more information and data than ever due to technological advancements in the delivery room.
According to Giddens, all OB/GYNs and medical staff follow the guidelines set by the American Congress of Obstetricians and Gynecologists, which is a professional association of physicians specializing in obstetrics and gynecology. These guidelines are updated constantly through a computer system so a physician can access them immediately when in the delivery room.
“Things happen quickly during labor and delivery, and a physician may not know the latest order set for a problem,” Giddens said. “Physicians can access it through a computer entry system. It is very helpful to physicians because it’s standardized, evidence-based data which is constantly updated. We must stay proactive and preventative, and this technology has assisted us in doing that.”
RELATED LINKS:
Spencer and Becky Wilson Baptist Children's Hospital
Le Bonheur Children's Hospital
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