The Fateful Call

“At 9:30 am last December 14, a fateful phone call interrupted the day of Newtown Connecticut pediatrician Laura Nowacki, MD, FAAP”, reported the July edition of AAP News.^1,2  “It was her office nurse calling to say a shooting just occurred at Dr. Nowacki’s daughter’s school. They needed to triage.” While the pediatricians in Newtown mobilized for emergency care on December 14, their subsequent leadership role in violence prevention, media engagement, and mental health care highlights the important determinants of child health that go beyond an office visit—they engaged a “system”. This blog entry explores some key questions surrounding systems-based practice.

What are Systems and Systems-based Practice?

The scientific concept of a “system” is based on the work of Bertalanffy³, ⁴ and can be thought of as a set of interdependent elements that collectively act as a whole to carry out a specific function.³ Systems thinking focuses on the properties of the whole (holism) and the interactions of the elements rather than the properties of the constituent elements (reductionism). Having been applied to biology, engineering, climatology, and many other disciplines, the systems approach is now making its way firmly into the clinical care of children.

Learning systems-based practice (SBP) begins in medical school and residency. The Accreditation Council for Graduate Medical Education (ACGME) program requirements have defined (SBP) as one of the six core competencies: “Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care”.

Read the ACGME Program Requirements in Pediatrics.

Pediatricians in practice may be the quarterbacks, but they can't do it alone; they need to work with the teams around them.

Although the competency approach to medical education has progressed steadily, SBP has been the most difficult to operationalize in practice.¹ The barriers are certainly real: inadequate support by payers, rapidly changing IT tools, and difficulty in developing the necessary partnerships and teams. However, the medical, social, and economic forces affecting both the patient and the pediatrician will only increase the importance of this competency in the future.

Why is Systems-based Practice Important to the Patient?

The morbidity and mortality for American children in the 21^st century arises mainly from complex chronic disease or injury. Both require systems-based practice for prevention and management.  While the scale of the horror in Newtown shocked the country, a dispassionate examination of CDC data in the figure below shows that unintentional injury, homicide, and suicide are among the top three or four killers of American children throughout most of childhood. As pediatricians, all of us either have been or will be touched by this in some way. Last year, AAP’s Council on Injury, Violence, and Poison Prevention outlined the evidence behind a series of systems-based practice recommendations to prevent gun violence.⁵

Complex chronic disease requires a system of accessible, comprehensive, coordinated care—a fact recognized by the growing number of patient-centered medical homes.

The widespread prevalence of racial and ethnic disparities among children with chronic illnesses only accentuates the need for a systems approach because disparities are multifactorial in origin with a complex interplay of genetic, socio-economic, cultural, and provider contributions.⁶

Why is Systems-based Practice Important to the Pediatrician and Society?

There is considerable debate about whether other healthcare professionals such as nurse practitioners should deliver primary care to children independent of physician oversight. Although the roles of the nurse practitioner, the pediatrician, and the other team members may vary depending on circumstances and the type of practice, the pediatrician is uniquely trained to integrate systems elements spanning from genome to the whole child to the society and environment in which the child lives. This is vitally important no matter the type of practice: urban, rural, private or academic.

The “ecobiodevelopmental” framework for early identification and intervention among children experiencing extreme adversity (eg, neglect, abuse, malnutrition, violence) and “toxic stress” is an example of a systems-based approach. It offers a scientific framework for how these types of adversity affect the neuro-endocrine and immune systems leading to higher risk not only of developmental and behavioral abnormalities but also cancers, asthma, and cardiovascular disease later in life. The pediatrician has the opportunity to apply this scientific understanding to the screening, anticipatory guidance, and referrals to community resources as well as policy education and advocacy.^7,8 If pediatricians limit their scope of involvement to the isolated medical encounter, the competition from other providers offering to provide the same care at lower cost is likely to increase.

From a societal perspective, pediatricians are in a position to impact future adult chronic illness and excess healthcare expenses. Adult cardiovascular disease (CVD) is a case in point. Current models forecast that adolescent obesity will increase future adult obesity and lead to more than 100,000 adult CVD deaths and increase healthcare expenditures by $254 billion by 2035.⁹ Pediatrician leadership in home and school-based interventions must be an essential component of the response to the childhood obesity epidemic.

What Does Systems-based Practice Mean for the ABP?

Although medical knowledge and patient care have been the traditional competencies assessed in the certification process, they are clearly not sufficient to assure the public of the high quality expected of a diplomate in the 21^st century.  In response, several pediatric organizations, foundations, and other groups have supported the incorporation of community pediatrics, population health, and systems-based practice into innovative residency training programs.¹⁰

ABP supports these efforts and has been able to incorporate some elements of SBP into its certification programs. As an example of Part 1 of Maintenance of Certification (MOC), ABP is one of many organizations to endorse the ABIM Foundation professionalism charter, which articulates principles of patient primacy and social justice, necessary elements in systems-based practice.¹¹ I am not the only one emphasizing the importance of SBP. Many pediatric groups around the country have formed quality improvement collaboratives (Part 4 of MOC) on SBP-related topics such as the family-centered medical home, obesity prevention and management, access to care, injury prevention, teen mental health, and more.  Finally, ABP led a working group of experts who have defined the SBP milestones that will become part of the indicators of a resident’s readiness for unsupervised practice.

Currently, SBP remains under-represented on certification exams. The task of constructing valid and reliable examination questions reflecting the systems-based practice requirements for violence prevention, obesity management, asthma disparities, toxic stress, and a host of other major child health problems will become easier as the evidence base grows and more and more residency graduates have received explicit training in these domains.  Ultimately, the child, the pediatrician and society will benefit. With sustained engagement, we can hope that events such as those at Newtown will become historical aberrations that spurred significant and lasting change.

This is what I think. Please let me know what you think by leaving a comment below.

David G. Nichols, MD, MBA
President and CEO  

1. Johnson JK, Miller SH, Horowitz SD, et al. Systems-based practice: improving the safety and quality of patient care by recognizing and improving the systems in which we work. In: Henriksen K, Battles JB, Keyes MA, Grady ML, eds. Advances in Patient Safety: New Directions and Alternative Approaches (Vol. 2: Culture and Redesign). Rockville, MD: Agency for Healthcare Research and Quality (US); 2008;2:321–30.
2. Wyckoff AS. Sandy Hook pediatricians share grief, advice, hope 6 months after tragedy. AAP News. 2013;34:1.
3. Bertalanffy LV. An outline of general system theory. Br J Philos Sci. 1950;1(2):134–65.
4. Bertalanffy LV. General Systems Theory: Foundations, Development, and Application. New York, NY: George Braziller, Inc; 1969.
5. Dowd, MD, Sege, RD; Council on Injury, Violence, and Poison Prevention Executive Committee. Firearm-Related Injuries Affecting the Pediatric Population. Pediatrics. 2012;130(5):e1416–23. Epub 2012 Oct 18.
6. Berry JG, Bloom S, Foley S, Palfrey JS. Health inequity in children and youth with chronic health conditions. Pediatrics. 2010;126(Supplement):S111–9.
7. Garner AS, Shonkoff JP; Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, and Section on Developmental and Behavioral Pediatrics. Early childhood adversity, toxic stress, and the role of the pediatrician: translating developmental science into lifelong health. Pediatrics. 2011;129(1):e224–31. Epub 2011 Dec 26.
8. Johnson SB, Riley AW, Granger DA, Riis J. The Science of early life toxic stress for pediatric practice and advocacy. Pediatrics. 2013;131(2):319–27. Epub 2013 Jan 21.
9. Heidenreich PA, Trogdon JG, Khavjou OA, et al. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation. 2011;123(8):933-44. Epub 2011 Jan 24.
10. Kuo AA, Etzel RA, Chilton LA, et al. Primary care pediatrics and public health: meeting the needs of today’s children. Am J Public Health. 2012;102(12):e17–23. Epub 2012 Oct 18.
11. ABIM Foundation. American Board of Internal Medicine; ACP-ASIM Foundation, American College of Physicians-American Society of Internal Medicine, European Federation of Internal Medicine. Medical professionalism in the new millennium: a physician charter. Ann Intern Med. 2002;136(3):243–6.