Bonnie Zima, MD, MPH, an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1989-1991), published a study this month that appeared in a special supplement of Pediatrics with articles by RWJF Clinical Scholars on child health quality. Pediatrics is the official journal of the American Academy of Pediatrics. Zima is a professor-in-residence in child and adolescent psychiatry at the University of California in Los Angeles (UCLA) and associate director of the UCLA Center for Health Services & Society.

Human Capital Blog: Why did you decide to review the new child mental health quality measures?

Bonnie Zima: This paper was written to stimulate discussion about the need for a paradigm shift for quality measurement for children that more closely aligns research with the accelerated pace of quality measure development. 

These are exciting times for those who believe that the quality of child health care can be improved through measurement and public reporting. However, this direction also raises questions about how to improve our methods and data infrastructure to monitor the quality of care received in real-time and to link adherence to quality indicators to clinical outcomes that are meaningful to parents, child advocates, providers, agency leaders and policy-makers.

HCB: Why did you focus on child mental health?

Zima: We focused on child mental health care because quality measurement poses additional challenges that can be used as a stimulus to improve future measure development.

Some of the areas for future research include development of a stronger evidence base to support nationally recommended care processes in community-based populations; models of care coordination across multiple care sectors that often have discrete funding streams, such as specialty mental health, public health, education, child welfare, and juvenile justice; and the development of interventions that more flexibly align service delivery with children’s clinical needs, especially for those with co-morbid mental and physical health conditions.

Lawrence Kleinman, MD, MPH, is vice chair and associate professor of health evidence and policy and associate professor of pediatrics at Mount Sinai Hospital. He is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (1990-1992) and helped guide a special supplement of studies by RWJF Clinical Scholars into publication in Pediatrics this month.

Human Capital Blog: How did this special supplement come to be and what impact do you expect and hope it will have? 

Kleinman: Des Runyan, MD, DrPH, director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program, called to ask me what I thought about the idea and whether I would be willing to shepherd the issue. Des had observed the historical and seminal role of RWJF Clinical Scholars in the emergence of the field of quality of health care, the work of Bob Brook, MD, ScD, chair in health care services at the RAND Corp., a professor of health policy and management, and of medicine, at the University of California at Los Angeles (UCLA), and an RWJF Clinical Scholar alumnus, and of many others, and also the more recent emergence of Clinical Scholars as leaders in the field of children’s health care. 

He also recognized that five of seven centers of excellence funded by the Agency for Healthcare Research and Quality (AHRQ) as part of its flagship Pediatric Quality Measures program (PQMP) were led by alumni of the Clinical Scholars program. I think Des viewed that as a seminal moment that showed that Clinical Scholars alumni had achieved similar leadership in child health that they had achieved in the area of adult health. He recognized the opportunity to celebrate that in a collection of work on children’s health quality by RWJF Clinical Scholars and alumni.

HCB: What are the key messages readers should take away from the series?

Kleinman: This supplement demonstrates the capacity and power of using conceptual models to inform quality and quality improvement research, suggests an approach to developing these kinds of conceptual models, and illustrates that a span of approaches—ranging from evidence synthesis to a highly reductionist analysis of existing data to an extremely generative qualitative analysis to the thoughtful integration of ideas by colleagues—may all inform the field in important ways. 

Further, the field of pediatric quality of care is blossoming; it truly needs studies that incorporate and extend its range. Finally RWJF Clinical Scholars are still thought leaders and change agents who as a group demonstrate remarkable versatility in their methods and prove notably capable of provoking progress in children’s health and quality research.

Antoinette L. Laskey, MD, MPH, FAAP, is an associate professor of pediatrics and division chief and medical director at the Center for Safe and Healthy Families at the Primary Children’s Medical Center at the University of Utah in Salt Lake City. She is an alumna of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2001-2003).

During medical school at the University of Missouri-Columbia, I had my first exposure to child abuse pediatrics.  As a third-year student on my pediatrics clerkship, I had the opportunity to participate in the care of a child whom I suspected had been beaten.  From that point forward I knew this was where I wanted to spend my career. 

I started looking into fellowship opportunities even before I had started my residency.  Early in my intern year in 1998, I reached out to Des Runyan, MD, DrPH, a pioneer in child abuse pediatrics and an alumnus of the RWJF Clinical Scholars program (1979-1981) who was then at University of North Carolina at Chapel Hill and who is now national program director of the RWJF Clinical Scholars program.  We arranged a visit so that I could learn more about the field through his expert eyes.

Before child abuse pediatrics was recognized as an official subspecialty of pediatrics, there were two different paths to enter practice: a one-year “apprenticeship” or a two-year clinical and research fellowship.  In my short visit to Chapel Hill, it became apparent to me that an RWJF Clinical Scholars position was the way I needed to go to not only practice in the field of child abuse pediatrics but to also gain the knowledge base necessary to move the field forward. 

Andrea Gottsegen Asnes, MD, MSW, is an assistant professor of pediatrics at the Yale School of Medicine and a Robert Wood Johnson Foundation (RWJF) Clinical Scholars program alumnus (2001-2003).

Human Capital Blog: What kind of work do you do in the area of child abuse pediatrics?

Andrea Gottsegen Asnes: I am a child abuse pediatrician.  Nearly eight years ago, I joined former Robert Wood Johnson Foundation (RWJF) Clinical Scholar and fellow child abuse pediatrician John Leventhal, MD, as a member of the faculty of the Yale School of Medicine. In 2009, we both became board certified in the new pediatric sub-board of child abuse pediatrics. At Yale, I am the associate director of the Yale Child Abuse and the Yale Child Abuse Prevention programs.

Most often, I am asked to evaluate suspected cases of child abuse by other medical colleagues, by my state’s child protective services agency, or by local police departments. I am frequently asked to testify in court as a medical expert in cases of suspected child maltreatment. I also participate in several multidisciplinary, community-based teams that are designed to improve both criminal prosecutions of those who abuse children as well as the care that abused children receive. 

I have a particular interest in optimizing recognition of subtle signs of physical abuse by frontline pediatric providers, and I teach on this subject regularly. I also have a special interest in linking abused children and their non-offending caregivers to mental health treatment. In 2006, I started the Bridging Program, which provides immediate, evidence-based mental health care to sexually abused children and their non-offending family members. My hope for the future is to devote increasingly more time to work in child abuse treatment and prevention.

Brendan T. Campbell, MD, MPH, is an assistant professor of surgery and pediatrics at the University of Connecticut School of Medicine and an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program (2000-2002).

Human Capital Blog: What kind of work do you do in the area of child abuse pediatrics?

Brendan Campbell: I am a pediatric general and thoracic surgeon and the medical director of the pediatric trauma program at Connecticut Children’s Medical Center in Hartford. Connecticut Children’s is a Level I pediatric trauma center, which means we see patients with relatively minor and severe multisystem injuries. Caring for abused children is one of the most important services we provide. When children with non-accidental trauma are initially identified, they are admitted to the pediatric surgical service to rule out life-threatening injuries. During their admission we work closely and collaboratively with the suspected child abuse and neglect team (SCAN) to make sure children with inflicted injuries are identified, have their injuries treated, and are kept out of harm’s way.

HCB: Why did you decide to focus on this area?

Campbell: It can be challenging to get a pediatric surgeon interested in child abuse because caring for vulnerable children who are intentionally harmed is not easy, and most of these kids don’t have life-threatening injuries that require an operation. What draws me to the care of injured children is that they are the patients who need me the most.  If we don’t identify the risks they are up against at home, no one else will. They need someone to advocate for them.

The other thing that draws me to child abuse pediatrics is that there is an enormous need to develop better ways to screen for and to prevent abuse.  Over the last 30 years we’ve made enormous strides in lowering the number of children injured in car crashes by enacting seat belt laws, toughening drunk-driving laws, and improving graduated driver licensing systems. Child abuse in the United States, however, remains a significant public health problem that needs more effective screening initiatives and prevention programs.

Two newly published studies examining different aspects of physician workforce trends suggest that the long-expected shortfall in primary care physicians could be averted or lessened.

A study in Pediatrics finds pediatric residents are more likely to consider primary care or hospital practice––rather than a subspecialty that requires additional training––if they have more educational debt. The researchers found that residents with at least $51,000 in debt were about 50 percent more likely to be planning a primary care or hospitalist career than residents who owed less or no money, Reuters reports. They also found that educational debt rose 34 percent from 2006 to 2010 for pediatric residents.

While an unintended consequence of student loan debt may be that it helps relieve the primary care shortage, another recent study in Health Affairs casts some doubt on the severity of that shortage. Most existing estimates of the primary care physician shortage are based on a simple ratio of one physician for every 2,500 patients, the study says, which does not take into account changing patient demographics and alternative care-delivery methods. The researchers found that the use of health care teams and non-physicians, as well as improved information technology and data-sharing have “the potential to offset completely the increase in demand for physician services while improving access to care, thereby averting a primary care physician shortage.”

Read the study in Pediatrics.
Read the study in Health Affairs.

Ruchi S. Gupta, MD, MPH, is a Robert Wood Johnson Foundation Physician Faculty Scholar. She is an associate professor of pediatrics and director of the maternal and child healthcare program at the Northwestern University Feinberg School of Medicine, and an attending physician at the Ann & Robert H. Lurie Children's Hospital of Chicago.

When I decided to specialize in pediatrics after medical school, I did it for my love of children and the prospect of a career spent improving their lives and those of their families.  Following my pediatric training, I completed a special fellowship in Boston to gain the research skills that would help me make a broader impact.  Completion of this training opened the door for me to work with a world-renowned expert in pediatric asthma in Chicago.  During this time, I met a family with two children with severe food allergy. This family would influence my work and my career dramatically.  Their interest, with its deep commitment and personal stories, became my passion.

As I started conducting research in food allergy, I realized how little we know compared to other childhood diseases like asthma.  There were so many unanswered questions.  At that point, it was not even clear how many children were affected by food allergy or how severe it was.  To address this, my research team and I conducted a comprehensive study of 50,000 families all over the U.S. and found that food allergy impacts 8 percent of the nation’s children, corresponding to two children in every classroom or almost six million children in the country.