Berkowitz’s – Section I: Primary Care Skills & Concepts

Child Advocacy

Grant P. Christman, MD, and Julie E. Noble, MD
CASE STUDY
A 15-year-old boy is brought to the emergency department with a gunshot wound to his left leg. He says he was hanging out at the park with his friends when a random car drove by and shots were fired. Though he denies being in a gang, his mother expresses concerns in a conversation with the social worker. His physical examination reveals a gunshot wound to his left lower leg, with intact sensation, movement, and pulses in the left foot, and no other signs of injury. A radiograph shows a fractured left tibia, and he is admitted for orthopedic surgical treatment.
Questions
1. What does it mean to be a child advocate?
2. Aside from caring for individual patients, how can pediatricians promote the well-being of their communities?
3. What is the role of pediatricians in child advocacy?
4. What are the levels of advocacy?
5. How do pediatricians implement advocacy?

Global Child Health

Suzinne Pak-Gorstein, MD, PhD, MPH, and Maneesh Batra, MD, MPH
CASE STUDY
You are watching television when the programming is interrupted by breaking news that a severe earthquake has struck a developing country that you have recently visited. You wonder if and how you could become involved in efforts to help the country respond to the disaster, prevent diseases, and rebuild its health structure.
Questions
1. What are the global trends in childhood disease and mortality? How does this compare with the United States?
2. What is global health (GH)?
3. What is the role of a pediatrician in GH?
4. What are the key organizations in GH that pediatricians work in?
5. How can pediatricians carry out international work in an ethical and effective manner?

Talking With Children

Geeta Grover, MD
CASE STUDY
The moment you walk into the examination room, the 2-year-old girl begins to cry and scream uncontrollably. She clings to her mother and turns her face away. The mother appears embarrassed and states that her daughter reacts to all physicians this way. After reassuring the mother that you have received such welcomes before, you sit down at a comfortable distance from the girl and her
mother. You smile at the girl and compliment her on her dress, but she does not seem to be interested in interacting with you at this point. You place an age-appropriate book on the examination table, indicating to the child that the book is for her. You begin your interview with the mother and try not to look at the girl. Out of the corner of your eye, you see that her crying is easing a bit and she has begun to examine the book you had placed on the table.
Questions
1. How does children’s age influence their understanding of health and illness?
2. Should physicians speak directly with children about their illnesses?
3. At what age can children begin to communicate with physicians about their illnesses?
4. At what age are children able to begin making decisions that affect their health?
5. How can positioning and placement of children in the examination room affect the overall tone and quality of the visit?

Talking With Parents

Geeta Grover, MD
CASE STUDY
An 8-month-old boy with a 1-week history of cough and runny nose, a 2-day history of vomiting, diarrhea, and fever, and a temperature of 101°F (38.3°C) is evaluated in the emergency department (ED). The mother is very concerned because her son’s appetite has decreased and he has been waking up several times at night for the last 2 days. A nurse interrupts and says that paramedics are
bringing a 5-year-old trauma victim to the ED. The appearance of the 8-month-old child is quickly assessed; he seems active and alert. Bilateral otitis media is diagnosed. Before leaving the examination room the physician says to the mother, “Your son has a viral syndrome and infection in his ears. I am going to prescribe an antibiotic that you can begin giving him today. Give him Tylenol as needed for the fever. Don’t worry about his vomiting and diarrhea; just make sure that he drinks plenty of liquids and don’t give him milk or milk products for a few days. Bring him back here or to his regular doctor if his fever persists, he doesn’t eat, he has too much vomiting or diarrhea, he looks lethargic, or if he isn’t better in 2 days.”
Questions
1. How much information can most parents absorb at one time? Did this mother receive more information than she can be reasonably expected to remember?
2. How do you assess parental concerns? Did the physician address the mother’s worries sufficiently?
3. How do you know whether a parent has understood all the information? Was this mother given a chance to clarify any questions she had?
4. What are some barriers to effective doctor-patient communication?
5. How does the setting itself influence communication?

Talking With Adolescents

Monica Sifuentes, MD
CASE STUDY
This is a first-time visit for a 15-year-old girl who is accompanied by her mother. The mother is concerned because her daughter’s grades have been dropping since beginning high school, and she appears fatigued and irritable. The mother reports no new activities or recent changes in the home situation and no new stressors in the family. Both parents are employed, the girl has the same
friends she has always had, and her siblings currently are doing well academically. The girl is healthy and has never been hospitalized. After the mother leaves the room, the girl is interviewed alone.
Questions
1. When interviewing adolescents, what is the significance of identifying their stage of development?
2. What are important areas to cover in the adolescent interview?
3. What issues of confidentiality and competence need to be discussed with adolescents before conducting the interview?
4. When should information be disclosed to others, despite issues of confidentiality?

Telephone Management and E-medicine

Emily Borman-Shoap, MD, and Iris Wagman Borowsky, MD, PhD
CASE STUDY
The mother of an otherwise healthy 10-month-old girl calls and tells you that her daughter has a fever. The girl’s rectal temperature has been 103°F to 104°F (39.4°C–40.0°C) for the past 2 days. Although she is cranky with the fever, she plays normally after receiving acetaminophen. The girl is eating well and has no runny nose, cough, vomiting, diarrhea, or rash. Mother also mentions 2 other concerns that she has been meaning to bring up with you. The first is questions about feeding and how to introduce solid foods; the other is sleep problems. Her daughter has been waking up several times a night for the past month, and mom is feeling exhausted.
Questions
1. How do telephone and face-to-face encounters between physicians and patients differ?
2. What are some general guidelines for effective doctor-patient communication over the telephone?
3. What historical information is necessary for appropriate telephone management?
4. What points are important to cover in home treatment advice?
5. For nonurgent issues, how can telephone encounters or e-medicine play a role in patient care?

Informatics

Alan Tomines, MD
CASE STUDY
You are a physician in a small pediatric practice. Your hospital is planning to acquire an electronic health record, which will be made available within the hospital and to the offices of its affiliated practices. The hospital chief of staff asks you to sit on the hospital’s informatics committee to participate in the vendor selection process and assist with the implementation of the selected system. You have previously used the hospital’s computer to check patients’ laboratory results, and your practice uses computers for billing and scheduling. However, you don’t consider yourself a technology expert and express your trepidation to the chief of staff, who asks you to speak with the head of the informatics committee.
Questions
1. What are the important informatics concepts to understand?
2. What are the important drivers of health care information technology?
3. What are the challenges to implementing successful health information systems?
4. What are the special pediatric considerations in health information systems?

Counseling Families About Internet Use

Alan Tomines, MD
CASE STUDY
A 16-year-old girl is accompanied by her mother for a routine visit. The girl is doing well in school, is active in team sports, and has a small circle of friends that are wellknown to her mother. The mother describes no new problems at home, nor any changes in behavior, except that she is concerned that her daughter “spends too much time on the computer.”
Questions
1. What are the commonly used Internet services?
2. What are the benefits and risks of the Internet?
3. What strategies may be used to make the Internet safer to use?
4. What signs may indicate that an adolescent is engaging in risky behaviors on the Internet?

Cultural Competency Issues in Pediatrics

W. Suzanne Eidson-Ton, MD, MS; Hendry Ton, MD, MS; Blanca Solis, MD; and Jesse Joad, MD, MS
CASE STUDY
You are seeing A.J., a 12-year-old Mexican American boy for a well-child visit. His mother speaks Spanish and “a little” English, is single, and works full time in motel custodial services. After school and during summers, A.J. is cared for by his older brother (17 years old) and his maternal grandmother, who lives a block away. His weight and body mass index are well above the 95th percentile for his age. When discussing his diet, you learn that his mother buys packaged foods that he can make for himself when she is away. She is concerned that he will not eat if she does not buy the processed, fatty foods that he likes. Further, these types of foods are more plentiful than healthier options at the local market where she shops. A.J. sometimes eats at his grandmother’s home, but she is elderly and not cooking much anymore. When discussing physical activity, he states that he wants to play soccer. His mother is concerned about this, however, because he often complains of headaches and stomachaches when it is time for practice, and she does not want to buy the equipment if he will quit after a few weeks, as has happened in the past.

Principles of Pediatric Therapeutics

Bonnie R. Rachman, MD
CASE STUDY
An 18-month-old girl who has had a cough, runny nose, and fever for 2 days is brought to your office for evaluation. The previous night she awoke from sleep crying and pulling at her ear. The patient has no other symptoms. Her mother states she has had previous ear infections, the most recent occurred 2 months ago. The last time she took amoxicillin she broke out in hives. Otherwise the patient has no significant medical history. On physical examination, the patient is febrile to 102°F (38.9°C) and has yellow rhinorrhea. The ear examination reveals a red, bulging, nonmobile tympanic membrane in one ear, while the other ear appears normal. The remainder of the examination is benign.
Questions
1. What are the current practice guidelines for antibiotic treatment of otitis media? How does treatment change with the age and symptoms of the patient?
2. How does the previous reaction to a medication influence the antibiotic choice?
3. How do factors such as child care, work, and family plans affect the choice of medication?
4. What role do over-the-counter medications have in the management of the patient’s symptoms?

Pediatric Pain and Symptom Management

Rick Goldstein, MD
CASE STUDY
You are caring for a 5-year-old girl with stage 4 neuroblastoma who is at home receiving palliative care. Her tumor is refractory. She receives oral chemotherapy and transfusions as an outpatient to offset the bone marrow depletion caused by her tumor. Pain from her metastases is becoming increasing problematic, most especially in her chest wall and right femur. Her spine is also involved, but she does not experience weakness. Though fatigued, she derives great pleasure from attending school and being surrounded by friends and family members, playing as she is able. She hates the hospital and her parents have chosen to avoid it, intending to keep her comfortable at home until she dies. You have remained closely involved throughout her illness and would like to help with the management of her symptoms.
Questions
1. What is the approach to pain management in children?
2. How does one assess the level of pain in children?
3. What is meant by adjuvant therapy?
4. What is the role of distraction in pain management?
5. What are non-pain symptoms that can cause distress?
6. What is the management of non-pain symptoms?

Complementary and Alternative Medicine in Pediatric Primary Care

Miriam T. Stewart, BA, and Erica Sibinga, MD, MHS
CASE STUDY
A 14-year-old girl is brought to your office to follow up on her migraine headaches. She has no other significant medical history but has experienced intermittent migraine headaches over the past few years. The headaches occur approximately weekly in the evenings, do not wake her from sleep, and improve with ibuprofen (400 mg), as had been previously prescribed at your office. At this visit, the girl states that she wishes she didn’t have to take medicine for her headaches. Her mother reports that a family friend has suggested acupuncture or herbs for the headaches and asks whether there are other complementary and alternative medicine (CAM) approaches that they could try.
Questions
1. What are CAM therapies?
2. How does a provider explore if there are any CAM approaches that are appropriate for the treatment of chronic or recurrent conditions such as headaches in a child or an adolescent?
3. What is the best way to determine if a family is using CAM?
4. What is the best way to communicate with a family about CAM therapies?
5. What is the best way to monitor the safety of CAM approaches?

Principles of Pediatric Surgery

Steve L. Lee, MD
CASE STUDY
A 4-month-old boy is evaluated by his pediatrician for swelling in the groin and is diagnosed with a right inguinal hernia. His parents are told that their child will be referred to a pediatric surgeon. The parents are concerned about surgery in such a young infant and ask their pediatrician multiple questions. Is he big enough to have surgery? Will he be able to eat before the surgery? Will he be in pain? Will he need to have blood drawn? Will he need to be hospitalized? Will he be put to sleep for the procedure?
Questions
1. What are the typical questions parents ask if their child is undergoing surgery?
2. What is the role of the primary care physician in advising patients and parents about surgical procedures?
3. What is the role of the operating surgeon in advising patients and parents about the surgery?
4. What are general guidelines for feeding infants and children prior to surgery?
5. What are the risks of general anesthesia in infants and children?
6. How long is the hospitalization following surgery?
7. What should parents do before meeting with the surgeon?
8. How do you prepare children who are about to undergo surgery?
9. What laboratory studies are needed prior to surgery?

Image Gently: Approach to Pediatric Imaging

Lindsay S. Baron, MD; Jane S. Kim, MD; and Benjamin H. Taragin, MD

CASE STUDY 1
A 15-year-old boy comes to your office complaining of 1 week of back pain after exertion. He reports no significant recent trauma. He does play varsity basketball but has not had any recent falls during games. He is otherwise healthy with no significant medical history. The pain does not prevent him from playing sports or going to school. He has no history of prior episodes of back pain. He says the pain is relieved by nonsteroidal anti-inflammatory drugs. On physical examination, he has left-sided paraspinal focal tenderness in the L3-L4 region. He has limited range of motion twisting to that side.
CASE STUDY 2
A 10-year-old girl is brought to your office with runny nose, congestion, cough, and headache. You saw this patient 4 months ago as well as 6 weeks ago, when she had similar complaints. Her mother reports full compliance with the antibiotic regimen you prescribed but states that her daughter’s symptoms have never fully resolved. On physical examination, the child is afebrile with purulent nasal discharge. There is tenderness to palpation over the cheeks and forehead.
Questions
1. What, if any, is the appropriate imaging for each patient?
2. How does one decide the appropriate imaging studies to obtain on a patient?
3. What is the ALARA principle?
4. What information is available for counseling patients about the risks of diagnostic radiation?
5. Where can one find appropriate imaging recommendations for pediatric patients?
6. Does the history influence the choice of imaging studies?
a. What imaging would be appropriate for the patient in case study 1 if there was recent significant trauma?
b. What imaging would be appropriate for the patient in case study 2 if her symptoms were new and started last week?

Simulation in Pediatric Health Care

Tom Kallay, MD
CASE STUDY
A 1-year-old boy is in your office for a routine visit and vaccinations. Upon receiving his vaccinations, he experiences an anaphylactic episode. The emergency equipment and medications are difficult to find. The child receives epinephrine and nebulized albuterol with minimal improvement. You are worried he will need airway support, but it is not clear if the equipment is serviceable.
Your staff calls 911; the paramedics arrive and eventually take the child to the nearest emergency department. You and your staff feel that you could have been better prepared. You decide to take measures to optimize the function of your staff and office environment for the rare emergency.
Questions
1. What is simulation?
2. How does simulation apply to health care?
3. What modalities of simulation are available for medical training?
4. How does one create and deliver simulation training?
5. Why should a primary care physician use simulation?

Pediatric Hospital Medicine

Grant P. Christman, MD
CASE STUDY
A 15-month-old girl presents to a community hospital emergency department with fever, cough, and rhinorrhea. On initial evaluation, she is found to be in moderate respiratory distress, with decreased air movement and patchy bilateral wheezes and crackles on lung examination. Her oxygen saturation is 87% on room air and rises to 96% with the application of 1 L per minute of supplemental oxygen by nasal cannula. The physician diagnoses the patient with bronchiolitis and gives a treatment of nebulized albuterol and an oral dose of prednisone. The hospital has no inpatient pediatric service, so the emergency physician calls the local children’s hospital to arrange a transfer. The emergency physician signs the patient out to a hospitalist, who accepts her onto the inpatient pediatric service and arranges for transport.
Questions
1. What is the role of hospitalists in inpatient pediatric care?
2. How can pediatricians implement principles of family-centered care and evidence-based medicine into the clinical care of hospitalized children?
3. How can physicians promote quality improvement and patient safety in the hospital setting?
4. What communication strategies can hospitalists use to ensure safe transitions of care within the hospital and back to the outpatient medical home after discharge?

Pediatric Genomic Medicine

Derek Wong, MD
CASE STUDY
A 4-year-old boy with moderate global developmental delay is brought to his pediatrician’s office for evaluation. The patient has an unremarkable family history and a normal physical examination. Previous evaluation included a normal karyotype and fragile X DNA test. The patient’s parents would like to know if there is anything else that can be done to determine the etiology of the delay. In addition, his mother has recently read about companies that offer multiple genetic tests to consumers and wonders if these tests will be useful as well.
Questions
1. How is microarray technology useful in pediatric practice?
2. How is next-generation sequencing technology affecting current practice?
3. What are the limitations of these new technologies?
4. What is direct-to-consumer genetic testing?

Principles of Quality Improvement: Improving Health Care for Pediatric Patients

Bonnie R. Rachman, MD
CASE STUDY
During a routine staff meeting at your group pediatric practice, it was noted that many of the patients followed by your practice are behind in their immunizations. The reasons for this are unclear, as you and your colleagues are strong proponents of the timely administration of preventive immunizations. You want to develop a mechanism to determine what factors are leading to a delay in vaccine administration.
Questions
1. What is quality improvement?
2. How does assessing the delivery of recommended health maintenance relate to quality?
3. How is the prevention of medical errors related to quality improvement?
4. What is the difference between harm and error?
5. What factors are associated with medical errors?
6. What is meant by organizational culture?