Quality care vs. bottom line?

Can a low-key, low-tech pediatric practice stay humane and solvent in an era of rising health care costs and intense pressure to improve the bottom line? A day-long visit to CP contest winner Just So Pediatrics in Brattleboro, Vt. illuminates the issues but provides no definitive answers.

Pediatrics is a medical specialty devoted to the care of children in its many ramifications: health supervision, prevention of disease, treatment of acute illness, advocacy for children's welfare. But the practice of pediatrics is also a business enterprise that must be solvent, able to pay its bills, and yield a reasonably comfortable standard of living for its practitioners. This article is a case study that explores whether those two imperatives-conscientious care of children, and solvency-are compatible, or can be made so.

Contemporary Pediatrics runs a contest

Dr. Katz Field is a graduate of the University of Medicine and Dentistry of New Jersey. She is adjunct assistant professor of pediatrics at Dartmouth Medical School and a clinical instructor at the University of Vermont College of Medicine. She did half of her pediatric residency at Cooper University Hospital in Camden, N.J., and the other half at UMDNJ, Newark Campus; is the mother of four sons, ranging in age from 18 to 31; and a transplant from what native Vermonters refer to as "away," drawn to Vermont for its mountainous landscape and distinctive life style.

Her prize was a day with Andrew J. Schuman, MD, who is adjunct assistant professor of pediatrics at Dartmouth Medical School and Contemporary Pediatrics' contributing editor and in-house maven on matters of computer-savvy, high-tech pediatric practice. When he is not writing Contemporary Pediatrics articles, Dr. Schuman is in private practice in Manchester, N.H.

Just So Pediatrics

The practice takes its name from a favorite children's book, one-time Brattleboro resident Rudyard Kipling's Just So Stories. It is located in what was once a private home, now converted to accommodate (in a somewhat cramped fashion) the basics of a pediatric office. A waiting room with toys for kids and chairs for parents was once the living room of the house; the front desk is where appointments are made, telephones answered, and superbills made out to send to the practice's billing service. Dr. Katz Field does her paperwork and phone calls from a small, crowded private office. A hallway leads to Just So's four examining rooms. The hallway is long enough to do double duty as a venue for testing children's visual acuity; the scale is out there, too. Two photo collages of the practice's patients decorate one wall.

The house is located on a tree-lined street in Brattleboro, Vt., a town of some 12,000 inhabitants and a rather colorful, art- and music-conscious, politically progressive tradition. Brattleboro nestles in the valley of the Connecticut River in southern Vermont, encircled by a network of hills and mountains. It is definitely not what Vermonters call a "gold town," which is local parlance for a town populated by well-to-do skiers in expensive second homes. On the contrary, Brattleboro is a place where the median family income is $45,000, and 9% of family incomes are below the federal poverty line. Dr. Katz Field's impression is that median income for the families she sees is lower than these census figures.