Tasks of the times

Difficult times call for bold strategies. Those proposed here renew traditional pediatric values and also go beyond them. Their goal is to help pediatricians not only adapt to changing conditions but thrive in the face of challenge.

Pediatric practitioners have historically adapted well to changing expectations and roles, but the transformation of health care delivery in recent years has presented special challenges.¹ The seemingly relentless changes embody for many health professionals the characteristics of a personal crisis-an event that is unanticipated, undesired, uncertain, and uncontrollable.

When people confront major change and contingencies that go beyond individual choice, experience has demonstrated the value of constructive goals as guides to successful adaptation. Goal-directed strategies help patients master the crises in their lives, and they also work well for physicians. While recent changes in the health care system have imposed constraints on physicians, we can also anticipate that they will stimulate professional renewal.

Consider appointments consultations, not visits

Apart from a physical appraisal of the child, administration of immunizations or other procedures, and the prescription of medication, the pediatrician's chief role is that of a consultant to parents on both child health and disease. Pediatric appointments, therefore, should be referred to as consultations rather than visits. The difference is more than semantic. For the patient, "to consult" means to seek information, recommendations, and counsel; for the physician, it means to provide expert help. The word visit, which has a more social or casual connotation, does not adequately convey the degree of professional competence the encounter requires.

Parents regard the pediatrician as an expert in child health and development. While they expect skill in the diagnosis and management of disease, they increasingly look for practical insights into their child's behavior and development. When such issues are identified during a scheduled health supervision session and require more time to discuss than is available, a supplementary appointment can be offered. This option is especially appropriate during a community epidemic of viral disease when the increased volume of acutely ill children reduces the time available for health supervision consultations. Similarly, when parents call to request help with behavioral or developmental complaints, it makes sense to arrange longer initial consultations than usual, and to schedule them for times when the office pace is expected to be less hectic.

Maximize communication

Full use of the communication channels open to pediatricians is a central goal in these strategies and comes up repeatedly in the sections that follow. Not just once but periodically, all of us need to look for ways to enhance communication through the pediatric interview; the physician-patient relationship, anticipatory guidance, parent groups, contributions of the pediatric nurse practitioner, links to community resources, and telephone consultation. Some busy pediatric practices now use nurses or nurse practitioners to screen calls after, as well as during, office hours.

Achieve an alliance with parent and patient

As Renee Sand has stated, "Health cannot simply be given to people. It demands their participation."² The pediatrician's success as a diagnostician and counselor derives from a patient-physician alliance in which both are actively engaged. Responsiveness to parents' expectations helps ensure their satisfaction.

A patient's identification with his or her pediatrician is a powerful therapeutic tool and should be consciously pursued. Similarly, parents who come to like, admire, and trust their pediatrician tend to adopt his or her beliefs about what is in the best interests of their children. Such identification is strengthened when parents believe that the doctor views them positively-when they find themselves thinking, for example, "she believes I'm a good mother," "he respects my ability," "she likes me," or "she is glad to see me." Contrary perceptions, such as "she disapproves of me," have a constraining impact.