The Mission of Pediatrics

The Mission of Pediatrics

I had the wonderful opportunity to accompany the Issa Trust Foundation on their annual mission trip to provide pediatric medical care to the children around Ocho Rios, Jamaica. It was an amazing experience and reinforced some key ideas for me: 

  • Children are much the same all around the world
  • Data is powerful
  • “Continuous Quality Improvement” isn’t just the phrase of the decade
  • A Medical Home is about people, not places 
The team saw almost 900 children over 5 clinic days at various locations. Each child went through registration, triage (full vitals and growth measurements), lab (Hgb as needed), fluoride teeth varnish, full history and exam with a physician or NP, eye exam with an optometrist, and pharmacy (over 1200 prescriptions filled onsite!). Everyone got worm pills, vitamins, and a “goodie bag” with patient education, toothbrush, toothpaste, and a beanie baby. Whew! I’m winded just thinking about it again!
 
The kids were curious (trying to sneak into our doc boxes to see what was hiding), engaging (huge smiles, albeit through some of the worst dental caries you will ever see), and trusting (reflexively took the hand or lap of anyone who offered). Toddlers are “picky eaters” in Jamaica, too … seems there must be a built in two-year-old aversion to green vegetables. The teenage girls blushed when asked about having a boyfriend, and the teenage boys sat up taller and proudly told us about their girlfriends. (Culturally, homosexuality is taboo in Jamaica, although we tried to be gender neutral about these conversations and offer a safe place for all teens we saw.) Everyone tried to negotiate some extra stickers!
 
The first few Issa missions were accomplished on paper. The last 3 were done using Office Practicum. We sat down with the team and asked what kind of data they were interested in collecting, then created templates to make that easy. Looking at the data, we found that in areas closer to the coast/resorts, obesity is as big a problem there as it is for many of us practicing in the US (BMI increases in proportion to your proximity to a KFC).  Failure to thrive is more common in the poorer remote/mountain communities. Asthma is worse in environments where children are exposed to smoke from tobacco and cooking fires. Dental caries are significant and affect the majority of children we saw. We treated a number of serious dental abscesses, and a fair number of children had several permanent teeth rotted/broken beyond hope of repair. Mission volunteers learned to use OP on an iPad after about an hour of instruction, and medications were tracked and filled by the mission pharmacists.
 
So what happens to that data? Fluoride varnish became an important part of the clinic after the initial need was identified. This year we had a respiratory therapist who got spacers donated and lots of asthma education was added to the clinic flow. All children under 3 and girls 11+ are screened for anemia, and iron is provided as well as education on iron rich foods and their importance. We saw a significant amount of eczema and fungal infections (no surprise during rainy season in the Caribbean!) and are strategizing about the best way to address them in the future. This year the Lions Club of Michigan provided eye exams and glasses to the 10% of patients who needed them. As you might expect, there are no HEDIS reporting requirements or P4P payer metrics in Jamaica. Using the information we gather to improve the mission each year is true Continuous Quality Improvement.
 
One of the most fascinating aspects of providing this care (since 2005) is that 40% of children are returning patients. Initially, children came mostly for treatment of acute illnesses because they had limited access to a hospital or clinic. Now, many of them simply come for a “check-up.” There is no formal well care in Jamaica. Immunizations are provided by public health nurses, but healthcare is not preventive or anticipatory. Issa Trust has begun to establish a true medical home for these children. Parents are eager to be reassured the children are developing and growing well, which we can now see in longitudinal growth curves!  Children flourish when we compliment them on their healthy habits and hard work in school. Some wait for hours in the rain and are seen between bedsheets strung across pews of a church to have the experience of someone taking the time to listen, connect with  them, and care about their health and well-being. For many of them, we are their medical home.
Every once in a while I wonder whether the craziness in the delivery of modern healthcare is worth it. This experience reinforced that yearning and desire I felt the first time I went into the pediatric clinic during medical school. The mission of pediatrics: it’s my medical home.