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Policy, Politics, and Procedure: Our Role in Building Systems That Improve the Health of Children

  • David M. Keller
    Correspondence
    Address correspondence to David Keller, MD, Department of Pediatrics, Children's Hospital Colorado, 13123 E 16th Ave, B065, Aurora, CO 80045.
    Affiliations
    Department of Pediatrics, University of Colorado School of Medicine, and Children's Hospital Colorado, Aurora, Colo
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      It has been a tremendous honor to serve as President of the Academic Pediatric Association (APA) for the past year. As President, I have seen the breadth and depth of the work of our members in a variety of venues, and have come to better understand the many ways in which APA members live their academic lives. There is no “typical” APA member; we take a myriad of paths in our quest to serve the needs of children. Wherever I went, however, I heard a common theme voiced by all of our members: pediatric practice, teaching, and research do not fully benefit children unless we incorporate what we do into the policies of the systems in which children live. I am not the first APA President to realize this; listen to the words of our late friend, Joel Alpert, former president of the APA.So you look back, and you look at where we are now, and you look forward, and you say, to me, at least, advocacy. Yes, we will take care of patients, yes, we will teach, yes, we will research, but I think that the lifeblood of the APA is advocacy.

      Alpert, J. October 10, 2008. APA Presidential Project: Past Presidential Interviews [.wmv file]. Available at: http://www.academicpeds.org/video/Alpert_Now_and_future_is_advocacy.wmv. Accessed July 25, 2014.

      These are words that I live by, but not all in medicine would agree with Dr Alpert's thesis. Some believe that academic medicine should focus on the biological sciences, and leave to others the task of incorporating our understanding of the science of medicine into public policy.
      • Huddle T.
      Medical professionalism and medical education should not involve commitments to political advocacy.
      I respectfully disagree. As physicians, we have accepted a duty to treat illness and improve the health of our patients. Because humans are social animals, human health takes place in a social context, and our ability to affect the health of our patients and the diseases that afflict them can only be enhanced when we embrace our duty to inform public policy with our clinical experience and scientific knowledge. Advocacy and public policy are at the core of our work within the APA, and, I will argue, should inform our work within academic medicine. As academicians, we need to understand our role in formulating policy, in navigating the politics around child health issues, and using institutional and governmental procedures to assure that those policies benefit the children and families that we serve.
      Today, I would like to spend some time with you exploring what it means to take an academic approach to advocacy and public policy. I will start with an example from my practice, illustrating the connection between practice and policy. Then I will use that case to illustrate how an academic approach to policy, politics, and procedure can work to help the children for whom we care. Finally, I would like to discuss how public policy and advocacy should be part of an academic career in pediatrics and how the APA can help you make advocacy for children part of your “lifeblood,” as Dr Alpert suggested.
      Let's start with a well-child visit that happened a few years ago. Gordon (not his real name) was a 4-year-old brought in by his mother and grandmother for a routine visit. I did not know them well, but when I walked into the room, I knew something was up. The grandmother appeared nervous and the mother distant. Although they had no stated concerns, they were worried about something. Gordon seemed a happy child, a little active perhaps, but nothing out of the ordinary. He spoke well, seemed developmentally appropriate, and interacted well with me. The only remarkable thing on his history was that he had been expelled from several day care programs, for reasons that seemed unclear to the family. After the examination, I went to get the nurse to give the immunizations. As I reached for the door, the grandmother shared “one more thing”; Gordon had injured several pets in the home, seemingly without remorse. As you can imagine, I immediately closed the door, sat down, and asked more questions. The day care issues became clearer. Gordon had injured other children in the day care settings from which he had been expelled. It turned out that previous providers had tried to refer the family for mental health services, based on behavioral concerns at previous check-ups, but the family had been unable to access those services. I enlisted our care coordinator, but we soon encountered similar roadblocks; the system was very complicated. Mental health referrals for children with Medicaid insurance had to go through a Behavioral Health Organization, with long waiting lists. Referral to the Department for Children and Families might help, but the family feared that it might result in the child's removal from the home, and likely would not get him services any faster. Referral to our Pediatric Emergency Room for an evaluation might get him hospitalized, but also might result in his becoming a “stuck kid,” waiting for placement. We ended up doing all of those things over the next month—cajoling a Behavioral Health Organization, referring to the Department of Children and Families, and sending the family in for an emergency evaluation. Eventually, the child and the family got the treatment that they needed, a happy ending of sorts, but a Pyrrhic victory at best. I was frustrated with a primary care system that connected poorly to the mental health system. I was frustrated with mental health systems that responded only to crisis rather than to need. I was frustrated at how little our understanding of the science of child development informed the structure of our child mental health and social service systems. I realized that if I did not engage in the processes that were creating these systems of care, I would find myself in this dilemma again and again. I also realized that, although I knew that the systems were broken, I had no idea which policies could be changed to fix them.
      Fortunately, there were others who did have new policy ideas. Policy, defined as “a course or principle of action adopted or proposed by a government, party, business, or individual,”

      Policy: Definition. Oxford Dictionaries: American English 2014. Available at: http://www.oxforddictionaries.com/us/definition/american_english/policy. Accessed June 1, 2014.

      should result from analytic thinking. There are rigorous analytic approaches to understand the ways in which systems interact to produce less than optimal results.
      • Institute of Medicine
      Crossing the Quality Chasm: A New Health System for the 21st Century.
      To address issues of patient safety in medicine, many have adopted a “root cause analysis” model, drilling backward from the adverse event to identify systems issues that result in adverse outcomes.
      • Wu A.W.
      • Lipshutz A.K.
      • Pronovost P.J.
      Effectiveness and efficiency of root cause analysis in medicine.
      • Bowie P.
      • Skinner J.
      • de Wet C.
      Training health care professionals in root cause analysis: a cross-sectional study of post-training experiences, benefits and attitudes.
      Some in the public health community have proposed that “health impact statements,” patterned on the “environmental impact statements” could identify ways in which specific policy recommendations could affect the health of specific populations.

      Smith L. Unhealthy Consequences: Energy Costs and Child Health: A Child Health Impact Assessment of Energy Costs and the Low Income Home Energy Assistance Program. Boston, MA: Child Health Impact Working Group. 2007. Available at: http://www.hiaguide.org/sites/default/files/ChildHIAofenergycostsandchildhealth.pdf. Accessed July 25, 2014.

      These often involve the construction of a logic model, establishing points of leverage within systems that are likely to affect outcome.

      Community Pediatrics: Logic Models. Available at: https://www2.aap.org/commpeds/resources/logic_models.html. Accessed June 1, 2014.

      The legal profession uses an approach called “issue spotting,” in which the ways in which specific facts in a case (or a patient story) raise specific issues of law, which can then be argued.
      • Sandel M.
      • Hansen M.
      • Kahn R.
      • et al.
      Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations.
      Some have even proposed a rubric for analysis called “evidence-based policy,” in which analysts specifically evaluate the strength of evidence for each component of a proposed policy, clearly stating the likelihood that a specific policy change will have a particular outcome, and highlighting the possible unintended consequences of change.
      • Brownson R.C.
      • Chriqui J.F.
      • Stamatakis K.A.
      Understanding evidence-based public health policy.
      Each of these methodologies allows one to deconstruct the complex array of policies and circumstances that led to a problem, to consider changes in policy that could resolve the problem. In my case, a coalition of child health advocates had done that analysis, identifying several policies that would need to change to allow the systems to run more smoothly, and had published their findings in a white paper shortly after the election of a new Governor.
      • Sudders M.
      • DeMaso M.R.
      Children’s Mental Health in the Commonwealth: The Time is Now.
      Among the many needs identified, they had focused on 3 relevant to my interaction with Gordon. We needed:
      • 1)
        Better integration of behavioral health and primary care services;
      • 2)
        Better avenues for agencies like schools, child protective services, and early mental health services to collaborate and share information, to allow intervention sooner rather than later; and
      • 3)
        New categories of behavioral health services that could be accessed urgently, that were neither “routine” or “emergent.”
      The report identifying these and other gaps had been written; it was good policy. To make it more than an academic exercise sitting on a shelf would require engaging in an equally rigorous assessment of the politics within our state and a clear understanding of the procedures by which change could occur.
      Politics is the term that causes the most agitation in academic circles, because, I think, it is so often associated with partisanship. It doesn't have to be. The dictionary defines politics in several ways: “the art or science concerned with winning and holding control over a government,” which suggests that it really is nothing more than the exercise of power; or, “political activities characterized by artful and often dishonest practices,” which implies that it is always about greed and corruption. Those definitions might drive us toward partisanship, in which power becomes an end in itself rather than a means to an end. I prefer to think of politics as “the total complex of relations between people living in society.”

      Politics: Definition. Merriam Webster Dictionary On-Line. Available at: http://www.merriam-webster.com/dictionary/politics. Accessed June 1, 2014.

      Politics is the essential activity that forms human societies and really cannot be avoided, unless one lives in a cave or on a mountaintop. Bismarck defined it as “the art of the possible,”
      • Bismarck O.
      • Butler A.J.
      Bismarck, the Man and the Statesman; Being the Reflections and Reminiscences of Otto.
      one that requires the ability to listen carefully to truly understand the nature of the problem from a variety of perspectives, and the ability to think strategically about how to balance stakeholder interests to move a policy forward. The analytic frame in a political context involves careful consideration of a number of questions:
      • 1)
        What is the problem, from a variety of perspectives?
      • 2)
        Who are the stakeholders and what are their interests?
      • 3)
        What are the levers with which we can implement change?
      • 4)
        What is the cost (not just dollars) to the various stakeholders?
      • 5)
        What would it take to create a solution marginally acceptable to all parties?
      From such an analysis, a road forward can be mapped. As I came to understand this analytic frame, I realized that this is not all that different from the approach one takes in the development of a care plan with a family and a multidisciplinary team. The challenge is to understand fully the views of the team members; when that is achieved, one can usually come to agreement on the plan. Getting back to my patient, I realized that his care was being adversely affected by the complex interaction of multiple systems in the pubic and private sectors. It seemed that a combination of efforts focusing on the legislative, executive, and judicial branches of government would be necessary to implement the policies cited. Fortunately, we had folk in the coalition who understood those things far better than I and were able to think with me on how best I could contribute to the effort. I wrote testimony, organized hearings, met with legislators, participated on advisory committees, and wrote a blog, all in collaboration with others who assure me that this would contribute to the process of change.
      Policy and politics are difficult, but it is difficult to accomplish much without also careful study of the procedures embedded in the organizations and social structures that shape the lives of children. The Accreditation Council for Graduate Medical Education recognized this 10 years ago, when “system-based practice” became 1 of the 6 competencies at the core of medical practice.
      • Dickey J.
      • Girard D.E.
      • Gehab M.A.
      • Cassel C.K.
      Using systems-based practice to integrate education and clinical services.
      As we learned from Dr Li,

      Li ST, Tancredi DJ, Burke AE, et al. What learning goals do residents develop? Abstract presented at: Pediatric Academic Societies Meeting May 5, 2014; Vancouver, British Columbia.

      it is one of the competencies for which residents find most challenging to set goals. This likely reflects our discomfort with teaching the importance of organizational structure in facilitating clinical excellence. Policies and politics happen within clinical organizations, communities, professional associations, and governments. As organizational guru Steven Covey pointed out, “All organizations are perfectly aligned to get the results that they get.”
      • Covey S.M.
      • Merrill R.R.
      The Speed of Trust : The One Thing That Changes Everything.
      We need to understand institutional structure and procedures to effectively intervene on behalf of children. The key points of leverage for the mental health services that Gordon needed were mostly embedded in the structure of the Medicaid system, but his case also raised issues of interagency collaboration.
      • Kenny H.
      Implementing the Rosie D. Remedy: The Opportunities and Challenges of Restructuring a System of Care for Children’s Mental Health in Massachusetts.
      The former can be addressed through challenges to regulations; the latter required changes in the law. Fortunately, the coalition with which I was now associated was able to address both. Out of all this came the Massachusetts Child Psychiatry Access Project,
      • Sarvet B.
      • Gold J.
      • Bostic J.Q.
      • et al.
      Improving access to mental health care for children: the Massachusetts Child Psychiatry Access Project.
      the Children's Behavioral Health Initiative,
      • Romano-Clarke G.
      • Tang M.H.
      • Xerras D.C.
      • et al.
      Have rates of behavioral health assessment and treatment increased for Massachusetts children since the Rosie D. decision? A report from two primary care practices.
      • Hacker K.A.
      • Penfold R.
      • Arsenault L.
      • et al.
      Screening for behavioral health issues in children enrolled in Massachusetts Medicaid.
      and the Omnibus Children's Mental Health Act of 2008.

      Massachusetts State Bill 2804, An Act Relative to Children's Mental Health. 2008.

      This was an example of system-based practice at the level of state government.
      To make advocacy part of our “lifeblood,” academic pediatricians must engage in discussions of policy, politics, and procedure. Despite Rudolf Virchow's famous statement that “Medicine is a social science, and politics is nothing more than medicine on a larger scale,”
      • Mackenbach J.P.
      Politics is nothing but medicine at a larger scale: reflections on public health’s biggest idea.
      most of our training does not prepare us for the work of public policy and advocacy. So how far into this foreign land should we go? I would say that it depends on you. How far you are willing to go for your patient? That is a decision that comes from your heart. To quote yet another former APA President, Abe Bergman, “Advocacy is not a specialty but rather a personal calling…”
      • Bergman A.
      Advocacy is not a specialty.
      Most of us are comfortable in the role of content expert, explaining the implications of the science of medicine or the reality of clinical practice to policy-makers. Most of us have gone to bat for a patient and their family, to assure that they get the care that need. Some of us have gone further, serving on committees or in offices at the local, state, and national levels that set policy. A few of us, like our Armstrong lecturer Karen Hein, have gone further, serving in state and national government, engaging fully in the struggles around the formulation and implementation of health policy, and frequently finding themselves in a position to make a real difference for children. It is not generally a part in our job description, but we do it as part of our job.
      That really begs the question: should it be part of our job description? If this is part of our duty as a professional and an integral part of the proud tradition of pediatrics, shouldn't it be valued as an academic endeavor? Engagement with advocacy and public policy can fall squarely into the Scholarship of Application, which Boyer defined as “the application of knowledge, as the scholar asks, How can knowledge be responsibly applied to consequential problems? How can it be helpful to individuals as well as to institutions.”
      • Boyer E.
      Scholarship Reconsidered: Priorities of the Professoriate.
      When we do research, we should ask the question “How should my work inform that way we care for children?” When we teach about patient care, we should reflect with our learners about the systems in which we care for patients, and how physicians can best contribute to their improvement. As we reflect on the care of our patients, we should consider how our practice experience can be used to inform the policy decisions that set the bounds of our practice. Those of you who are here for the entire plenary session will note that the first 4 abstracts presented each used science to dissect a problem in public policy. Those whose stay later will see examples of work that should inform future policy interventions. This is scholarly work in public policy. Policy briefs, option papers, legislative testimony, reflective essays, op-ed pieces, even commentary on the evening news—all of these can be scrutinized for scholarly value, and should become part of the story of an academic's life work, his or her curriculum vitae. Some institutions are incorporating such work into their promotion assessments.
      • Jacobs D.B.
      • Greene M.
      • Bindman A.B.
      It’s academic: public policy activities among faculty members in a department of medicine.
      There should be more of that.
      Clearly, I believe that we should engage in the policies, politics, and procedures that affect our patients. This is not a call for partisanship—in fact, excessive partisanship might make us less effective in our advocacy. We need to listen to all stakeholders with an interest in children, and that includes pretty much everyone. We need to put the needs of children and families above ideology and partisanship. We need to use all of the skills that help us to work with complex families with diverse points of view to engage in conversations that result in change that helps children.
      I was fortunate when I was confronted with the clinical challenges presented by Gordon and his family. I had 20 years of community-based practice under my belt, a decade of experience with the APA's Advocacy Training Special Interest Group, years of training through the American Academy of Pediatrics (AAP) Community Access to the Child Health Program, and experience working with attorneys through our medical-legal partnership. I had been recently awarded a Physician Advocacy Fellowship though the Center for Medicine as a Profession at Columbia University.

      Institute on Medicine as a Profession. Physician Advocacy. Past Fellows List. Available at: http://imapny.org/physician-advocacy/past-fellows-list/. Accessed July 2, 2014.

      Afterward, the Robert Wood Johnson Foundation Health Policy Fellowship gave me time to understand what we had done.
      • Helms C.M.
      • Rieselbach R.E.
      • Genel M.
      The Robert Wood Johnson Health Policy Fellowship. The experience and perspectives on its academic applications.
      My experience gave me the ability to engage; the Fellowships gave me the time to do so in a rigorous and academic fashion. We in the APA need to provide support for our trainees and junior faculty, to help them discover how they will integrate the “lifeblood” of the APA into their academic life. The APA's Public Policy and Advocacy Committee has hosted many discussions of the effect of pending changes in Federal policy on children and child health, in person and on the listserv. The APA works with the AAP Federal Office through the Pediatric Policy Council to align efforts among academic organizations. The APA's special interest groups frequently encourage their members to consider the implications that their work in education, research, and clinical care have for policy makers, resulting in commentaries and policy statements that reflect the APA's core values. The APA journal, Academic Pediatrics, has published an increasing number of commentaries and supplements on policy-related areas, building a scholarly literature in the field.
      • Szilagi P.G.
      • Shuster M.
      • Cheng T.
      The scientific evidence for child health insurance.
      • Berdahl B.
      • Owens P.L.
      • Dougherty D.
      • et al.
      Annual report on health care for children and youth in the United States: racial/ethnic and socioeconomic disparities in children’s health care quality.
      • Keller D.
      • Chamberlain L.J.
      Children and the patient protection and Affordable Care Act: opportunities and challenges in an evolving system.
      Members of our Advocacy Training SIG published a set of educational objectives for pediatric training programs intent on integrating child advocacy into their work.
      • Wright C.J.
      • Katcher M.L.
      • Blatt S.D.
      • et al.
      Toward the development of advocacy training curricula for pediatric residents: a national delphi study.
      Working with the AAP's Community Pediatric Training Initiative, our Educational Scholars Program supported a cohort of scholars intent on integrating community engagement with medical education. The Community Pediatric Training Initiative has pushed that work onward, developing Entrustable Professional Activities for consideration by the American Board of Pediatrics as part of professional definition. This year, for the first time, the APA cosponsored a successful meeting on Child Health Policy with AcademyHealth in Washington. All of this activity is laudable, but it has not yet created the critical mass of academics we need if we are to truly engage in the work of creating a better world for children. We need to do more.
      In my post-Presidential year, I plan to develop a new program within the APA, patterned on our successful Educational Scholars and Research Scholars certificate programs. The APA Policy Scholars program would offer junior faculty the opportunity to develop their analytic skills, and work with senior mentors with experience and expertise in the effective implementation of child health. Although we will use the Pediatric Academic Societies meeting as an opportunity to demonstrate how the Scholar's work in policy integrates with the other academic pursuits, I hope to collaborate with others, such as the AAP Federal Office and AcademyHealth, to create an integrated model for the development of academicians who see policy as central to their career development. Through this program, we will create a cadre of scholars who will assure that the “lifeblood” of the APA is the lifeblood of academic pediatrics around the country.
      This is not just about what your association can do for you, however. Increasing the interchange between academic pediatricians and the systems that serve children in this country requires us all to ask ourselves “What else can I do for children?” and to make our default answer “yes” when someone asks for your help. Can you be on the Health Advisory Council of your local HeadStart Program? Yes, you can. How about helping a school system draft its wellness policy? Sure. You'd be happy to help. Should you serve on the State Death Review Panel? Absolutely. Are you ready to run for State legislature? Perhaps. All of us hit our limit somewhere. There are literally hundreds of ways for you as academic pediatricians to serve your communities and the greater good of children in those communities. Say “yes” as often as possible. The connections you build will allow you to do more for your patients. We in the APA can help you think about ways to leverage your efforts on behalf of children.
      In his Presidential project, Benard Dreyer has engaged the APA in the struggle to address child poverty in the United States, recognizing that child poverty is a main driver of child health disparities in our country and an intractable problem that is the result of many factors in other (nonhealth-related) spheres.
      • Dreyer B.P.
      To create a better world for children and families: the case for ending childhood poverty.
      In all of his talks, he ends with a quote from Judaism, the Tikkun Olam: “It is not your obligation to complete the task of perfecting the world, but neither are you free to stop from doing all you can.” We need to think hard about that when deciding how far we are going to go for our patients. We should embrace the opportunity to help children individually, in our communities, and across the nation. The APA should work with you to ensure that you, as academic pediatricians, have the tools at hand to do the work.
      Thank you again for the opportunity to serve as your President. Now, let's get back to work.

      Acknowledgments

      Previous presentation: This was given as the Presidential Address at the 2014 APA annual meeting.

      Supplementary Data

      References

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