It’s a Brave New World for Your Child’s Pediatrician


If the late Dr. Alexander Menzer of West Hartford, Connecticut, a Holocaust survivor, had been your family’s pediatrician, you would speak with a deep sense of satisfaction as I do now. Cumulatively, for 45 years he provided care to my family’s three children now grown in what was clearly a multi cultural practice. Dr. Menzer knew nothing of being inconvenienced by those awkward and ill-timed illnesses children pass through. He was the only physician whom I knew or heard of who had call-in hours from 7:00 AM to 8:00 AM seven days each and every week. He made the profession of pediatrics very appealing.

Pediatrics is at this time in the practice of medicine going through a rough patch but so is medicine. The Patient Protection and Affordable Care Act will add scrutiny to the services the medical community provides and it will use a number of components to track the quality of care and the extent to which it is effectively and efficiently dispensed. Performance related sanctions are built in to the scrutiny.

The ACA will pay special attention to the incidence of medical errors as a marker for quality and effective care or their absence. It is a little known fact that errors in diagnosis constitute a sizable proportion of medical errors in the United States and are responsible for significant costs and harm. Medical errors related to medication and surgery have received much-needed attention. However, data regarding diagnostic errors in pediatric practice settings are especially limited. Currently, knowledge of these errors is confined to malpractice law suits. Some 32 percent of the closed pediatric malpractice claims are attributable to diagnostic errors.

Types of Errors and Their Implications

In hospitals, medication errors are the single most common type of medical error. Studies have also established that drug errors have consistently been the major cause of iatrogenic illness (illness associated with physicians’ decisions), followed by prolonged hospitalizations and injury to patients in hospitals. A recent Institute of Medicine study reported that the underlying cause of medication errors is frequently due to inadequate drug knowledge. Additionally, the majority of the medication errors are more likely to occur while physicians are placing the order (74%), order transcription, and nurse administration.

However, medication errors are more likely to be intercepted before reaching the patient if the source of the error occurs early in the process. For example, 48% of errors are likely to be caught during ordering of the medication versus 2% during the actual medication administration. The research also reports that the profession most likely to detect and intercept an error is nursing (86%), as compared to pharmacy (12%).

"Our study provides new data about types of diagnostic errors among children and their cause and lays the groundwork for a multifaceted approach to reduce such errors," wrote the authors of a recent study led by Hardeep Singh, MD, from the Houston Veterans Affairs Health Services Research and Development Center of Excellence, Baylor College of Medicine. This study was their attempt to address the issue of pediatric errors more substantively. Their findings show that more than half of pediatricians make diagnostic errors at least once a month, and almost half make diagnostic errors that cause harm to patients at least once a year, according to the results of their survey.

There are over 83,000 pediatricians. More than one-half (54%) of survey respondents reported that they made a diagnostic error at least once or twice per month. Almost one-half (45%) of respondents reported diagnostic errors that harmed patients at least once or twice per year. Failure to gather information through history, physical examination, or chart review was the most-commonly reported process breakdown.  Viral illnesses being diagnosed as bacterial illnesses were the most-commonly reported diagnostic error. Physicians ranked access to electronic health records and close follow-up of patients as strategies most likely to be effective in preventing diagnostic errors.

System-related errors, organizational issues, or communication problems (79%) were deemed the most common contributing factors for diagnostic errors. Inadequate care coordination, teamwork, and/or communication across clinical sites and providers (82%) was rated the most important system-related factor.

Culture and Communication in Pediatric Practice

One aspect of the data as reported by Dr. Singh’s team that attracted my attention was that of the contribution communication breakdown makes to the error rate. Communication as an issue has risen very high in the practice of effective clinical outcomes because of the expansion of diverse cultural groups’ perspectives regarding wellness and the role of healthcare literacy in achieving effective communication between clinician and care receiver and ultimately on treatment outcomes.

Because most clinicians are trapped in the cultural constrains of professional bio-medical language, they often times are unaware that they have not achieved real understanding of what they are passing to the patients who are reluctant to express their befuddlement. They simply do not want to appear stupid.

The health industry is increasingly coming to realize the importance of cultural sensitivity and health literacy in the delivery of care services. But the burden of effecting organization cultural change rests disproportionately on nurses because of their sustained patient engaged practices. In an address to pediatricians in California, Professor Fernando Mendoza, chief of the division of general pediatrics at the Stanford University Medical School drew their attention to data that showed that 100 different dialects and languages are spoken by children in that state--a challenge for educators to say nothing of school nurses.

“Becoming cross-culturally effective means borrowing techniques from anthropology,” counseled Dr. Mendoza as he asked pediatricians to watch, listen, and elicit family participation by asking the question, "What do you think is going on with your child?" He urged pediatricians to focus on the interaction between patient and physician because this will contribute to building physician-family partnerships and measurably improve physician-family trust. But he cautioned that learning the details of each culture represented in one's practice, particularly as the U.S. pediatric population becomes less and less white, while admirable will add an undesirable burden on an already demanding service profession.

Nurses contribution to patient satisfaction

Why is it virtually impossible to achieve appropriate medical outcomes when culture is ignored? It is related to what is understood regarding the notion of care and how we define ourselves. Notions of satisfactory care are influenced by the alliance developed between the care provider and the care receiver as well as the expectations of each regarding the outcomes from advised protocols. In healthcare, how we define ourselves is a reflection of what we believe about how illnesses affect us. It is also a reflection of family dynamics and interactions, socio-economic status, religious beliefs and values, inclusive of beliefs held regarding the use and efficacy of non-Western medicine. It is the nurse who is particularly well positioned to identify and respond to these attributes on the part of patients.

A healthcare organization for every cultural group is not the answer. It is the responsibility and willingness of care organizations to develop or strengthen internal capabilities around cultural and literacy healthcare competence and expanded notions of service to diverse populations.

Effective, competent, cultural and healthcare literacy is not the delivery of care services that treat patients using the methods and practices of their native countries. Cultural and literacy competence informs a persuasive case as practitioners seek to understand the different expectations care receivers have when interacting with a clinical setting. No place is this more critically relevant than when the parent is representing the interests of children who cannot speak on their own behalf. In their capacity as pediatric partners nurses can provide leadership in responding to our changing demographics and continue to impact the rate of medical errors.

As a pediatrician, Dr. Menzer modeled these attributes admirably and his nursing staff paid him close attention.