Closing the gap between pediatric and adult care

Sad Woman Silhouette Walking Alone At SunsetMy colleagues who are trained in both Medicine and Pediatrics (commonly known as Med/Peds) describe themselves as being able to speak two languages. They can speak “pediatrics” when they are in child health settings and they can speak “internist” when they are in adult medical settings.

I myself combined three different types of training because I believed being trained in Pediatrics, Psychiatry, and Child and Adolescent Psychiatry would provide me with the skills I needed to care for chronically ill children and young adults. What I did not realize was that this training would lead me to become an ambassador between systems.

From this ambassador position, I quickly realized that the gaps in culture between these specialties were not just academically interesting they were actually causing harm. There is a documented increase in morbidity and mortality for young adults around the time of transfer from pediatric to adult settings, often related to youth dropping out of care or being unable to effectively navigate the adult system. Young adult patients are suffering in part because the pediatric and adult medical systems are not compatible with each other.

In 2015 my collaborator, Richard Chung, MD, and I received a Picker Gold GME Challenge Grant for the Duke Transition Collaboration Clinic. This clinic brings together dyads of trainees in pediatric and adult medicine to see adolescents and young adults with chronic illness (medical, developmental, and/or psychiatric). Didactic and clinical experiences are designed with the aim of helping trainees develop empathy toward the patients, but also toward providers with different backgrounds and training.

Residents and fellows from a range of programs have participated in this clinic including trainees in Pediatrics, Internal Medicine, General Psychiatry, Child and Adolescent Psychiatry, Combined Medicine and Pediatrics, and Combined Medicine and Psychiatry. The clinic provides them with opportunities for residents from pediatric and adult programs to see patients together and to meet in teams that often include a parent navigator and young adult peer coach.

Residents may only do one or two transition appointments during the clinic session, but they are able to dive deeply into the lived experience of one patient and to reflect on their own experience in delivering care. For me I was always filled with wonder whenever I walked into our team meeting room after seeing a patient. It was never quiet. Residents were speaking to one another or listening to our peer coach share his story or working with a social worker to identify resources for a family that was struggling. It was experiential learning; an opportunity to engage with the challenges facing young adults and their families.  A description of the clinic is scheduled for publication in the Journal of Graduate Medical Education.

As part of the Picker Gold Challenge Grant, we conducted a survey of over 400 trainees at our larger institution and found that most trainees did not feel confident in their ability to communicate with other providers about adolescent and young adult patients and did not feel knowledgeable about the differences between the pediatric and adult medicine systems. However, there was a strong positive relationship between residents receiving formal training or mentorship around transition and their confidence in their ability to communicate effectively to other providers.

To me, this is an exciting finding because it shows that if we take the time to talk about the cultural differences between the pediatric and adult health system with trainees and dedicate time in residency curricula we can address a significant training gap and hopefully improve patient outcomes. While we cannot train all physicians to be ambassadors between the pediatric and adult health care systems, with a brief focused clinical experience we can provide a training experience that will get the conversation started.

One resident provided feedback that is a clear summary of our hopes for this type of humanistic educational endeavor:

Helping to strategize with patients about how to transition their care, take more responsibility in their overall physical and mental health, and problem solve while on their own without parents/caregivers was very rewarding.  A visit that was dedicated to patient based care rather than to a singular problem was, I believe, beneficial to both the patient and myself.

Gary Maslow

Gary Maslow, MD, MPH received the Gold Foundation’s Leonard Tow Humanism in Medicine Award during his time at Dartmouth Medical School. He is currently an Assistant Professor at Duke University School of Medicine practicing as a primary care pediatrician and is the co-chief of the Division of Child and Family Mental Health and Developmental Neurosciences in the Department of Psychiatry.