Pediatrician FALL 2012 Back to the Future For private-practice pediatricians, “The times they are a-changin’,” notes Maryland pediatrician Dan Levy. R egardless of the demands he faces in daily practice, pediatrician Dan Levy takes a thoughtful, upbeat approach in caring for his patients. wings Mills, Md., pedia- he was asked earlier this year to do a What evolved out of that era of the trician Dan Levy recalls presentation at Johns Hopkins’ annual simple doctor-patient relationship, driving by a park a few sum- Pediatric Trends conference on Sept. starting in the mid-1960s, were groups Omers ago not too far from 20, it was only natural that he’d select like the American Academy of Pediatrics his favorite summer vacation spot, Lake “Imagining the Future of Pediatric and guidelines for preventive care and George in upstate New York. The sign at Medicine” as his topic, but in the wellness, which led to Bright Futures, the entrance – “The Abraham Jacobi and context of what physicians like Abraham the gold standard of pediatric care Carl Schurz Memorial Park” – stopped Jacobi brought to pediatrics. today. In the 1990s came managed him in his tracks. “We have to start thinking about the care and initiatives to make health care “I did a double take and pulled the changing dynamics and demographics of more efficient and affordable. What it car over,” says Levy, a self-described pediatric practice, and we have to adapt meant for a lot of pediatricians, Levy medical history buff who knew well the to that and understand the realities,” added, was less control of care and more story of Abraham Jacobi, the so-called Levy said. “But we can’t talk about the work for the same or less amount of father of pediatrics who established one future until we talk about where we compensation. An expansion of pediatric of the first children’s clinics and pediatric came from.” sub-specialists – and a decline in pediatric departments in this country. “I found Jacobi and some of his contempor- primary care – followed, along with the town historian, who took me into aries, Levy explained, initiated and higher expectations among consumers. the town hall, a back room and a whole developed concepts like prevention, “This put more pressure on the system file on Jacobi.” wellness and primary care for children because there’s more demand for the Rummaging through the archive, in this country. The initial concept of services we can provide but there just Levy reflected on his own 35 years as prevention was well-baby clinics and aren’t enough of us to provide that a pediatrician and changes in pediatric care rendered in pediatric offices, Levy service,” Levy said. “Fewer and fewer medicine during that time – like explained. “The expectation,” Levy said, people are interested in going into managed care, the Affordable Care Act, “was you’d walk into the office and the primary care.” and the retail medicine craze. So when doctor would sit and talk with you.” continued on page 5 In Clinic Radiology In Practice In the Community 2 3 4 6 Director’s Column In Clinic George Dover, M.D. Director, Johns Hopkins Children’s Center Given Professor of Pediatrics Looking back, moving ahead I n Bloomberg Children’s Center’s upgraded echocardiography suite, equipped with advanced telemedicine technology, pediatric cardiologists W. Reid As I’m pretty sure you’ve heard by now, we’ve Thompson, left, and Phil Spevak review images. moved into a marvelous new building, The Charlotte R. Bloomberg Children’s Center. As we look ahead at how pediatric medicine might change in our new home, we thought Screening for Critical it might be constructive to look back to our origins, which surprisingly were in a tiny two- story building known as the “Bath House.” Congenital Heart Disease Apparently, in 1896 baths were considered therapeutic. ritical congenital heart disease and an echocardiogram is done to check At the time we had no full-time pediatric (CCHD) – heart conditions like for CCHD. Studies have shown that the faculty, training or research program. But with pulmonary atresia associated combined use of pulse oximetry and a the opening in 1912 of the Harriet Lane Home with hypoxia that require physical exam along with focused prenatal came the first full-time academic department C interventions like surgery or catheterization echocardiography identifies 80 percent of in pediatrics in this country. The melding of soon after birth – has been responsible for infants with CCHD. pediatric research and training with patient more deaths in the first year of life than Through simulations and actual screens, care followed and Hopkins became known for any other birth defect. Fortunately, around Hopkins staff in obstetrics, neonatology pioneering pediatric treatments. By the late half of CCHD patients are diagnosed by and pediatric cardiology prepared for 1950s the Harriet Lane Home was outmoded ultrasound prenatally – and of those missed the statewide screening kickoff Sept. 1. and drawings were drafted for the Children’s about 60 percent by symptoms on physical At Johns Hopkins Hospital and Johns Medical & Surgical Center (CMSC), where exam soon after birth – and appropriately Hopkins Bayview Medical Center the pediatric academic medicine would thrive over treated. But some 280 infants born with test is administered in term infants by a the next half century. The CMSC eventually CCHD in the United States each year are pediatric nurse practitioner or nurse in outlived its space, too, and in 1998 we began undetected and discharged from nurseries, the nursery. Neonatologist Christopher planning a new building – Bloomberg Chil- notes Hopkins Children’s Center pediatric Golden explains that physiologic changes dren’s Center – with a new challenge: How cardiologist Phil Spevak, placing them in the neonatal heart in the first 24 hours would we sustain the innovation that sus- at greatest risk of deteriorating before after birth may give false positive or false tained the Harriet Lane Home and CMSC? diagnosis. negative readings; hence, screening is done Interestingly, in a parallel way, pediatrician “They may get metabolic acidosis, poor after one day of life. If the infant fails the Dan Levy in this issue looks back at pioneers perfusion and, potentially, brain and first screen, a second and, if necessary, in pediatrics like Abraham Jacobi and his em- kidney failure,” Spevak says. “It’s not the third screen is done, each an hour apart. If phasis on primary care, prevention and well- controlled prenatal presentation where all three tests are abnormal or borderline, ness – and shares how such early hallmarks of you’re stabilized in the neonatal intensive an echocardiogram is ordered. pediatric medicine are being stressed in new care unit (NICU) and have elective Spevak stresses that pediatric cardiology models of care today. Similarly, neonatolo- management.” staff have added resources, including gist and informatics expert Chris Lehmann However, a new non-invasive screening advanced telemedicine technology, to opens a wide window to our future with elec- test recommended by the Department handle the anticipated increase in calls tronic health records in this era of dynamics of Health and Human Services and from both Johns Hopkins and other like the Affordable Care Act. The take-home mandated by the state of Maryland aims Maryland hospitals requesting echo reminder is that regardless of whether our to significantly reduce the number of readings: “We have the ability to receive space is a state-of-the-art children’s hospital missed diagnoses among those born with the calls, interpret the test, and get the with a rich history or a demanding pediatric CCHD. The test, called pulse oximetry, results out quickly.” n practice, we all bring ideas to the table. Col- involves placing a small sensor on both laboration and innovation continue to be es- the baby’s hand and foot to measure the For more information on CCHD screen- sential as we strive to provide the very best amount of oxygen in the blood. If no ing, visit the Centers for Disease Control care possible for children. n other reason for low oxygen saturation is and Prevention at www.cdc.gov/ncbddd/ found, pediatric cardiology is consulted pediatricgenetics/pulse.html 2 | PEDIATRICIAN FALL 2012 Radiology Imaging for Kids Only t wasn’t too long ago, Children’s Center areas for inpatients and Pediatric Radiology Director Thierry outpatients that reduce Huisman notes, that a 4-year-old would their risk of infection. Ifind himself in a radiology waiting room Also, Children’s Center sitting next to a 85-year-old man, or a healthy radiologists are using child next to a sick child. That’s because the newest imaging pediatric radiologists shared space with equipment optimized their adult counterparts where they treated for low-dose radiation, both inpatient and outpatients. Also, their reducing exposure to offices and the imaging suites they used were children. dispersed throughout the hospital. In a sense, Family-friendly the division had no home. initiatives include glass- No more. Now housed on the fourth enclosed alcoves in the floor of the new Charlotte R. Bloomberg radiology suites to allow I n the new CT suite for children only, (from left to right) Children’s Center, pediatric radiologists – young patients to have pediatric radiologists Melissa Spevak, Thierry Huisman for the first time – have their own space. visual contact with their and Aylin Tekes. “It’s much more convenient for parents parents while undergoing and children to go to one place in a imaging. Also, dedicated “quiet rooms,” the studies and ED physicians. “This pediatric setting,” says Huisman. “They do designed to have a calming, soothing effect will greatly improve the quality of not have to walk into a hospital for adults.” on young children awaiting imaging, is interpretation of imaging studies,” says Another plus, Huisman notes, is helping them avoid general anesthesia.