Serving Alaska’s Smallest Patients
Pediatricians care for the whole health of the state’s children
The bimodal nature of our state’s healthcare system, pressure on pediatric specialists, and the rugged nature of the state are all challenges facing pediatricians who practice in Alaska.
“The way I heard it when I was a student was most healthcare providers walk into the pediatric floor and think it’s the saddest part of the hospital, right? Because there are sick kids,” says Dr. Monique Child of Polar Pediatrics. “Some of us walk in there and go: this is the best part—there are popsicles and stickers and kids get better.”
Child points out that unlike many instances in adult medicine, children’s bodies seem determined to heal themselves.
“The beautiful thing about kids and pediatrics is that if you’re lucky, even when something is bad, like let’s say a congenital heart defect or something’s wrong with the heart, the whole rest of the body is working to get better,” Child says. “When I was doing adult medicine, it sometimes felt like you tried to fix something with a heart by adding a medicine or doing something and the kidneys don’t like it or the liver goes off line. And so you end up chasing your tail.”
Creating an environment to put kids at ease is an important part of a pediatric clinic.
No matter where they work, one problem pediatricians are forced to troubleshoot is communication barriers. Children are often unable or have difficulty describing events or incidents that led to a medical issue or the severity of their pain or symptoms.
“We have to take into consideration the developmental stages of kids, which changes quarterly in the early years of life,” says Dr. Wes Gifford, a pediatric hospitalist at Alaska Regional Hospital. “Understanding what they’re able to do is extremely important for interpreting their clinical presentation. For example, a six-month-old infant with a noticeable head lag and inability to roll from their chest to back is abnormal and suggests developmental delay which itself can be a harbinger of many different neurologic issues from brain tumors to subclinical seizures to child abuse. This kind of assessment is not in the wheelhouse for an adult doctor.”
Another issue pediatricians face when it comes to communication is that it’s not just their patient they need information from; they also need to work with parents to get a full picture of the medical situation.
“It takes a lot of social skills to help parents feel comfortable with your recommendations and motivate them to comply with what you think is really necessary for their child. A big part of our job is to advocate for our patients; we need to ensure that parents are following through with our recommendations since children can’t look out for their own best interests,” Gifford says.
“In the adult world, if a parent doesn’t want to show up to clinic, it’s their problem. But in the children’s world, if they don’t want to show up to the clinic, we have a burden to follow-up—and in some cases—notify the Office of Children’s Services.”
These challenges are often compounded by additional obstacles like long-distance healthcare or difficulty accessing specialists.
Child, who has been working as a pediatrician in Alaska for twelve years, explains that the state’s need for specialists varies from year to year.
“Right now, we have six pediatric cardiologists, but we have only two gastroenterology specialists. We have no rheumatologists. So it kind of depends on which specialists we have in the state in any given year,” Child says.
Even with the right specialists in Anchorage, there are occasions when Child determines it’s in her patient’s best interest to fly to a facility in the Lower 48 where the necessary specialists can provide backup in a worst-case scenario.
Gifford notes that while Alaska does have many specialists, the bimodal nature of its healthcare system makes it more difficult to provide the same sort of wraparound services available at a fully integrated children’s hospital.
“We have this discombobulated system where the Native system is essentially running parallel to the non-Native system,” Gifford says, noting that working for the Alaska Native Tribal Health Consortium is essentially taking a federal job, while other practices in the state are essentially private practices. “I really love the Native system because it provides culturally sensitive and directed care to this community, and I’m also very impressed with the care delivered by the private practices outside of the Native system, but in a sense [these paralleling systems], this division, ends up limiting many pediatric patients’ access to some subspecialists.”
Even taking into account both healthcare systems, there are still holes in the spectrum of specialists or subspecialists practicing in the state. According to Gifford, there isn’t a pediatric geneticist, pediatric biochemical geneticist, or a pediatric rheumatologist.
There are some pediatric psychiatrists, but not enough, Gifford says.
“There’s an increased need for pediatric psychiatrists everywhere in the country, and Alaska is certainly no different. As an example of a recent situation in Alaska, I saw a teenager in the emergency department after a suicide attempt by overdose of a dangerous medication. I admitted them to my medical service due to medical complications from the overdose.”
But when the patient was medically cleared to go home a few days later, Gifford was unable to find a psychiatrist to come to the hospital and evaluate the child, and the social workers on shift had little adolescent mental health training. Gifford explains his only two options at the time were to discharge the patient from the hospital and to the emergency department at Providence by ambulance or to discharge the patient without a proper psychiatric evaluation, despite the suicide attempt. “I spent four hours prior to [the patient’s] discharge trying to find an outpatient counselor that would accept this patient’s insurance and be able to start seeing the patient in less than a month. Passing this insurance/scheduling burden on to the family or to another clinician would have been irresponsible.
“I mean, it’s just a mess… basically, I was functioning like a social worker, psychiatrist, and the pediatrician all at once and taking on the risk of liability as well,” Gifford says.
He asserts this scope of responsibility might be one of the reasons that the state struggles to recruit pediatric specialists.
“I think the biggest factor is that newly trained specialists are afraid of being overworked. As a physician, you really can’t go home at the end of the day if you’re responsible for a patient and there’s nobody else to transfer their care to,” Gifford says.
“So you’re morally—and I believe legally—responsible for continuing to work until you have back up. If you don’t have back up, you’re trapped: your sleep is gone, your family life is gone, your vacation is gone, and everything is gone.
“If you don’t have a system that’s going to protect you, you’re just going to get chewed up and spit out. It’s actually a small miracle that we have some good doctors in town that are willing to be that on-call doctor all the time.”
The demands of our modern healthcare system, in which there are more medications; more diagnoses; more necessary steps to licensing, credentialing, and maintenance of certification; greater attention to customer service; increased liability risks; and the ongoing intricacies of electronic medical records, are making young doctors more hesitant to be on-call day and night, Gifford says.
“Younger physicians are really trying to balance all of these new demands that are put on their shoulders,” Gifford says. “They increasingly want to be put into situations where they’re salaried and employed in a system that is going to, sort of, protect them. But in Alaska, for historical reasons, a lot of the care is given via private practice entities, which is dissimilar to the systems they trained under.”
“I think the biggest factor [preventing Alaska from recruiting pediatricians] is that newly trained specialists are afraid of being overworked. As a physician, you really can’t go home at the end of the day if you’re responsible for a patient and there’s nobody else to transfer their care to.”
“I would love to see us, as a state, fund fruits and vegetables and healthy eating options in more rural and remote places.”
Improving Health Statewide
Child started her private pediatric practice about a decade ago. She says that two of the biggest issues facing child healthcare can be boiled down to a lack of universal healthcare and lack of access to nutritious foods in many parts of the state.
“If you’ve got a sick kid, I want you to have access. I really hope we get to a place in the country where we have universal healthcare. We’re not quite there yet, but I’m hoping we do get there,” Child says, noting that she worked with the Obama Administration on the Patient Protection and Affordable Care Act. “I’ve had to make policies here at the office to make sure parents can pay me whatever they can and finance with zero percent [interest] for as long as they need so they’re not worried about the fact that they have a deductible. For some families, a $500 deductible might not mean anything, but for another family, $500 could mean whether or not they can go to the grocery store this month.”
Insurance issues can be compounded by the costs of travel in Alaska, which has more than 200 remote communities beyond the reach of the road system, Child says, noting that she’s had patients travel from Adak and smaller villages to her office for care.
“I think access to healthy foods [is also an issue]. I would love to see us, as a state, fund fruits and vegetables and healthy eating options in more rural and remote places. And, even here in Anchorage, helping us lower the prices,” Child says. “One of the best things I saw was some of the farmer markets now accept food stamps.”
Gifford says he also believes that certain preventative care measures are essential to pediatric health, especially immunizations.
“It is the single most cost-effective thing that we do,” Gifford says.
Another important part of pediatrics is providing well-child visits, which are designed so that pediatricians can check on a child’s growth and development.
“There are so many things that you can interpret from a growth chart that the family may not realize,” Gifford says. “For example, the second most common form of cancer in children is brain tumors. Just tracking a child’s head circumference can often clue the clinician into the problem. The family may not notice this problem because the head circumference may only be a centimeter off. If the kid is going to all their well-child visits, the pediatrician can pick up something literally months or years before it would otherwise be identified.”
Well-child visits also help pediatricians identify mental health issues early, Gifford says.
“There are a lot of resources that are available for these kids, but if you don’t pick up on problems early it puts you behind… When a kid’s already depressed and cutting themselves or thinking about mechanisms of suicide, it takes a lot more time and effort to provide the help needed,” Gifford says.
In an already complicated field of medicine that requires the skills of various specialists to provide full wraparound services, pediatricians in the Last Frontier face a daunting task of providing for one of the state’s most vulnerable populations. And, yet the state does boast many specialists and dedicated pediatricians.
“Because we’re concerned about the safety of the child… we don’t get to rest just when we send the child home, we get to rest when the child is better,” Gifford says. “Pound for pound, one child patient can sometimes weigh a lot more than a patient in the adult world because of the burdens of the additional care needed to serve these small patients.”
“I’ve had to make policies here at the office to make sure parents can pay me whatever they can and finance with zero percent for as long as they need so they’re not worried about the fact that they have a deductible. For some families, a $500 deductible might not mean anything, but for another family, $500 could mean whether or not they can go to the grocery store this month.”
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Meeting in the Middle
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