1. The Family Tree of “General Pediatrics” Where is it Going? Thomas F. Boat, MD Professor of Pulmonary Medicine Cincinnati Children’s Hospital Medical Center Executive Associate Dean for Clinical Affairs University of Cincinnati College of Medicine

2. General/Community Pediatrics Evolution Differentiation Cohesion Leadership

3. J 1980sUNC History Tree 1990s 2000s 1960s 1970s Iowa Minnesota Rainbow CCHMC

4. Connecting Science and Service Innovation Translation Basic Science

5. Basic Science 1.Psychology health-related behaviors motivation prevention 2.Sociology cultural barriers poverty 3.Engineering systems redesign standardization information systems

6. Basic Science (continued) 4.Economics cost : benefit affordability 5.Law/political science/government regulatory milieu legislation advocacy 6.Business business plans marketing human capital outcomes

7. Basic Science (continued) 7.Epidemiology magnitude of health problems longitudinal tracking 8.Biology human genetics environmental pathobiology

8. Connecting Science and Service Innovation Translation Basic Science

9. Prediction Translation/Practice Innovation

10. Prevention Elements 1.Defining problems 1.Identifying risks 1.Reducing risks 1.Intervening early

11. Prevention 1.Universal 2.Selective 3.Indicated

12. Emotional And Behavioral Problems 1.25% of pediatric visits 2.20% of 0-18 year olds (cross-sectional) 3.40% of 0-18 year olds (longitudinal) 4.Enormous cost 5.No systematic response

13. Screening Sites For Risks 1.Primary care 2.Schools/day care Risk Reduction

14. Risks For Emotional And Behavioral Problems (Evidence-based) 1.Parental mental disorders 2.Exposure to violence; neglect 3.Divorce 4.Death of parent 5.Harsh parenting 6.Bullying 7.Foster care 8.Catastrophic events 9.Poverty 10.Chronic disease

15. Screening and Early Interventions 1.Tools 2.Model programs 3.Can this approach be incorporated into practice?

16. Barriers to Screening 1.Time 2.Unreimbursed cost 3.Inability to assess, intervene How do we surmount barriers?

17. Prediction Translation/Practice Innovation

18. Prediction 1.Genetic factors 2.Environmental exposures 3.Psychosocial experiences

19. Adverse Childhood Experiences (ACE) Study (Felliti, Am. J Prevent Med 14:245, 1998) Cohort: 17,421 adults in the San Diego Kaiser Permanente system (68% of eligible adults) Measures: A. Recall of 8 adverse childhood experiences 1) recurrent physical abuse 2) recurrent emotional abuse 3) sexual abuse 4) family member who was alcoholic or a drug abuser 5) imprisoned family member 6) depressed family member 7) mother who was the target of violence 8) separated or divorced parents B. Health assessment (average age = 57)

20. Adverse Childhood Experiences (ACE) Study (Felliti, Am. J Prevent Med 14:245, 1998) 1.4-12 fold increased risk of alcoholism drug abuse depression suicide Adults who reported 4 or more types of ACE had:

21. Adverse Childhood Experiences (ACE) Study (Felliti, Am. J Prevent Med 14:245, 1998) 2.2-4 fold increased risk of smoking poor self-related health sexually transmitted diseases 3.An increased risk of obesity ischemic heart disease cancer COPD skeletal fractures liver disease

22. Prediction Translation/Practice Innovation

23. Pre-emptive Health Plans 1.Individually tailored 2.Risk-specific interventions education modification of health behaviors self-management support systems - action plans - monitoring

24. Prediction Translation/Practice Innovation

25. Health Services Delivery 1.Shortfalls in safety, effectiveness, efficiency, equity, access, family/patient centeredness 2.Opportunity for leadership Intervention design Outcomes measurement Implementation - community practice - home Defining and enhancing value Influencing public policy Redesigning payment systems

26. QI Research Methodology 1.QI methods 2.Application and interpretation of quasi-experimental designs 3.Systematic reviews and meta analyses 4.Implementation of RCTs

27. Connecting Science and Service Innovation Translation Basic Science

28. Should General Pediatrics Continue To Differentiate? 1.It’s inevitable 2.Heterogeneity is desirable 3.Foster collaborative efforts 4.Be the conduit, cohesion factor for child health programs that span discovery to implementation

29. Leadership Not empire building Creating shared vision Enabling an array of stellar contributions

30. Visualize the Whole Tree Add branches (leadership) Sprout many leaves (training) Reach toward the sky