On SOAPM the other day, this question was posed to the group to an unfortunate radio silence:

What do we view as the biggest issues we must address and prepare for over the next 3-5 years as primary care independant pediatricians?

During our Users' Conference last month, I had the opportunity to sit in front of a big crowd and prognosticate on a similar question. "What do pediatricians have to worry about?"

I remember most of my answer and I'll try to share it here. I'd love to hear from anyone who agrees, disagrees, wants to add, etc.

First, I am an optimist at heart. I not only feel, but have data to show, that pediatricians are generally much better off today than they were 10 years ago. Sure, plenty of new annoyances and problems, but overall the medicine is substantially better and the money is measurably better.  Kids are better served by pediatricians today than they were 20y ago and pediatricians make more money as a rule.  That makes me optimistic.

There are things that keep me up at night, however. Here they are.

• I worry about anything that erodes the delivery of, value of, or even the perceived value of preventive care. Preventive care is the heart and soul of pediatrics. Without preventive care, ambulatory peds is done.
  
  What interferes with preventive care? The distraction of minute clinics, hospitals offering sports physicals and cheap telemedicine, and the watering down of critical, scientific thinking.
• I worry about anything that limits access to your patients.
  
  Hospitals and insurance companies and health care systems want to get in between you and your patients. Narrow networks ought to be illegal, imo. My feelings about mandated insurance coverage are complex, but when grandfathered insurance plans don't want to pay for any element of well care for children, I wonder what their vision of health care is?
  I also fear any process (referrals, formalaries, stupid billing requirements) that get in between you and doing what you need to do for your patients.
• Healthcare is incredibly regional and anything that affects your local birth rate in a negative way should be a red flag.
• Continued consolidation of forces that don't value primary care, especially pediatrics.
  
  Children's hospitals announcing new buildings in saturated markets on the same day tells me that children aren't the focus of expansion. How exactly do the children of Dallas/FW benefit from all the money being spent here? Or is this just a cold war race to see which hospital "wins?" 
• I fear continued dependence on EHRs remaining the source of most of the soul-sucking that happens in pediatrics. As long as your EHR is used primarily to defend your billing and prove some quality measure, you will always be someone else's click monkey. The Feds have a huge role in this problem, as do the payors.
  
  I've seen the arrival of an EHR trigger too much latent OCD in individual physicians, killing their productivity and joy. I've seen EHRs "capture" pediatric practices and put them in a position where the practice can't leave, dooming the enjoyment of work. I've seen EHRs that are designed for inpatient use forced on community docs, adding hours of unnecessary work.

Ultimately, I explain to practices all the time: as long as families keep having babies, you should be good.  Some of the larger fish (sharks, really)  in your area are trying to interfere with your crucial work, but the nimbleness, flexibility, and fundamental importance of independent pediatrics gives most of you a very, very safe and rewarding profession...even if it doesn't feel that way.