by Gonzalo J. Paz-Soldán, M.D., C.P.E., FAAP
The drive to deliver value and achieve the triple aim is
creating tremendous pressure for change in health care
organizations in general and in primary care in particular. Primary care teams need direction and leadership,
and pediatricians need to be equipped with essential
skills and knowledge to assume leadership roles at the
practice level as well as the larger organizational and
Increasingly, new payment models require providers
to take on more risk, focus on population health and
demonstrate measurable outcomes and value.
In Massachusetts, for example, the creation of 18
Medicaid accountable care organizations (ACOs) was
approved in June to allow the state to move almost
all its Medicaid patients to that model. These changes
have increased stress on a primary care delivery system
already experiencing significant challenges due to increased time demands on providers, electronic medical
record implementation, increasing use of metrics, the
need to address social determinants of health, increasing complexity of patients and a workforce shortage.
Not surprisingly, primary care doctors experience
high rates of burnout and an alarming rate of suicide.
Although these problems are felt more acutely in adult
primary care, pediatrics also is struggling with the same
In this context, physicians have a critical and unique
role to play in taking the lead in developing and implementing the changes needed to move primary care
practice from “survival mode” to a “thriving mode” and
restore the joy of practice.
There is consensus and good evidence that a signif-
icant part of the solution to problems in primary care
has to rely on team-based care and a patient-centered
Reliant Medical Group, a large multispecialty physician group in central Massachusetts with a significant
portion of patients in full risk contracts, has been piloting co-located care teams. Pediatric primary care
teams consist of a pediatrician, nurse practitioner,
receptionist, medical assistant and nurse, and an integrated extended care team that includes a behavioral
health provider, nurse care coordinator for children
with special health care needs and a medical social
worker or community health worker. Early results are
encouraging and show the potential to restore the joy
of practice for pediatricians, increase staff engagement,
decrease staff turnover and improve patient experience.
Physicians generally are perceived as the role models
and leaders for their team, and they need to embrace
that role. Leading a team in a fast-paced, unpredictable
work environment requires certain competencies that
most of us may not have learned in medical school or
residency. To be effective leaders, pediatricians need
to develop strong skills and feel comfortable with the
• communicating effectively within the team as well
as across and up and down the organization;
• setting clear expectations and goals and holding
people accountable to them;
• giving feedback — both positive and negative —
in a timely manner, and coaching team members
so they can perform at their best; and
• having a good understanding of the business mod-
el in which the practice operates and being able
to translate business imperatives into patient-cen-
tered priorities that resonate and motivate team
Physician leadership at the practice, organizational
and health care system levels is going to be essential to
transform the health care system into one that delivers
on the “quadruple aim” — quality, value, patient expe-
rience and provider and staff wellness and engagement.
Medical schools, residency training programs, health
care organizations and professional organizations
would benefit from the development of training and
education opportunities for pediatricians to develop
the skills and knowledge to be effective leaders.
Pediatricians are uniquely positioned to play a key
role in leading the change, given our longstanding fo-
cus on providing patient- and family-centered care,
addressing social determinants of health and working
in a team-based environment that can deliver com-
prehensive, quality and accessible care to all patients,
including those with complex and chronic illnesses.
Change is stressful but also presents opportunity.
Alternative payments models and ACOs can open
the door to implementation of the patient-centered
medical home model on a large scale across primary
care — something pediatricians have been eager to do
for several decades. To do this, however, we need to be
ready and willing to step up to the leadership challenge.
Dr. Paz-Soldán is a member of the
AAP Council on Community Pediatrics
and is regional executive medical director,
pediatrics, at Reliant Medical Group.
Pediatricians need to take leadership roles to restore joy of practice