The sign at Fernandez-Stein's clinic is patterned on one created by her mother for the school she started in the Dominican Republic in the 1960s.
The sign at Fernandez-Stein's clinic is patterned on one created by her mother for the school she started in the Dominican Republic in the 1960s. Photo credit: Tom Gasparoli

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A North Carolina pediatrician figures out how to spend most of her time counseling parents – and it pays off.

By Tom Gasparoli

MedPage Today/ North Carolina Health News

“When you have a 10-year-old who weighs 160 pounds walk into your examining room, you know it’s not just the act of overeating at the core of that problem,” said Rosemary Fernandez Stein. “It’s a bigger behavioral issue. And that means parenting skills too.”

Rosemary Fernandez Stein is founder of the International Family Clinic in Burlington, where providers offer care in several languages. Photo credit: Tom Gasparoli

Fernandez Stein is the founder of International Family Clinic (IFC), a pediatric practice in Burlington with five bilingual physicians that the Dominican Republic native built to serve the local low-income, low-education Hispanic population. In 2012, she started incorporating behavioral health parenting sessions into her practice.

“Over the years, I kept seeing poor behavior in the kids, a lack of self-control and self-esteem. It was getting worse, not better. This was contributing to poor health. Everything was connected,” she said.

Since 2014, the pediatrician said, she spends roughly 70 percent of her clinical time with patient families working on behavioral health. With the help of her military-trained physician husband, and after a few years in rocky financial terrain, she’s figured out how to code and bill for her time – including Medicaid.

Many of the mothers IFC sees with their kids are constantly struggling to handle just the logistics of life, Fernandez Stein said.

“Children respond to parenting, period. Whether it’s good parenting or bad parenting. Children yearn for structure and priorities,” said Fernandez Stein, a mother herself to 14-year-old Hannah. “It’s not so much about being strict. It’s about being smart.”

A practice transitions

The drawing on the IFC logo matches one that Fernandez Stein’s mother had put on the sign at a school she started in Santo Domingo in the 1960s: a blue-and-red drawing of a smiling boy and girl with arms wide in welcome.

When Fernandez Stein opened the IFC doors a dozen years ago, she knew the simple image of two content children would cross the sea and become her own.

The sign at Fernandez Stein’s clinic is patterned on one created by her mother for the school she started in the Dominican Republic in the 1960s. Photo credit: Tom Gasparoli

“My family was full of educators,” Fernandez Stein said. “Beyond my mom, my aunt also started a school in the Dominican Republic. And my grandparents were instrumental in creating a widely adopted curriculum for students on the island.”

Fernandez Stein graduated from Universidad Nacional Pedro Henriquez Urena in the Dominican Republic in 1988, and completed her pediatrics residency at Overlook Hospital in Summit, NJ in 1993.

“I guess you could say I have education in my genes,” she added. “When I became a pediatrician, I knew teaching would eventually be a big part of what I did with the children and their parents.”

In 2012, Fernandez Stein told her husband, David Stein, who is also IFC’s administrator, she wanted to begin transitioning most of her individual work into behavioral medicine. “I know I can help,” she remembers telling him.

“So let’s do it,” Stein recalls saying to his wife.

“I’m an Army-trained and -educated doctor,” he said. “I try to maximize our efficiency and execution as we move through the day.”

And efficiency is exactly what it took for Stein to carve out the now 20 hours a week that his wife spends in behavioral health parenting sessions with patients and their families.

Fernandez Stein set out to provide health services to the local Hispanic community, and more than half of the 400 weekly patients at IFC are Hispanic.

National childhood obesity rates are higher among Hispanic kids than black and non-Hispanic white children. Fernandez Stein said the children who visit IFC are not only at risk for major health complications but also social stressors like bullying, shaming and learning challenges.

Fernandez Stein typically spends at least twice the amount of time per visit with these families than she and the other doctors would spend on everyday pediatric patients.

“The goal,” Fernandez Stein said, “is what we all want: a good outcome for our children.”

Who’s the boss?

For years, Fernandez Stein said, she has watched the child-parent dynamic become less parent-centric and more child-centric. Far too often, it looked like the child was in charge.

Since Fernandez Stein started focusing her time on behavioral health interventions with parents and kids, her practice has grown. Photo credit: Tom Gasparoli

The pediatrician saw parents who were anxious, angry and often simply overwhelmed. By consequence, children were less confident, less attentive and accomplishing less in school.

And, Fernandez Stein said, she began to see a rise in serious weight problems among her patients.

“After I learn about their situation at home, the next thing we talk about is putting the parent back in the position of authority,” she said.

“It is often common sense, but no one ever showed some of these mothers how. No one listened to them either.”

The child is present during these parenting sessions. Fernandez Stein said she often begins with something along the lines of: “Your parent has done an incredible thing in taking time to be here – because she wants you to succeed. This is for you. And I am your second-best supporter in all of this.”

Not long into the process, she gives the parent ideas and instructions that resemble a lesson plan. As the sessions continue, the pediatrician measures results carefully.

“Rosemary gives parents more tools to put in their toolbox,” Stein said. “She is a resource they often just do not have.”

Everything changed

Last spring, Samantha, age 9, was about to flunk out of her grade.

“I understood that Samantha would challenge me intensely when she was an adolescent,” said the girl’s mother, Laurie Newlin, “but had no idea it would happen so aggressively when she was 9.”

One day in clinic, Newlin unloaded to Fernandez Stein, who saw an opportunity to intervene, and soon the three of them were sitting down to sessions on behavior, relationships, boundaries and health.

Newlin said she began to take control of life decisions for her daughter, and “take away” some of the things Samantha feels are most important, like flashy clothes.

With simpler items replacing Samantha’s wardrobe, Newlin said her daughter’s attitude has been shifting. She eventually responded to the authority, and even her grades improved.

“We definitely had some rough spots after the quick success [in the beginning],” Newlin said. “But I knew what to take away and how assertive to be about it.”

Soon after, Newlin said, “Samantha told me, ‘I know this is my fault, Mom.’”

The mother now had her daughter’s attention: Mom was now in charge. Everything changed.

Speeding up change

Around the same time she was seeing Newlin, Fernandez Stein made the sharp move to spending most of her clinical time on parent-child behavior work. IFC has been experiencing growth since the beginning of her new clinical focus, creating a need for more hands on deck.

“I decided I had to go without my salary, so we could pay a new doctor. I didn’t know how long it would be before my work would mature to the point of paying myself again,” Fernandez Stein said. “But at some point, you just have to make the call.”

After five months with no paycheck, the pediatrician finally put herself back on the payroll with an amount approaching what she was making in the spring.

“We were prepared to absorb the hit for a good while, and we did,” Fernandez Stein said. “I know the parenting clinic is making a difference, the word is getting out and I see the patient load rising steadily now.”

The move has also worked because insurance payments – both private insurance and Medicaid – have been covering the new clinical focus.

‘No way I have the time’

At medical meetings, Fernandez Stein frequently talks to pediatricians about her program, and their first reaction, even as they hear of her success, is, “There’s no way I have the time or staff.”

She says to them, “I absolutely get it. It is time consuming. But once in a while, we have to give the patient the time because … when you change a child’s life, you change them forever.”

Sophia Yen, an assistant professor in adolescent medicine at Stanford Medical School, said she agrees. “This kind of medicine is preventive medicine, and the positive impact can be permanent.”

“You have to have a license to drive a car, but you don’t have to have a license to have a child,” Yen said. “So, too often, parents are just lost. Many need help – no question.”

Yen often says to the adults she sees, “Don’t be your child’s friend. Be a parent. Kids are looking for boundaries. They depend on you for that.”

But it’s not easy.

“And I am always emotionally fatigued after I finish these sessions,” Fernandez Stein said. “But right now, I feel I need to keep learning what is working and what isn’t. And I am usually elated too when the light bulb goes on. That means we got somewhere.”

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