EDUCATION
Grover F. Powers, M.D., Contributing Editor
A
POSTGRADUATE
PROGRAM
FOR
THE
LONGITUDINAL
HEALTH
SUPERVISION
OF
INFANTS
By Morris Green, M.D., and Mary Stark, M.S.S.
Department of Pediatrics, Yale University School of Medicine
ADDFESS: (MG.) 333 Cedar Street, New Haven 11, Connecticut.
CONTRIBUTORS’
SECTION
499
C
ONTINUITY of medical care and healthsupervision is receiving increased
em-phasis in both undergraduate and graduate
medical education. Clinical training in
pediatric health supervision has generally been inferior to experience in the care of illness. Although it has been assumed that adequate skill in the care of well children could be developed after completion of for-mal training, this supposition may be ques-tioned in view of the dissatisfaction cx-pressed by many practitioners with their preparation for this aspect of child care.
Pediatric house officers have generally taken
for granted that they would be provided adequate experience in the diseases of child-hood. They are beginning to expect similar preparation for health supervision.
One of the challeiiges facing medical
educators is the development in the medical
trainee of an understanding of the
funda-mental concepts of human behavior. Dde-gated largely to departments of psychiatry
in the past, the accomplishment of this objective is being shared increasingly of late by other clinical departments such as
pediatrics and internal medicine. While
child guidance clinics and child psychia-tnists are still used for the teaching of nor-trial development, child health conferences,
nursery schools, outpatient departments and
coliil)rehenSive ward rounds are being
5111)-stituted to some extent for the former, and
child psychiatrists with special experience in pediatrics on specially trained pediatni-cians for the latter. The program reported here represents an effort to acquaint
pediat-nc house officers with the segments of hu-man behavior represented by the prenatal period, pregnancy, parenthood and the first 3 years of life.
DESCRIPTION OF THE PROGRAM
An experimental project concerned with the teaching of well-infant care was begun in the Department of Pediatrics at Yale in the summer of 1953. In this program each member of the hotmse staff provides corn-plete pediatric cane for one family begin-ning in the prenatal period and extending for 1 to 3 years. Five members of the senior
staff provide individual supervision of the
seven imiternes and six assistant residents who participate in this project. Families ane selected by a social worker. #{176}
The program begins in July with
intro-dtmctony sessions given by members of the
senior staff on two successive Saturdays.
Assignments to families and general onienta-tion are accomplished in the first meeting. Each house officer and supervisor receives
a written summary of the initial interview
that the social worker has had with the prospective parents. For the second session the supervisors meet their groups of two or three house officers for a discussion of prenatal interviews, the pediatrician’s role
during the lying-in-period and home visits
during the neonatal period.
Families to participate in this program
0 Drs. Rose Coleman, Sally Provence, Milton Senn, Albert Solnit and the authors constituted the
are selected in June from expectant mothers who receive their prenatal care in the Uni-versity and Hospital Clinics and who ex-pect their infant between August 15 and September 15. For the most part these have been mothers who are having their first child. A few families who were expecting their second or third child have been ac-cepted to permit discussion of problems arising when there are other children in the family. Although the racial, vocational and cultural backgrounds of these families have varied considerably, their socio-eco-nomic status has approached that of families who receive pediatric care privately. Of the 33 families who have participated, only two have not continued their association throughout the year. Enrollment of the families terminates after 1, 2 or 3 years with completion of the house officer’s period of training. The families are then referred to a private physician.
Following his assignment to a family, the house officer arranges an appointment for a prenatal interview sometime between July 15 and August 15. Many of these interviews are held in the evening so that the father can also attend. Prospective parents have appeared desirous of meeting their pedia-trician prenatally and of talking with him about the expected baby. House officers have found the initiation of a continuing relationship at this time to be helpful and time-saving in their later contacts with
parents.
Delivery of the infants usually occurs be-tween August 15 and September 15. The pediatric house officer is notified by the mother when she enters the hospital in labor. This permits him to visit her during the period of labor and to be present at the delivery. While this phase of the program would not usually be practical for the
pediatrician in practice, it has appeared to offer a worthwhile educational experience for the resident. During the lying-in period the house officer functions as the pedia-trician for his family even though he may not at that time be assigned to the new-born service. The mother is seen once or
twice a day. Before she goes home, she will have discussed with her pediatrician many of the common concerns and problems that mothers have in the neonatal period.
After the mother’s discharge from the hospital, the house officer makes one on two home visits during the early neonatal period. These visits usually occur between August 20 and September 20. Besides being of help to the mothers, the physician has an opportunity to see his patients in their home environment and to gain an apprecia-tion of a mother’s feelings and problems at this time.
The infants are then seen on the first or second Saturday of each month in the pro-ject child health conference. Families as-signed to internes are seen on the first
Saturday while those being followed by
the assistant residents are seen on the second Saturday. This arrangement permits the doctors to be free of responsibilities for hospitalized sick children during that time,
their duties being covered by the alternate
group of house officers. It is recognized that doctors find it difficult to give optimum care to well children while under the pres-sure of caring for seriously ill patients. At the time of the first clinic visit in October the infants are 4 to 6 weeks old. Generally
both
parents
attend
the conferences. Inaddition to these scheduled visits, mothers
may reach their doctor by phone much as
would
be
the case in private practice. If the infant is ill, the doctor either makes a home visit or arranges to see the baby in the hospital. If the doctor is not avail-able, the infant is caned for by the pediatric resident on call.501
families are known to the supervisor as well as to the house staff, discussions are
individualized in terms of a particular
family. While these discussions are in
progress, the infants are undressed and weighed by the nurses. Since a common waiting room is used, the parents have a chance to talk with each other, and the social worker has an opportunity to make observations of the group. The families are then seen by the doctors between 1 1 : 00 and
11 :45 AM. After this, there is another
meet-ing with the supervisors at which time questions based on the experiences of that
morning may be raised. The fact that all
the infants seen on any one day are
approxi-mately the same age is advantageous in that
the interest and discussion of the group has a central focus. The management of a great number of the situations that arise in the provision of pediatric cane to families has been reviewed in these sessions. Discussions have often centered about physical prob-hems, such as the treatment of seborrhea,
hemangiomas, infant feeding,
immuniza-tion, croup, circumcision, diaper rash, use of pacifiers, etc. It has been stressed that the availability and provision of adequate
physical care is psychologically comforting
to parents. Other discussions have included breast feeding, introduction of solid foods,
weaning, sleep problems, toilet training,
preparations for the birth of a sibling,
pnob-lems of separation, negativistic behavior,
(hisciphine, problems of parents of
prema-tune infants, the working mother, the
par-ents who obtain no pleasure from
parent-hood, the dependent parent, the aggressive
parent, etc. Since these presentations are
based on experience with an actual family
with whom the house officer and supervisor have a considerable acquaintance, the
dis-cussiomis are realistic and patient-oriented
rather thami (lidactic and nonspecific. While
most of the emphasis is on the first year of life, house officers in their second or third
year of training bring up problems
con-cenned with the second and third years of life. It is felt important to include expeni-ences with children in these years because
this is a period with which physicians have little experience. This is because such cliii-dren customarily are brought less fre-quently for health supervision and are often seen only during illness.
DISCUSSION
The preceding sections have reviewed the program for longitudinal health super-vision by pediatric house officers. The pro-gram differs from the usual house officer experience in child health conferences in that both the physician and the family have a longitudinal and continuous rela-tionship from the prenatal period through the first, and perhaps, second and third
years of a child’s life. This is a fundamental
requirement in programs of this type. Lack of continuity of cane is a serious defect in the educational and service functions of most child health conferences staffed by pediatricians in training and amounts to a partial denial of the present day purpose of such conferences. Something can be learned and contributed in sporadic con-tacts, but an understanding of the corn-plexities of an individual family comes
only after many visits.
Because the house officer is a physician and is realistically able to function
diag-nostically and therapeutically as such, it is
believed that this type of longitudinal
pro-gram has educational advantages over that
staffed by medical students. The physician-patient relationship can be discussed more directly and cogently than in programs in-volving a student, a family and an adviser. The project reported here also differs from the usual experience in a well-baby clinic in that the house officer provides care in
times of illness as well as health.
Arrange-ments whereby these medical functions are divided between different physicians would
seem to offer less than optimum medical
care or educational experience.
In reviewing the experiences of this
pro-gram during the past 3 years, it is evident
that certain general principles were
de-tailed content. The idea that there are standard solutions for most of the situa-tions that one encounters in well-child cane and standard answers to the numerous questions that are asked was often negated. It is true that, at times, disappointment was expressed because the supervisors did not provide a simple solution to some of the child cane problems the house officers faced; however, they came to appreciate why this must be so and how, nonetheless, they could be helpful to parents. It was recur-nently demonstrated that there is no one right attitude or practice and that there is more than one best way. An important role of the pediatrician in many instances was pointed out to be that of helping parents to find their own solution to many of the problems rather than to attempt to force on them something called advice. This ap-proach derived from respect for the ca-pabilities of parents, a philosophy that was pervasive in the program. On many occa-sions, however, direct suggestions and ad-vice by the doctor were indicated and help-ful. Here the physician served as a health educator. But the fact that instruction alone does not assure adequate cane was often evident. This was shown to be true in the case of parents of superior intelligence and, at times, extensive formal education as well as in others less well endowed. There were a number of experiences that pointed up clearly some of the limits of such educa-tion when the difficulties really were in the parents rather than in the child.
Another fact often alluded to was the reciprocal determination of the relation-ship between the parent and child: parents often behave the way they do because of their own life experiences and personality development but also because of the man-ncr in which they react and adapt to the growth and development of their child. An additional point often stressed was the in-dividuahity of each infant. The house offi-cers came to recognize that the character of response to all sorts of stimulation differs
between individual infants from the
new-born period onward.
A basic objective of the program has been to enhance the physician’s ability as ami oh)-server. Certainly in the management of ill-ness, expert diagnosis and treatment must derive from astute clinical observation aiid
individualized application of the physi-cian’s background of experience and kmiowl-edge. That this is similarly true in the case of health supervision has not been suffi-ciently emphasized. Knowledge of emo-tional development, developmental diagno-sis, physician-patient relationships and re-lated subjects help increase the perceptivity and skill of the physician in health
super-vision much as knowledge of physical
diag-nosis and disease states does in illness super-vision.
As a rule house officers have no super-vised experience in interviewing. They have little occasion to take a history in situations of health in which there is no “chief complaint” on in which, as in the prenatal period, there is no child patient
as yet. Experience with history taking has
largely been confined to illness. In the
pro-gram reported here attention has been given to presentation of the principles of inter-viewing and to demonstration of the
con-tribution of interviewing skill to well-child
care. There were a number of instances in
which the interview was shown to be a potent diagnostic and therapeimtic tool ca-pable of dramatic effects. In sonic instances the house officer discussed his interview with the supervisor immediately after the child health conference. At other times the
supervisor was present during the
inter-view as an observer and on a few occasions the supervisor conducted the interview with the house officer present as an ob-server.
demonstrated to contribute much to sound
child care practices. The techniques of
de-velopmental diagnosis were discussed and
demonstrated before each clinic visit, and the house officer did a developmental ap-praisal each month. Developmental
diag-nostic kits containing wooden cubes 2.5
cm on a side, a wooden loop with a string attached, a bell, pellets and a small glass vial in which a pellet could be placed were
supplied to each doctor. The fact that all
the infants attending the conferences were about the same age permitted the
discus-sion of development to be focused on one
age period at a time.
The supervisory staff has been able to
observe marked changes in some of the
house staff’s interest and skill in health
supervision over a period of 1 to 3 years.
Such a house officer becomes more
pencep-tive about people, himself and others, and
about family life. As lie comes to match, under supervision, his social, cultural, ceo-nomic and educational background with its
resultant attitudes towards child rearing
practices against the different background
of his stu(ly families, lie gains a better
awareness of his own behavior and its
antecedents. He tends less to attempt to impose his own cultural attitudes concern-ing child nearing upon other parents. At
the same time he fimids health supervision
to be interesting and challenging and
nec-ognizes that some of the problems in this
field are just as serious and just as difficult to manage as those in illness. In the process
of making home visits and in having direct
responsibility for the medical care of a
family the house officers, as one who
anx-iously treated a child with infectious croup in the home expressed it, have an increased respect for the private practitioner. By
hay-ing the longitudinal responsibility for the
care of a family, the house officer cannot
avoid dealing with many of the problems that arise in this phase of pediatrics as he might if respoflsil)ility were limited to one-visit encounters. Skilled supervision also brings him to face some of the phases of
child care that are often glossed over. In this program the doctors begin to demon-strate how they may relate in their own practice to families for whom they have a long term responsibility. We see here the doctor who so ovenidentifies with the
fam-ily that he is no longer an objective
physi-cian, the doctor who tends to be authoni-tarian, the doctor who must have patients who overevaluate him, and thie doctor who fosters dependency. Many other examples could be given.
Although mature and interested house
officers would undoubtedly learn much for themselves as a result of following families longitudinally without supervision, such an arrangement would not differ much from that which they could later obtain in pni-vate practice. The availability of adequate supervision is, therefore, of great impor-tance if the program is to make a contnibu-tion to postgraduate education. The small number of house officers assigned to each supervisor has permitted personalized
teaching. This type of supervision, so well
developed in social case work and in psy-chiatry, has not received the attention that it should in pediatrics. The fact that the
supervisory pediatricians and the social
worker have worked together for a number of years and have basically the same ap-proach to child cane has undoubtedly con-trih)uted to the smooth functioning of the venture. They have enjoyed working in this project and believe that it is an effec-tive way to teach health supervision for at least one segment of child life.
The house staff has increasingly looked forward to participation in the program and have enjoyed contacts with the fami-lies. They have frequently commented upon the educational benefits that the pro-gram has provided. Former house officers now in practice have written that these
sessions were among the most valuable
