LETTERS
TO
THE
EDITOR
Comments on the Contents of PEDIATRICS OT any topic of general interest are invited. Queries
and answers may be exchanged between correspondents. Letters accepted for publication will
not be s-ub/ected to editorial alteration except as to proper form. The Editor reserves the right to
publish replies to letters and to solicit responses from authors and others.
This column has been established to provide a forum for all members of the profession for
exchange of information and views. Statements and opinions expressed in letters are those (if
the authors and do not represent tile official position of the American Academy of Pediatrks,
Inc.. , or its Committees.
A New Development in Pediatric Education for the Practitioner and the Student
To TIlE EDITOR:
In view of the recurring criticism from
prac-ticing pediatricians directed in one way or
another to the schism developing between themselves and the academic pediatrician, all
ongoing program at the University of
Minne-sota might be of interest to pediatricians of
either calling. This program was initiated on
two premises that may not have been
particu-larly unique fifteen years ago but do need
re-emphasis at this time. The first premise (and
perhaps the more startling) was that the
prac-ticing pediatrician has a significant
contribu-tion to make to academic pediatrics. This
con-tribution consists, in part, of making available
to the medical student and the house staff, the experiences distilled from applying medi-cal knowledge and skills to the pediatric pa-tient in an extremely intense and personal
re-lationship. Other contributions within their
realm of excellence are community health
pro-grams, neonatal medicine, and preventive
health care. The second premise is not so
con-troversial, and is concerned with the need for
the practicing pediatrician to change gears
(and oil) and to look at pediatrics with an
ob-jective and contemplative eve. This, of course,
is the intent of many pediatric postgraduate programs which face the severe limitations of their brevity and suffer the afflictions of “spoon
feeding” without much bilateral participation. These objectives were achieved b
provid-nig a temporary staff appointment with a
modest stipend which carried with it specific
staff responsibilities in the Pediatric
Compre-hensive Clinic Program at the University of
Minnesota. In my specific experience, these
responsibilities consisted of working with the
senior medical students in their management
of patients in the clinic. Though hospital clinic
patients are DOt entirely comparable with the private patient relationship, the resemblance
was enough to make me feel comfortable and
effective in this type of teaching role. Enough
time is available beyond these designated
re-spollsibilities to attend ward rounds, seminars,
etc. , and to become involved in any particular
facet of pediatrics that may be of interest to the physician.
I
had the opportunity to spend one monthin this program, and feel that it was the most
meaningful postgraduate experience that I have had in fifteen years of practice, and would
modestly hope that the teaching program
re-ceived a small jolt in the right direction. One
month is rather short to fulfill the basic
oh-jectives adequately, though I should think two
or three months would permit a most
satisfy-ing experience for all concerned. The
difficul-ties which the private physician must deal with
in becoming involved in such a program are
obvious to all who are in private practice. It is
very likely that such a commitment would be
possible only for the pediatrician in a
partner-ship practice, or where adequate coverage
dur-ing the period of absence could be achieved.
As far as I know this program is unique and
represents a significant effort to re-unite the
academics and practice of pediatrics. I would
hope that others would be encouraged to
de-velop similar programs and that pediatricians
would avail themselves of this type of
sab-batical at appropriate times in their
profes-sional lives.
CHARLES A. BRANTHAVER,
\I.D.
Sacramento Medical Clinic,
2615 Eye Street,
Sacramento 16, California
Keeping Pediatricians in Practice
To THE EDITOR:
790 LEfl’ERS TO THE EDITOR
myself. I am a board certified pediatrician, a graduate of New York University College of Medicine, with pediatrics training at Bellevue
and Kings County Hospitals, as well as a
period at Children”s Hospital of Michigan as
a Hematology Fellow. This experience coupled
with private practice of several years makes me somewhat conversant with the problems
and rewards of the practicing pediatrician.
After almost eight years of practice, I de-cided this past year to leave practice and be-come a psychiatrist, probably to specialize in children and adolescents. My reasons for this
decision were many and varied. I felt that
most of them were unique with me. However,
as I have continued my training in psychiatry
I
have met several other pediatricians whohave taken a similar course and surprisingly
enough characteristics common to us have
emerged. We all found the experience of
hos-pital pediatrics exciting, challenging, and
re-warding in a personal and professional way.
We enjoyed the wards, the children, the families of our patients, and probably above
all the feeling of accomplishment. The private
practice of pediatrics was looked forward to
with pleasure and anticipation. Peculiarly
enough it seems that most of us did not
ques-tion whether private practice was similar to
residency work. We loved children. They were
enjoyable to work with, and there was a lot
to accomplish with them. The features of
pri-vate practice in pediatrics in most cases were
neither shown nor discussed with us. We were
sitting on top of a very happy professional
cloud.
The first few years of practice produced no
real difficulties for me. I was finding pediatrics
a stimulating, professionally rewarding field.
My practice increased by leaps and bounds, my income rapidly rose, and I had no
corn-plaints. Soon rny practice grew so large that
I required an associate. Over a five-year
period I had two associates, both of whom
found practice in my city dissatisfying for
diverse reasons. The reasons for their
depar-hire are unimportant. The fact remains that
I did
not find partnership the solution to theproblems of practice. Other former
pediatri-cians with whom I have discussed this
prob-lem left despite having the most satisfying partnership and group experiences. It would seem that such relationships ameliorate but do not remove the basic problems.
These problems are fairly well known to
most practitioners. The heavy case load, the
majority of visits concerning well-baby care
and simple self-limited respiratory and
gastro-intestinal illnesses, the oppressive telephone,
the frequent nights and weekends n, and the
relatively low remuneration for such work
present real difficulties. The problem lies not
with the lazy pediatrician. The conflict arises
with the conscientious pediatrician (as almost
all of them are) who has a warm and abiding
regard and interest in his patients and their
families. Does he have the half hour to spend
with the anxious, crying mother of a colicky
baby? Most anxious distraught parents need,
at the very least, fifteen to twenty minutes of
understanding advice and guidance from
someone professionally qualified to guide them. Do we have time to practice the New
Pedia-trics? Even if we could, will the low and
middle income people of this country be able
to pay for the increased amount of time they
necessarily need?
I have written this letter because I am
deeply concerned with the future of American
pediatrics. I do not believe that pediatrics can
survive in the direction it is going. There must
be an “agonizing reappraisal” of the future of
private pediatric practice in this country. The
general practitioner will soon be no more. The
brunt of routine infant and child care will fall
ever more heavily on the already overworked
and at times disgruntled pediatrician. At least
four pediatricians have left practice in my city
and one quarter of my house staff at Bellevue
(1953-1954) have done similarly. This cannot and must Ilot continue or the children of this
country will be the losers.
I believe some radical changes in pediatrics
practice must result before the basic
disaffec-tions are removed. One solution could be the
training of intelligent, skilled registered nurses
to perform well-baby examinations and
pro-vide the necessary well-baby advice and
guid-ance. Such nurses could operate within the
pediatrician’s office, under his supervision. If
nurses can provide competent anesthetic
med-ication in operating rooms all over this
coun-try, surely they can be trained to do a
well-child examination. Any deviation from normal,
be it heart auscultation or abdominal
palpa-tion, would be immediately brought to the
attention of the pediatrician. Such all approacil
LETTERS TO THE EDITOR 791
work and allow him to spend more time with
those children requiring his care more
ur-gently.
Another solution to the problem might be
the upscaling of fees for pediatric
profes-sional care throughout the United States. In
this way the physician will be compensated
fairly for the longer periods of time spent with
individual patients. Perhaps this might be
done on an hourly fee schedule. The
pediatri-cian of this country must face this problem
realistically and honestly. These difficulties
that present a crisis to our specialty (I can’t
bring myself to say “former specialty”) must
be discussed, rediscussed, and finally solved
within the profession. There must be
con-certed efforts at patient education through
the national and state organizations once
appropriate decisions are made. People must
be told what the problems are in American
pediatrics and what steps will be taken to
correct them. If this is not done, the future of
private pediatric practice in America is indeed glooms’.
KENNETH S. GOULD, M.D., F.A.A.P.
322 Livingston Ave.,
New Brunswick, New Jersey
EDITORIAL Noit : We recognize here an old
prob-lem which is nonetheless a serious one. The Editor
likes the inquiring spirit in which suggestions are
made in Dr. Gould’s last two paragraphs. Can any-one suggest other solutions?
Early Gastrostomy in Feeding Prematures
To THE EDITOR:
The good results of Berg et al. reported as
“The Use of Gastrostomy in Feeding
Prema-hire Infants”l will encourage others to explore
this technique.
There has long been a reluctance to
con-sider surgery for a so-called medical condition.
In 1837, W. Stokes (in connection with
trach-eostomy in diphtheria) wrote: “There is
al-ways that kind of feeling connected with a
surgical operation in acute diseases, which
prevents its being proposed, assented to, or
performed, unless under nearly desperate
cir-cumstances and when all other means have
failed.”2 Berg et al. gently echo this in their
statement “it may prove expedient to initiate
feedings via gastrostomy in such patients
rather than to utilize the method after gavage
feedings have resulted in vomiting, aspiration
or other complications.” Our own experience
suggested that in the hands of Dr. Hugh Lynn
and his staff gastrostomy was accomplished
with greater dispatch than, say, a tedious vein
cutdown in a premature.
One of our objectives in 1958 in performing gastrostomv in premature infants was to
oh-serve the influence of early alimentary
abund-ance.3 The problem of earls’ introduction of
anything into the stomach of small premature
infants is more mechanical than metabolic.
Many developmental events of the first hours
and days of life are as et not fully
under-stood, although it is thought that timing may
be a critical point as exemplified by
circula-tory and immunological events.
Whether abruptly stopping exogenous
en-ergy sources for several days in the smallest
of prematures is in part responsible for neural
and visual developmental defects can be
neither affirmed or denied. It is noteworthy
that in 8 of their 11 prematures, early
gas-trostomv (from 26 to 44 hours of age) was
performed, and that feedings were begun 1 to
12 hours after gastrostomy.
Among the advantages enumerated by the
authors is the economy in nursing care; our
experience indicated that early high caloric
feeding almost halved the duration of
hos-pitalization of the smallest prematures, with a
dwindling but significant time-saving
advant-age for the larger prematures.
Careful studies such as are feasible with a
relatively small number of identical twins
observed for a significant time-span may be most useful in determining whether a
reduc-tion in the unhappy developmental sequelae
of prematurity can be associated with earls’
adequate feeding. The individualized selective
use of the method outlined
by
Berg et at.should facilitate the conduct of such studies. ALEX
J.
STEIGMAN, M.D.920 E. 59th St.
Chicago, Ill. 606.37
REFERENCES
1. Berg, R. B., Schuster, S. R., and Colodny,
A. H. : The use of gastrostomy in feeding premature infants. PEDIATRICS, 33:287, 1964.
2. Stokes, W. : A Treatise on the Diagnosis and Treatment of Diseases of the Chest. Dublin:
Hodges and Smith, 1837.
S. Steigman, A. J., Cruise, NI. 0., and Falkner,
