1008 LETTERS TO THE EDITOR
treats parents with a strep throat can no
more ignore the feverish child, than the
pediatrician can ignore the parent.
Manage-ment of behavior problems is more easily
Ilandled when one has a more thorough
knowledge of the parents. The management
of a juvenile diabetic or the treatment of a
child in heart failure is more easily
accom-plished by one who has been treating these
diseases daily.
A year of pediatrics incorporated into the training program of internal medicine would
easily qualify one for routine pediatric
prac-tice. If one were to subspecialize much like an allergist on cardiologist, then additional
training would be encouraged and
sub-specialty boards maintained.
To admit that we are in a field which has
less to offer than we have been taught is
distressing. To continue to mislead fine
young men into a specialty that does not
exist is more unfortunate.
J
ULIUSJ.
WINEBERG, M.D.Waukegan, Illinois.
To EDITOR:
Your editorial in the February issue of
PmIA-rmcs was most apropo and frank-a
just criticism of the economics of the “new pediatrics.” Your invitation for further
com-ment has stimulated me to write
concern-ing two other aspects of the problem. First of all, a conffict of interests arises
in the young pediatrician’s mind when, on
the one hand, he wants to encourage the
mother to return as often as necessary in
order to build up his practice while, on the
other hand, he is attempting to help her
develop independence. If he truly helps her
to handle the many vexing problems of
child rearing and minor illnesses, he will
develop a pleasant practice with a limited
number of frustrating telephone calls and
few night visits. However, this is poor
eco-nomics for the pediatrician starting out in
practice. He would do better financially, if he permitted the parents to have a little
anxiety and encourage them to depend on
him through frequent office visits, etc.
The other economic conflict involves
hos-pitalization. There are a number of
in-stances in pediatric practice where the
de-cision of whether or not to hospitalize the
patient is equivocal. Admission can be
pre-vented in many cases by spending some
extra time in working out a therapeutic
regimen with the parents, placing more
re-sponsibility on the pediatrician’s shoulders,
and “sitting tight” in an unscientific but
psychologically sound fashion. However,
our present llealth insurance plans make
this economically unsound, because the
doctor is paid considerably more if lie
ad-mits the patient.
Perhaps there is a place in pediatrics for
the oriental custom of paying the doctor
only when the patient remains healthy, on
perhaps the modern counterpart, charging
a flat fee for a year’s coverage. Education of
the insurance carriers must be added to
our goal of educating the public
In defense of the “new pediatrics,”
how-ever, I must add that it can be a most
sat-isfying experience despite its unsound
ceo-nomics.
R. DEAN CODDINCTON, M.D. Red Bank, New Jersey
To mE EDITOR:
The answer to the question posed in the
recent editorial (PEDIAmIcs, 23 : 253, 1959),
“Can the New Pediatrics Be Practiced?”
may be conveniently divided into three
parts:
1) What is the job of the pediatrician?
2) Do present training programs in
pedi-atrics prepare their graduates for the “new pediatrics?”
3) Can the “new pediatrics” be practiced
under the present set-up of medical
ceo-nomics?
What is the /ob of the pediatrician?
Names compartmentalize our thinking
proc-esses and terms sometimes restrict our abil-ity to think. Thus the term specialist, which now lumps the pediatricians, internist,
gen-eral surgeon, cardiovascular surgeon,
LETTERS TO THE EDITOR 1009
of the patient, on the whole patient for a
very limited period of time on when he has
a particular illness. By this terminology a
generalist would be a pilysician who cares
for tile whole patient and supervises the
entire health needs of that person, but who
may call on a specialist to advise on
super-vise a particular illness as the need arises.
The general practitioner would thus be a
nonspecialized generalist, the pediatrician
and internist, specialized generalists. The
term specialist would be used for such
pilysicians as the cardiologist, endocninolo-gists, surgeon, etc.
Tile trend of pediatrics today, the
de-mands made of the practicing pediatrician
and the needs of children, all seem to
in-dicate that the pediatrician of the future
must be an expert generalist who limits his
practice to a special age group. If this is
true, he cannot hope to be an expert non
assimilate all the knowledge about all the
rare and obscure diseases which afflict
chil-dren.
Any practicing pediatrician can and
should be able to treat a patient with
rheu-matic fever, but can hardly expect to make
the definitive diagnosis and disposition in a
case of congenital heart disease. He may
know how to diagnose and treat a cretin,
but can hardly know how to make the
dif-fenential diagnosis beween all the rare
dis-orders of the endocrine system. If he is to
practice pediatrics, he must know how to
supervise in an expert fashion the child’s
nutrition and immunization program, and
guide the child’s physical and emotional
development. He must practice preventive
pediatrics in all areas both physical and
emotional. It is nonsense to expect the
pnac-ticing pediatrician to be able to expound
brilliantly on the latest theories of bilirubin
metabolism or to have on the “tip of his
tongue” the name of the enzymes that
con-trol it. He should know how to diagnose
and treat the baby with erythroblastosis
even though he might transfer the more
severe cases to someone else who is more
skilled in doing exchange transfusions.
tnician know? What should he be prepared
to do for his patients? To a certain extent
this must be determined on an individual
basis, i.e., on his own skills, knowledge and
interests. He should do that which he does
best. However, there are certain general
principles to be followed. Every
pediatni-cian must be a good diagnostician. To be
this he must know a great deal. He must
know how to recognize symptoms of
on-ganic illness, how and when to order
laboratory tests and other diagnostic
pro-cedures, when to refer to the specialist. He
must also know how to recognize
nonor-ganic or emotionally-caused illness, bow to
differentiate this from organic illness with
the same symptoms, how to handle the
minor problems and when to refer to the
specialist. If he does not know how to diag-nose a psychogenic illness he will
misdiag-nose at least a third of the patients who
come to his office. If he does not know
anything about this aspect of medicine non
how to treat the minor emotional problems,
he will be unable to cane for a large
per-ccntagc of the ills which afflict his patients,
and may very well do harm by his clumsy
attempts at treatment. Every pediatrician
should be able to treat: the common
prob-lems of the newborn; the common
infec-tious diseases such as respiratory infections, otitis media, bronchiolitis, diarrhea, etc.;
the common allergic diseases; and the less
severe kinds of common emotional
prob-lems. He may also learn how to manage one
or more of the rarer problems in pediatrics,
but if he is a skilled generalist he must
know how to handle the common everyday
disorders, including the emotional ones.
Do present training programs prepare
pediatricians for the “new pediatrics”? The
answer to this question is a resounding no!
There arc a few exceptions, but in general
the traditional, inpatient-oriented,
labona-tory-dominated training program for
pcdi-atnic residents is no more designed to
pre-pare the physician for pediatric practice
than a life of ease would prepare a man
Re-1010 LETTERS TO THE EDITOR
ing center returned to complain to his
pro-fessor that while he had been trained to
race at the Hialcah race track, he was now
out pulling the chuck wagon like any old
dray horse. Actually, this man had missed
completely the major point of pediatric
practice. It is no more challenging to treat
a case of meningitis on handle a patient
with hypcrclectnolytcmia than it is to
man-age that 4-year-old who began having
en-copresis last week. It is different, it requires different skills and training, but the job is just as interesting. The opportunity to make
a living from a referral practice in
pedi-atrics is a thing of the past for two reasons.
First, it is economically impossible for the
person beginning a practice, and second,
the information in the field of pediatrics is
so immense that it is impossible to be
master of it all. Because of this the referral
case will go more and more to the true
specialist in pediatrics, the pediatric sub-specialist.
In spite of these very obvious conditions,
the tendency in pediatric residencies is to
concentrate more and more of the resident’s
time on study of the complex and rare
problems of pediatrics. Thus he is spending
much of his time acquiring knowledge and
skills which he will, in the private practice of pediatrics, rarely be called upon to use.
Every pediatric resident, even if he knows
he is going into a subspecialty, should first
have a good background in the common
ordinary problems of pediatrics, i.e., nutri-tion, preventive pediatrics, emotional prob-lems, allergy, diarrhea, respiratory infec-tions, etc. This kind of training is especially
important to the person who plans to enter
the private practice of pediatrics. In short,
the pediatric resident should be trained for
the practice of pediatrics. He should not be
trained to be a second-rate subspecialist in
half a dozen or more subspecialties.
Can the “new pediatrics” be practiced
under the present set-up of medical eco-nomics? This is the most difficult question to answer, but is certainly at the core of any solution. It will probably be the toughest
problem to solve of any that arc involved
with the future of pediatric practice. If the “new pediatrics” (which is synony-mous with better pediatrics) is to be prac-ticed successfully, it must be economically
supported. In general this means that the
pediatrician who practices this kind of
pedi-atnics must be able to have an income
which is at least equal to the income of
othr physicians, including those who
prac-tice a less complete and thorough form of
pediatrics. This means that under the
pres-cnt economic system the per visit cost of the
new pediatrics will be greater than the per
visit cost of the physician who practices a
less complete and adequate form of
mcdi-cine, on the latter will have a higher income. The real question is: Is it possible to do
this? The answer will come with time, but
present conditions seem to indicate failure unless some drastic actions arc taken.
Under the present structure of medical
economics (i.e., free-enterprise,
private-practice, fcc-for-service system) there is a
great deal of subtle pressure to conduct the
office practice of pediatrics in a rushed and
hurried manner with the employment of
short cuts. Much but by no means all of this
pressure is economic in origin, i.e., the
physician who sees the largest number of
patients makes the most money. These
pressures must be reversed if truly
compre-hensive pediatrics is to be practiced to its
full potential.
There are two general ways to
accom-push this. One way is to educate the
pub-lie so they will demand, and pay for, the
best of medical cane. The alternative is to
so alter the economic structure that the
pediatrician’s income is no longer so
corn-pletely dependent upon the volume of
pa-tients seen.
Columbus, Ohio
