EDUCATION
111
Grover F. Powers, M.D., Contributing Editor
Simplification of infant feeding and the prevention and cure of many infectious diseases,
to-gether with remarkable advances in scientific and technical medicine, have modified clinical
pediatrics. While this modification has been taking place, standards of practice have been raised due in large measure to the influence and accomplishments of the American Board of Pediatrics. Recently the question has been raised, “Should the requirements for certification by the American Board of Pediatrics be extended?” The affirmative position is taken in the following letter.
C. F. P.
DEAR DocroR Powims:
I am glad to write you a note in support
of my opinion that the time has come to increase the required pediatric training in hospitals for Board certification in
Pediat-rics from 2 to 3 years. I must state at the beginning that I don’t believe that one can advocate this increased requirement as a
necessity in absolute terms. The whole
con-cept of the desirability of Board certification in any field has been challenged repeatedly, although I believe any objections that have
been raised to such organizations apply less to pediatrics than to any other program. American children, in my opinion, are im-mensely better off due to the establishment
of the Board of Pediatrics and the Academy
of Pediatrics. The level of pediatric care,
both in quantity as well as in quality, has been greatly raised during the years that
these 2 organizations have existed and to a considerable extent, in my opinion, due to the activities of these organizations. How-ever, the generalization that all good
train-ing
one can get is valuable hardly needs support and the fact that the present is good does not mean that it might not bebetter. The discussion of this question can
be considered in answer to 4 questions
which, of course, overlap in their signifi-cance.
First, what are we training a pediatrician to be? Do we intend him to be an internist,
a specialist in all the medical problems in childhood, or a general practitioner with
particular training in this age group? In other words, how much of a specialist do we expect him to be?
Second, what would a 3-year residency
enable us to teach a young pediatrician
that cannot be offered in 2 years? What are the things required in teaching that de-mand a 3-year program?
Third, what are the demands for
certifi-cation by the Pediatrics Board at the pres-ent time as compared with other specialty boards? How do our standards compare with those of other countries?
Four, can we afford a 3-year program of
approved residency in pediatrics? Is it ceo-nomically feasible for the young man, for
the institution, and for the public?
What do we want the pediatrician to be? Already there has been extensive discussion of whether we are really training a “special-ist” and whether we want a pediatrician to be so considered, or as a general
practi-tioner in a limited age group. Or, as I cer-tainly hope, could it be possibly both? One
of the greatest demands that we hear from the public, or from those who presume to
speak for the public, is for the general prac-titioner. Of course no one, when he bothers to think about it, wants a general practi-tioner who becomes one only because he has limited training, though in all truth, that is usually what happens. What is
wanted is a man who can handle the
com-mon problems in the home but knows when special services, demanding more than his skills, are necessary. The pediatrician is the
only one of all the specialists who is really
trying, with superior training, to function in the dual role of general practitioner as
and to a certain extent because he is
in-sufficiently trained. We certainly hear the
feeling expressed that the pediatrician’s training, in cardiology for instance, is not
adequate, and if a child does have heart trouble he should see a “real” specialist. The same attitude is increasingly expressed
in respect to many other fields such as endocrinology and allergy, certainly in
psychiatry, and to a lesser extent even in
such fields as neurology.
With certain groups of pediatric
educa-tors, the consensus has been that the sort
of training we are now offering a man is adequate for what is expected of him. Some claim that there should be 2 kinds of pedi-atricians; the usual men who have met our
present Board requirements and might be expected to confine themselves to the ordi-nary needs of children-immunizations,
feeding, colds, etc.; and then another group
who will have had specialized training in
particular fields. That there should be some of the latter is logical enough, and we see the system developing, particularly around teaching institutions or referral centers, quite as it should. But how far should we
expect this arrangement to extend? Should we have 2 Board requirements, one for the
general run of men and the other for the “real” specialist? Perhaps along with
dif-ferent Board requirements would come different titles and different little framed
certificates to hang up in an office. I hope not. I hope we do not allow the growth of a system in this country approaching that which seems to be developing in the Scan-dinavian countries where the highbrow and intellectual doctors are the only ones who
are allowed to practice in hospitals, and those who have not made the grade are re-stricted to home practice. To me, a further
division of pediatricians into different levels
is quite wrong in principle, but this is
cer-tainly a matter for wide differences of opinion. I hope and believe that most young
American doctors are not going to accept a 2-level certification, if it ever comes to
that, one for the pediatrician who will be
expected to restrict himself to ordinary
problems, and one for the others who are
going to be consultants.
We must still expect the pediatrician to
make his own decision as to when he is going to call for help, and to bear a very crucial part in decisions regarding surgery and many special procedures in which men in the anatomical specialties are, to a very
great extent, dependent on personal experi-ence derived primarily from adults. The
distinction in the skills necessary to care for
children and for adults is, in many cases,
far more important and crucial than the distinction between the skills needed in
the different anatomical specialties. We do not expect our pediatrician to do surgery,
even with 3 years training, but undoubtedly he would be in a far more critical position
to protect his patient from unwise surgery, or other procedures than with less training.
I think it is very important that we do not
let him lose his status as a specialist, to be consulted about problems other than simply vomiting and diarrhea in infants and normal feeding. But to do this he must keep up, to
a certain extent at least, with the manage-ment of special problems as they occur in children. I do not think this is being
ac-complished in 2 years.
Numerous suggestions have been offered
by many wise and sincere physicians urging
that various aspects of pediatric training should have much greater emphasis than
at present. It may be of interest to discuss these proposals and estimate roughly what they might require in time. The backbone
of any training program is on the wards
with sick children and in the Out-patient
and Well Baby clinics. Although it has been
argued to be wrong, the greatest bulk of
the work is on the wards. I would still
sup-port this in spite of the fact that contact
with such patients with rare or serious
ill-nesses on the wards is out of proportion to
similar problems that the physician will
encounter in practice. People still seek
physicians for the care of their children
EDUCATION
113which they might be maimed or killed. They may go to a physician only as a matter
of reassurance. Even though serious dis-eases are disappearing in quantity and may
only require a small fraction of the
practic-ing pediatrician’s time, the recognition and care of such serious conditions is still the main purpose for which the public wants
pediatricians, and substantial experience is necessary.
How much time do we require on the wards? A rotating system as short as 2 months is pretty impractical. With the seasonal incidence of disease, we would
require at least 2 periods of 3 months with small infants, and 2 periods of 3 months with children. There goes 1 year. We would
require at least 3 months with infectious
diseases or contagious diseases, and 2
months with the newborn. There goes an-other 5 months. Our Out-patient experience has been greatly underemphasized in the past but all agree it is of very great
im-portance. It is certain that the general Out-patient work, i.e., the Out-patient care of
children not yet separated into the various anatomical problems which occupy the special clinics, should dominate the training
period.
I
don’t know any basis fordetermin-ing an ideal Out-patient training period but 4 months might be thought a minimum. Thus, so far we’ve used up 19 months in requirements for a basic training program
that is minimal.
Now, let us look at some of the other things which have been advocated: First,
the special clinics in the Out-patient
Dc-partment. Depending on the organization of the hospital, we have clinics for allergy,
cardiovascular disorders, renal disorders, epilepsy, child guidance, nutrition, endo-crine disorders, and undoubtedly many others. Again, if these clinics are well estab-lished, it is difficult to spend with profit
less than part time for a month in any one of them though part time simultaneously in more than one may be practical. The Well Baby clinic work alone should take up
a large amount of a man’s time for quite a
long period, 2 or 3 afternoons a week for months, in order to give some continuity of care for healthy children.
Next we come to face the demands for training in certain specialties dealing with
children, such as psychiatry, anesthesiology, orthopedics, general surgery, and particu-larly allergy, which has reached such a status of importance that it might well be
a full-time job in itself for some time. Then, should not a pediatrician in training have some time in an emergency or admitting
service, and possibly in some big cities, an
ambulance service, although seldom is that included in pediatrics? Now, we have not included time to have a special assignment in child psychiatry which, if it is going to
take up any time should occupy at least 2 or 3 months, and even that would be con-sidered worse than nothing by some
psychi-atrists.
We have not yet considered a training
period which I think should be most im-portant, namely, a required period in the laboratory. No man can use a laboratory
technician in his practice with good judg-ment if he doesn’t know something about the techniques involved. I know of no better
training period for a pediatrician than a period in a laboratory well integrated with
ward work, and this usually should be divided between at least bacteriology, chemistry and special hematology. How much time for this? Certainly no time at all
unless it is a couple of months in one or another, or in each of these fields.
Should any man have a specialty training without having some little contact with re-search? We must regret it if he doesn’t have such an experience. But if such experience
doesn’t take a block of time, it must take up a lot of time intermittently during a
Should he not do some school health work?
I would think so. It is a wonderful experi-ence to have some supervised public school work whenever that can be arranged.
Should he do some externe work? If not simple home visits he should have at least
some contacts for a long period with
cer-tam families in the home where he is a
home doctor and does some home visits.
These experiences are all valuable, but all take time.
Just the listing of these training experi-enccs, and I have not exhausted them, makes it clear that they cannot possibly
be included in a 2-year program without great loss in the basic training program or without reducing the training to the level
of the hop, skip and jump superficialities of the 1-year, dizzy, rotating internship.
It is of some importance here to consider
the relation between our requirements in
pediatrics and that of other specialties.
Pediatric requirements are the lowest of all. For instance, the American Board of Surgery
requires 4 years of hospital training; the American Board of Obstetrics and
Gyne-cology requires 3 years; the American Board
of Otolaryngology requires 3 years; the
American Board of Internal Medicine
re-quires 3 years.
I hope that not many men choose pedi-atrics because it is easiest, but certainly it
is the easiest. However, we find that the per
cent of residencies filled does not vary
ac-cording to the length of service. In fact, the surgical specialties show the highest per-centage of openings filled.
As to the economic feasibility, we must
admit that many of our young doctors in
training cannot financially afford even the
2 years training, particularly if married.
However, somehow or other they have managed to make the grade often with as-sistance from their wives, friends, and
sometimes the Government. As they are
ac-complishing it in other specialties, as well as in ours, in increasing numbers, I think
we can pass this over, important as it is.
Somehow or other, if the end is important,
facilities can be made available so that young doctors can afford it, so we can aid them in affording it, particularly since the work of a third year would in every case be
a real contribution to public welfare. The next question is, can our institutions afford it? This is a more difficult question.
No increase in quantity of training should
be made by a sacrifice in quality. At the end of the last war, during the period of the survey of pediatric facilities and the subsequent analysis of the survey, it was clear that it was very hard to find enough good hospitals to meet the demand for
training facilities for the 2 years that were required, to say nothing of another year.
A
tremendous number of young men com-ing back from the armed forces, who wanted this training, quite overwhelmed our facilities. However this demand has now greatly decreased and the number ofpossible training areas has increased both in quantity and in many places in quality, and there is still capacity for more increase.
Though there is no question but that some
problems would arise if a 50 per cent in-crease in these required years was estab-lished, if the need for further training is real, then somehow or other it can be met.
Next, can the public afford it? The
de-mand for more pediatricians in general practice is so great from so many places, from established pediatricians, from clinics,
and from the people themselves, that it might be argued that any lessening of our
supply is not yet justffied and that it is possible that increasing the requirements to
3 years would lessen the supply. It is
pos-sible, although I doubt it, that many young doctors who want to be pediatricians would be turned away by a 3-year training period who would accept the 2-year program. Though this argument must be considered,
I
personally doubt that the urge to practice pediatrics is so superficially motivated thatthe relatively short training period of 2 years determines the choice of a career.
ex-EDUCATION 115
cept perhaps during their first year as an intern (a year, by the way, which is many times wasted and should be changed), are
making great contributions to public health
as resident physicians and instructors. They
are engaged in active service and their
years in training are a contribution to the
public weal as much as if they were in practice. The only one who loses out from
a lengthened training is the young doctor himself from a financial point of view and
even here he should not lose in the long run. Although it is likely true that his
probable income may not be much in-creased by the difference between 2 or S
years training, the pleasure and satisfaction
in practice to many is almost surely going
to be increased.
Sincerely yours,
J
AMES L. Wn.soN, M.D. Chairman, Department of Pediatrics and Communi-cable DiseasesUniversity of Michigan
Ann Arbor, Michigan
IRON AND OTHER METALS IN HEr1AToPoIEsIs. (Nutrition Rev., 13:292, October, 1955.) Recent work concerning the metabolism of iron and the importance of other metals, namely copper, cobalt, zinc and molybdenum, in hematopoeisis is reviewed. It is pointed out that although in animals cobalt, copper, zinc and molybdenum have been shown to play essential roles in hematopoiesis, little is known about the roles
of these metals in human nutrition or in hematopoiesis in the human. Claims that
