Letters
to the Editor
PEDIATRICS Vol. 54 No.
2
August
1974
249
Statements appearing here are those ofthe writers and do not represent the official position of the American Academy of Pediatrics, Inc., or its Committees. Comments on any topic, including the contents of PEDIATRICS,
are invitedfrom ailmembers ofthe profession: those acceptedfor publication will not be subject to editorialal-teration, thougjz shortening ofletters more than .300 words in length may be requested. The Editor reserves the right to publish replies, and nay solicit responses from authors and others.
. . C
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Are the Academicians
to Blame?
To THE EDITOR:
Although I should hate to sound cynical or even
“anti-in-tellectual,” Dr. David G. Nathan’s solutions to the primary
medical care problem seem to carry a hidden ‘Is the
problem an absence of available persons to deal with
pri-mary care or a crowd of weary old bones obstructing his view
of the bench? In no other area of investigation would a
re-searcher suggest that a particularly vexing problem be
tack-led by those no longer productive in the areas of their choice.
Furthermore, it is these same “grand old men” who
de-em-phasized patient care in the first place by calculated
empha-sis on more “scientific” areas. Dr. Nathan’s implication that our present state of affairs was reached in a laissez-faire hap-penstance is an error. It occurred as a result of the distortion
of Flexnerian goals orchestrated by the men he feels so
corn-fortable with-the same men who advised the federal
gov-ernment where to put its money, and who in their
depart-ments slowly weeded out anyone not doing enzyme research.
The suggestions sound not unlike our President’s solutions to
the investigation of Watergate. My own feeling is that the
issue is mainly one of role models, and emphasis. If a student
never sees a competent clinician who considers patient care
his primary goal, he will probably never take that path. Such
contact would require more primary care in medical school
settings and working relationships between medical schools
and the private sector-not a few research warhorses sent out
to primary-care pasture.
950 East 61st Street
Chicago, Illinois 60637
MICHAEL K. POSNER, M.D. Acting Medical Director
The University of Chicago
Department of Pediatrics
Woodlawn Child Health Center
REFERENCE
1. Nathan, D. G.: Primary medical care and medical
re-search training. Pediatrics, 52:768, 1973.
Intellectual Elitism Attacked
To THE EDITOR:
There is today universal agreement on the existence of a
health care crisis in this country, and total lack of agreement
on how to improve the situation. Dr. David Nathan in his
commentary’ proposes no solutions, but rather suggests
peo-ple whom he feels are best qualified to effect a cure, and, by
implication, the manner by which solutions should be
sought. Beginning with the trenchant observation of Dr.
David Rogers2 (not found, incidently, in the reference cited
by Dr. Nathan3) that academic medical centers are partly to
blame for the present health care mess and that they should
aid society in correcting the situation, Dr. Nathan calls for
established, research-oriented medical faculty to switch
in-terests, “retrain themselves” where necessary, and solve the
problems of health care by scientific investigation. I feel that
the utter confidence expressed by Dr. Nathan in his
imme-diate peers to the exclusion of all other interested persons or
methods is indicative of an underlying intellectual elitism
which pervades our “prestigious” medical centers.
The consumer of the health industry has been and
con-tinues to be the loser, but for many years has been quiet. But,
as has been well-documented in the media, the consumers
and their occasional mouthpiece, the government, are
disen-chanted with rising costs of acute care, a deficiency of ambu-latory care, a lack of chronic care and practical benefits from
research inappropriate to the level of support. The recent
federal budget cuts, while difficult for those of us involved in
basic and clinical research, capricious and overreactive, are
nonetheless a sign that society is questioning the profession’s definition of what is important. I doubt that society will have the patience to wait for significant numbers of senior acade-micians to close out research grants, turn over administrative duties, “retrain themselves” and begin to analyze the health
care issues of the present and future.
The charge of intellectual elitism is not a pleasant one to
make, but Dr. Nathan provides ample documentation in his
article, in addition to his major thesis. By emphasizing that
the problems of health care must be solved by persons
trained in biomedical research he is implying that these
problems can be analyzed by quantitative means. The
sim-plest argument against his example of the physiologist
exam-ining the deployment of physicians has been made by Dr.
Robert H. Ebert, “. . . one cannot define with any accuracy
the manpower requirements for a system of medical care
that has yet to be clearly defined.”
Perhaps Dr. Nathan would begin by evaluating and
re-forming the system. However, as pointed out by Dr. Rogers
among others, many crucial aspects are not yet open to
sci-entific analysis.2 The effects of present modes of care on
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250
LETTERS
TO THE
EDITOR
ciduals have never been adequately documented and the
ex-pectations of future systems cannot be defined without total
regard for the variety of human factors involved.3 I would
urge any scientist, before attemping quantitative analyses of
problems concerned with subjective human characteristics, to first consider whether or not the scientific method is really
applicable or necessary, and if so, how the data might be
used by other professionals, the government, etc. Lest this be labeled as anti-intellectualism, I offer the current contro-versy over the heritability of IQ as an analogy. Only recently
have people begun to realize that this “problem” and the
terms being employed are not clearly defined (and possibly
irrelevant), the means of assessing certain human traits are
largely unacceptable, the previous research is unscientific, it
is impossible to conduct experiments on humans in which
ge-netics and/or environment are satisfactorily controlled, and,
finally, that society in general is upset by and incapable of
dealing with the results of quasiscientific research.’” Dr. Nathan states that the “top” of the medical profession
is defined as specialty and research medicine. This one fact
precludes many medical students or young physicians (still
predominantly white, middle-class and male) from
consid-ering or staying with primary care medicine.’2 Yet, a number
of practicing family or community physicians have stressed
the intellectual challenge of being continually and often
solely responsible for differentiating lethargy and meningi-tis, gas pain and intussusception, poor school performance
due to the psychological upset of obesity and true learning
disability, and so forth. But as long as primary care
physi-cians are considered second-class professionals and not
ad-mitted to the academic hierarchy and as long as bioscientific
faculty perpetuate intellectual elitism, young physicians
will continue to be misdirected.
Dr. Nathan explicitly rejects many possible reforms in
medical education. He does my contemporaries great
disser-vice by accusing us of being “. . . naively cynical about the
value of the scientific basis of medicine. “ I have found that
medical students, including those from minority groups,
realize that much of the griping that goes on in the first sev-eral years at “prestigious” medical schools stems from either
poor teaching or fntstration at the artificial separation of
basic science and clinical training. Students are, however,
cynical about two aspects of their education. We recognize
the health and medical problems of our communities but
find it difficult to believe that the need for primary care
phy-sicians can be met by training everyone almost exclusively in
the academic tertiary-care setting. In addition, while not
questioning the tremendous importance of a rigorous
prepa-ration in traditional science, we note with skepticism that
these sciences are promoted as the only basis on which to
practice medicine. A paradox arises when Dr. Nathan
ex-presses little confidence in a “biosocial but he
then goes on to state:
. . . careful study of the social sciences relevant to primary
care delivery must be critically important for the
devel-opment of a leadership group of physicians who will
evolve new methods of primary care delivery to large
groups of patients. A knowledge of public health
proce-dures, medical economics, basic sociological principles,
and the interactions of government with society will be
of great importance to the graduates of training
pro-grams who intend to make major inroads into the health
care crisis which confronts us.
In Dr. Nathan’s opinion, who is to say what aspects of the
social and behavioral sciences will be relevant to primary
care? Hopefully not his corps of untrained researchers and
administrators. Many psychologists would even question the
usefulness of attempting to “retrain” someone who has
accu-mulated one half or three fourths of a lifetime of biases and
prejudices.
Dr. Nathan also gives support, perhaps unwittingly, to
those of us who argue that a person’s environment,
personal-ity and commitment to societal improvement are important
determinants of who is cut out to be a primary care
physi-cian.7’2’3 In their preoccupation with strong scientific prep-aration and ability to compete with one’s peers (i.e., grades),
admissions committees are simply not admitting the
stu-dents with the greatest likelihood of entering primary care.
There is no question that leadership is presently in short
supply, but to suggest that only one type of professional is
needed, even capable of attempting leadership, is
advocat-ing an oligarchy of the clerisy. The physicians to whom Dr.
Nathan issues the call can indeed make a significant
contri-bution, and it would be an encouraging development at our
medical schools to have faculty at least begin a dialogue on
these issues. I think immediately of Linus Pauling as an
example of a scientist who assumed leadership and made
im-portant contributions of overriding concern to society (and I
am not referring to vitaniin C). Nothing should stand in the
way of individuals wishing to “change careers in
mid-stream,” but let us hope they will have the benefit of working
with the myriad of other professionals and consumers who
will represent all interests of society.
It would be well for us to heed the words of a physician of a
past era, who also had “unimpeachable academic
creden-tials:
Should medicine ever fulfill its great ends, it must enter
into the larger political and social life of our time; it
must indicate the barriers which obstruct the normal
completion of the life cycle and remove them. Should
this ever come to pass, Medicine, whatever it may then
be, will become the common good of all.’
REED E. PYERITZ, Ph.D.
Teaching Fellow in
Biological Chemistry Medical Student
Harvard Medical School
Boston, Massachusetts
REFERENCES
1. Nathan, D. C.: Primary medical care and medical
re-search training. Pediatrics, 52:768, 1973.
2. Rogers, D. E. : Health care and the academic medical
center. Pharos, April 1973, p. 49.
3. Rogers, D. E. : The American health-care scene. New
Eng.
J.
Med., 288:1377, 1973.4. Ebert, R. H.: The medical school. Sci. Amer., 229:139,
1973.
5. Brook, R. H., and Appel, F. A.: Quality-of-care
assess-ment: Choosing a method for peer review. New
Eng.
J.
Med., 288:1323, 1973.6. Kessner, D. M., Kalk, C. E., and Singer,
J.:
Assessinghealth quality-The case for tracers. New Eng.
J.
Med., 288:189, 1973.
7. Heyssel, R. M., and Carter, R. A.: Training for primary
care.
J.
Med. Educ., 48:158, 1972.8. Daniels, N. : The smart white man’s burden. Harpers,
October 1973, p. 24.
9. Bowles, S., and Gintis, H.: IQ in the U.S. class structure.
Social Policy, Nov/Dec., 1972; Jan./Feb., 1973.
10. Lewontin, R.: Race and intelligence. Bull. Atom. Sci.,
March 1970, p. 3.
11. Kamin, L.: Heredity, Intelligence, Politics and Psychol-ogy. Text of invited address of the Eastern
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LETTERS
TO THE
EDITOR
251
logical Association Convention, May 5, 1973, p. 97.
12. Funkenstein, D. H. : Medical Students, Medical Schools
and Society During Three Eras. In Coombs and
Vincent (eds.): Psychological Aspects of Medical
Training. Springfield, Ill.: Charles C Thomas, 1971. 13. Johnson, D. A., Kerr, D., Pyeritz, R. E., Quevedo-Grado,
S., and Rivera, R. : Program in biosocial medicine.
Harvard Med. Alum. Bull., 48:20, 1973.
14. Virchow, R.: Die Einheitsbestrebunger in der
wissen-shaftlichen Medizin. Gesammelte Abhandlungen
aus dem Gebiet der #{246}ffentlichen Medizin und der
Seuchenlehre. Berlin, 1879.
Dr. Nathan’s
Assumptions
Attacked
To THE EDITOR:
David C. Nathan’s commentary (Pediatrics, 52:768, 1973)
on problems of delivery of health care suggests that the
ra-tional application of scientific methods which have been so
successful in the biomedical research area to the problems of
the delivery of health services to our population, will
pro-duce comparable achievements in this new arena.
Nathan may well be correct in his faith in the research
process. However, he also seems to believe that persons
en-gaged in research possess talent (“the cream”) which is
equi-potential in all areas. Thus the same person, who has been
most productive in developing new thoughts on how
potassi-um moves in and out of red cells, is best able to develop new
thoughts on the delivery of primary care.
It is this latter assumption which I wish to question. What
evidence suggests that the attributes of successful clinicians, students of health care, sociologists, or biomedical
research-ers, are all the same? Without professing expertise myself, I
venture to suggest that what little evidence is available
might more support the opposite hypothesis.
What if I propose that we pull out our senior public health
and hospital medical staff clinicians, who have reached a
stage in their careers when they are no longer truly excited
by clinical practice. Administrative duties pull them away
from their office for progressively longer periods of time. Is
there not a moment when it is clear to all that younger men
might best be appointed to replace them, while they move
toward a period of retraining which would enable them to
provide expert leadership, in the complex area of biomedical research?
I for one, would feel much more comfortable seeing a man
who is capable ofunderstanding the problems of the delivery
of health care in New York City, studying the rate at which
potassium enters the red cell, than the reverse.
Dr. Nathan’s naivet#{233}with respect to problems outside the
hematology laboratory is matched only by his arrogance.
AYRUM L. KATCHER, M.D. Director, Pediatric Services
Hunterdon Medical Center
Flemington, New Jersey
pediatrics as a response to house staff interests and also in
re-sponse to the needs of the surrounding community. This
in-terest in primary care is perhaps even more evident among
medical students. Maintaining and further stimulating this
interest is a challenge to all programs offering pediatric
training.
Primary care must be recognized as a field with unique
problems, solutions, and academic challenges. These may
well not be encountered in a traditional career focusing on
the research lat)oratory. To assume that one who has devoted a lifetime to research in molecular kinetics could, with
rela-tive ease, assume a position of leadership in
community-based programs is naive indeed. The laboratory milieu, with
its precisely controlled variables and its generally compati-ble teams, is quite different from the world of health care
de-livery, family dynamics, public health, and medical
con-sumerism. We believe, as does Dr. Nathan, that valid
re-search designs should be applied to community problems,
but would argue that this approach could be better learned
from sources other than the medical research laboratory.
The position of the laboratory, insulated from the
communi-ty, does not promote understanding of the problems of
deliv-ery of primary care or investigation of same.
Community-oriented programs, since they serve a
teach-ing function and in addition are called upon to develop new
approaches in patient care, necessarily demand the very best
leadership that pediatrics has to offer. This must include
ju-nior members capable of original organization of health
ser-vices, research, and stimulation of the interest present in
house staff and medical students. It is to those who have had
this continuing interest in the teaching and research aspects of primary care that we can look for leadership. In addition,
physicians who have been closely involved in other areas of
research and teaching may find primary patient care an area
worthy of their best creative efforts and may serve as another resource for leadership in this field. Any physician involved
in this area, with its serious and difficult challenges, is aware that it demands great interest, energy, and originality, often
in areas for which traditional medical education and
re-search leave one unprepared.
We are hopeful that those who occupy positions of
leader-ship in pediatrics and medical education will meet this
chal-lenge better in the coming years.
Boston, Massachusetts
J
OEL BASS, M.D.DOROTHEA JOHNSON, RN.
JACQUELINE KIRBY, MSW
GEORGE A. LAMB, M.D.
J
ANICE C. LEVY, M.D.PAUL L. MCCARTHY, M.D.
CAROL ROBINs, M.D.
CYNTHIA Ross, RN.
Division of Community Child Health
Children’s Hospital Medical Center
The
Guest
Speaker
Adds Some
Thoughts
Viewpoint
From
the Division
of Community
Child
Health
To THE EDiToR:
We read with interest Dr. Nathan’s comments on primary
medical care (Pediatrics, 52:768, 1973), but feel compelled to
add another viewpoint.
One of the striking changes occurring today in teaching
hospitals and medical schools is an increased awareness of
and interest in primary care. Some institutions, including our own, have created residencies and fellowships in ambulatory
To THE EDITOR:
I am greatly honored by your publication of my Blackfan
Lecture at Harvard on “Health Services in the Home.”
I also appreciate the notice given to the article by the
commentary from Dr. David Nathan.2
Dr. Nathan is certainly entitled to interpret my feelings
(“Be off” she states “with your ultrascience”) and I am
grate-ful to him for his interpretation. I was rather ashamed of my
own moderation. But this was not what I stated.
I cannot discover where I “refused to lay the responsibility
of the development of an adequate system of maternal and
