cept of the “¿NewerPediatrics,― embracing as it does the emotional and psychologic guidance of children and their parents, may be so prohibitive in time expenditure as to be impractical. We feel that pediatric group practice may solve this problem in whole or in part in any one of three ways:
First, the group may include one mem ber whose principal interest lies in the field of psychologic pediatrics and who devotes most of his time to this type of work. Such a group member should have had special training and be able to handle all of the problems falling in this sphere for the group at large.
Second, by virtue of the coverage possi ble with a group, each member may so schedule his time as to have certain pe nods free to devote to his patients needing special efforts in the guidance phase of pe diatrics. This presupposes that each physi cian has had sufficient training to do a proper job along these lines for all but the more serious emotional and psychiatric problems.
Third, and I believe ideally, the mem bers of the group may each handle the routine problems of guidance and psycho logic pediatrics for their own patients and, being sensitive to and perceptive of the need, may refer his more involved prob lems to a good child psychiatrist. This lat ter method seems to us the best. There are, of course, areas where this is not feasible at present. Even this method of attempting to accomplish the aims of “¿Comprehensive Pediatrics― will require that the pediatri cian be able to devote some time each week
I N ORDERto deal with the question' in an intelligent manner it will be necessary to define both “¿newpediatrics― and “¿mixed group.― It will be further illuminating to
to patients who need more time and dis cussion than routine office visits permit, and this is feasible in a group. It will also demand insight and understanding on the part of the pediatrician as to which pa tients need referral for special psychiatric help.
Many otherwise competent pediatricians today have not had the good fortune to have the training background in psychologic pediatrics to enable them to go further than the mere recognition of established psychiatric difficulties. Most of them have had, however, a training adequate to en able them to prevent a portion of early problems from becoming more serious.
Group pediatric practice should make it possible for the members of the group to so organize their time as to give excellent serv ice to their patients in the broad context of “¿ComprehensivePediatrics― by one of the three means discussed above. “¿Comprehen sive Pediatrics― may not really be so new, but the pressures . of practice, engendered by the wide public acceptance of over-all health care and supervision for children, make it necessary to re-evaluate our meth ods of effectively bringing it to fruition in our everyday work. In doing this, the group approach offers certain real advantages.
A properly functioning pediatric group has the potential of protecting its members from the likelihood of falling into the purely production-line type of practice, which is so often thrust upon a man practicing alone. This in turn should be reflected in a better quality of care for the pediatric patient.
ask why the question should be asked: Can the new pediatricsbe practiced?―It seems fair to state in answer that the question is asked chiefly because of the discrepancy
MIXED GROUP PRACTICE
Donald M. Burke, M.D.
878 PRACTICE OF PEDIATRICS
of the mixed group, however, a few char acteristics which might be considered spe cifically related to the question will be dis cussed. The characteristics of mixed groups vary greatly in this widespread medical ex periment and I will only attempt to ab stract them, making no guarantee that the statements I make pertain to all such groups. Usually several persons joining to practice medicine hope that by pooling their resources they may be able to attract physicians who exemplify assorted disci plines, and that their combined assets ma)' yield a larger amount of diagnostic and therapeutic equipment. Persons may enter group practice for more personal reasons, but this is beside the point. A few related group traits which seem most pertinent are noted.
There is first of all a great advantage in the lack of jurisdictional disagreement which can arise between overlapping spe cialties.3 Two places where the practice of pediatrics is most likely to be involved are in the care of the adolescent and in the neonatal period. From the mortality stand point the more important of these is the newborn period. The practice of having all newborn infants turned immediately over to the pediatric service is probably stand ard in mixed groups. In the case of abnor mal delivery, maternal disease, suspected anomaly or prematurity, the pediatrician is summoned in advance so that he may be prepared to take whatever precautions may be necessary. He may wish to obtain a his tory in the prenatal period; such history taking may be of value from the scientific viewpoint as well as in the establishment of confidence in the mother-pediatrician rela tionship.
Of similar nature, but at the other end of the pediatric spectrum, is the handling of adolescents. With the increasing recogni tion in pediatric circles that the adolescent is a proper subject for pediatric care, there has arisen a certain amount of speculation as to where the borderline between pedia trics and internal medicine arises. In many communities an arbitrary chronologic age, between the type of patient who is seen in
pediatric residency and the type of patient encountered in everyday pediatric practice. It should be pointed out that implicit in this discrepancy is a known change in the character of pediatric practice in general; the pediatrician of today sees few of the dis eases considered both common and serious in the practitioner's office a generation ago.
The ex-resident entering practice today may find that the knowledge gained from the more difficult periods of his residency training is not put to frequent use. He might further find that he is at a loss to cope with some of the many questions a mother can ask regarding her child, which do not seem related to the child's organic illness; her attention may be focused on something which appears minor in the eyes of the pediatrician. He finds himself often in the position of health counselor and practitioner of preventive medicine rather than a physiologist delving into the newly known metabolic disturbances or the fine techniques of cardiac catheterization. He must learn the truth of Dr. Wyman C. C. Cole, Sr.'s statement that, “¿Wemust think of the pediatrician as the child's physician, not merely as one who treats the diseases of childhood.―2
The “¿newpediatrics― might be defined as the comprehensive care of the child from birth through adolescence; at least this is the sense in which the definition will be used in this paper. This care embraces treatment and prevention of disease, men tal hygiene, supervision of growth and re assurance of mothers. The acceptance of such care on the part of the physician im plies a responsibility which is broad and long-lasting.
A medical group might be defined as a voluntary association of physicians who unite to practice medicine together. The “¿mixedgroup,― as used here, indicates one in which members of various specialties are represented other than those in pedi atrics and pediatric sub-specialties.
such as 12 or 14 years, is used for the cutoff time between pediatrics and internal medi cine. It is much easier in a mixed group to make allowance for the physiologic differ ence that separates the near-adult from the early adolescent. The absence of competi tion in the ordinary sense makes the choice of specialty that should handle the adoles cent more often a matter of clinical rather than administrative judgment. Too, the pa tient may decide who is to treat him, a de cision which makes for better rapport.
An obvious and often stated advantage of the mixed group is that of the ready availability of the specialists in other fields who are available for consultation in case of puzzling disease or reassurance of physi cian or mother. Some of the questions that might arise concerning the close ties with members of other specialties are:
1. Does this tend to circumscribe the area of pediatrics so that one cannot treat the rare disease? 2. Do the policies or atti tudes of the other specialties impose them selves on the free and proper handling of certain disease states by the pediatrician?
Neither of these problems has been in surmountable. It has been my experience that obstetricians and other members of the hospital staff are usually only too happy to have judgments concerning the child made and executed by the pediatrician. Usually my colleagues have been very ready to have a pediatric opinion on a case which came first to their attention, but occurred in a child. It is usually possible to reach a har monious solution even when two physicians are tryingto decide proper care from the pedestalsof differentspecialties.Adamant disagreementsare quite uncommon and have usuallybeen resolvedby requestingad ditional opinions either within or outside the group. Sometimes questions are decided by staff meetings where the problems are dis cussed freely. In this respect a group seems to offer an advantage because diagnostic problems often become more or less com mon knowledge. It appears to me that hav ing one's cases open for scrutiny by col leagues tends to make each individual keep
abreast of knowledge in his field and de fend his views in such a way that his an swers are convincing. I have no doubt that this often tends to keep the persons in a group more cognizant of new developments than otherwise they would be.
The presence of these additional factors in one's practice does not prevent the pedi atrician from establishing his own policies and standards very much as he would in private practice. The care of well babies and children goes on, but it requires less time to speak of this than it does of the other problems I have mentioned. The fre quency of telephone calls from anxious mothers is not lessened because they have to go through a switchboard. The responsi bility for care and counsel cannot disappear for the conscientious physician.
One qualification I should make is that my experience has been in a small-town community so that perhaps I do see a some what high incidence of pathology. Dr. Ju lius Richmond commented on rural areas that “¿thepattern of practice may be simi lar to that prevalent in the country at large 25 years ago.―4Some of this greater inci dence of pathology evident in rural areas is probably due to the dearth of medical school and organized welfare clinics, so that persons who would be teaching ma terial or non-private cases in the city might come to us for treatment. The presence of the medicallyindigentcases,while adding interesttomedicine,does not invalidatethe
880 PRACTICE OF PEDIATRICS
the county, the largest in West Virginia, has only approximately 30,000 people.
One of the common objections to group practice is that it may depersonalize care by having the patient seen on a production line basis by a number of uninterested per sons. This is not usually the case, at least I do not think it arises any more often than it occurs in private practice, where it is necessary to make referrals to two or three other men for fairly comprehensive exami nations. Such situations may arise either in side or outside a group, but it would seem possible to save some time as well as dupli cation of laboratory work by having it done within a group. It is also possible for the physician to keep in touch with the patient being studied because the study is carried out within one physical plant.
There is some possibility of depersonali zation because of the alternation of night calls by various members within services of the group, however, this has its good as well as its bad side. While the patient must be made to understand that his own physi cian may not always be available any hour of the day or night, this is compensated for by the assurance that someone else will be available. This type of assurance is often acceptable to persons who have had the experience of vainly searching for an alter nate physician when their own doctor was out of town. Under such alternate type of nighttime coverage it is usually customary for the physician who sees the patient on an emergency basis to refer the patient back to the attending physician at the next visit; at the same time a more continuous record is kept because notes are added to the same chart.
Before summarizing and concluding, I might state that I know of no set of stand ards for groups, such as there is for mdi vidual specialties or for hospitals, so that a group may be almost any combination of licensed physicians operating under any type of administrative set-up permissible
by law. I am tempted to speculate that as large cities expand, there will be further development of groups which will act as transition points between teaching centers and independent practitioners, and that as groups become more common a set of standards may be necessary in order to in form the users of the qualifications a given group possesses.5
The conclusion I reach, therefore, is that the “¿newpediatrics― can be practiced in a mixed group. It is probably avoided only in the pure teaching, research or public health position where one does not cope with the day-to-day problems of patients. It is my opinion that the “¿newpediatrics― can be enhanced by group practice be cause:
1. The unusual cases that arise may be studied more easily.
2. Well-child care and guidance may often be aided by an easily obtained consultation.
3. Interest is stimulated by an increased number of sick children who often seek first the advice of someone in the group who represents a more limited specialty.
4. The child is considered under pedia tric jurisdiction from before his birth until late adolescence.
REFERENCES
1. May, C. D. : Editorial: Can the new pedia tries be practiced? PEDIATRICS,23:253, 1959.
2. Cole, W. C. C., Sr.: Pediatrics in the space gae. J.A.M.A., 171:641, 1959.
3. Croatman, W., and Barland, P.: What's gone wrong with specialism? Medical Economics, 37:86, 1980.
4. Richmond, J. B.: Some observations on the sociology of pediatric education and prac
tice. PEDIATRICS, 23:1175, 1959.
1960;26;877
Pediatrics
Donald M. Burke
MIXED GROUP PRACTICE
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Donald M. Burke
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