LETTERS TO THE EDITOR 1013
for his restriction to a limited age group
and avoidance of minor surgery and
ob-stetnics. Although this situation is actually
taking place in many parts of the country,
particularly around medical schools,
cen-tainly the trend can be wrong if it is going further to rob the routine practice of
pedi-atnics of the intellectual stimulus and
men-tal alertness which does result from the
cane of seriously ill and puzzling patients.
What is more, if we argue that my brother’s
cilildren and mine should be taken cane of
by a pediatrician who is really a specialist,
we can still argue that all patients should
be caned for also by such men.
If it could somehow be brought about,
it would seem to mc that it would be far
better for the public if the “average”
pedia-tnician could take more time with his
pa-tients, have more fun with them, have
more time to study them and to talk over
tileir problems at greater leisure. Now,
would this result if larger fees could be
charged? We could well imagine that no
such a result at all would occur, but simply
that the physician would have a greater
income. If it did result that he had more
leisure, this would be brought about by
fewer patients coming to see him, some
being kept away by his higher fees, and
this could certainly be looked upon as a
very unfortunate circumstance in that the
poorer persons would be deprived of this
better medical service. Certainly this would
be the greatest objection that could be
raised to any increase of fees. Nevertheless,
it might be well to consider what the
pedia-tnician earns as compared with other groups
of people who give service-such as
carpcn-ters and plumbers. It is actually no joke that
on a fec-for-service basis, a home call by a
plumber on an electrician may result in
exactly the same fee, and hardly any more
time being spent, as that being given by a
physician who has spent 12 years more in
his training. One can amuse oneself by
speculating on what a plumber, electrician,
or carpenter might earn if he worked on an
hourly basis (with time and a half for
over-time over 40 hours, and double time over
week-ends) and worked the same length of
time that a pediatrician does. The
differ-ence between their two take-home incomes
would actually be little.
I conclude that the general raising of
fees by pediatricians, if it enabled them to
restrict their practice in number of patients
and give more time to each child, would
probably result in good, and that with the
increased number of pediatricians, even
though they are still inadequate in
num-bens, the time is probably now ripe for the
initiation of some such trend.
J
AMES L. WILsoN, M.D.Ann Arbor, Michigan
To rm EDITOR:
Your excellent editorial in the February
issue of PEDIATRIcS should be provocative
of additional constructive thinking on the
problems of the practice of pediatrics.
I believe the new pediatrics can be
pnac-ticed, but not in old frameworks. This is
new wine and cannot be contained in old
wine skins.
Comprehensive cane means a new focus.
The focus shifts from “shot and formula”
and “diseases,” to the whole child in whole
families. The approach is longtcrm.
Philo-sophically the concern is with the child and
his family’s total fulfillment, emotional and
physical. The concern is not merely with
illnesses as such, but with the child with
an illness, whether it be emotional or
physi-cal and how it effects the fulfillment of his
potential destiny in the family and social
milieu.
Comprehensive pediatrics is not only
in-tenested in the horse that is out of the barn.
This is important and is given due
con-sideration, but a comprehensive approach is
not satisfied with an attempt to simply
re-turn the horse to the barn. This is “sick-call”
pediatrics and probably, if this phase of
child cane is all that is going to be given,
in most instances it could best be done by
the general practitioner, who knows and
treats the whole family. This would leave
the pediatrician in the role of consultant
prob-1014 LETTERS
TO
THE
EDITORlems. Such is not comprehensive pediatrics
and won’t support very many pediatricians.
It will mean that much knowledge about
child care that is available to society will
go unassimilated. The pediatrician who
does comprehensive pediatrics is a liaison
person between society and the Ivory
Towers of the centers of learning in
pedi-atrics, psychiatry, sociology, philosophy,
and many other fields.
Timewise, the new pediatrics will be
strongly weighted on the preventive side.
Relatively little time will be spent on
ill-nesses. Much time will be spent on all types
of prevention in the realms of both physical
and emotional illness. Comprehensive care
goes even beyond simple prevention into
the realm of “becoming” so that an attempt
is made to help every child fulfill his
emo-tional and physical potential for maximum
health and happiness. It goes beyond the
child to his relationships in the family and
his community as well. Such a pediatrician
gives support to better family life and uses
the child as a spring-board to manifest his
interest in the emotional climate of the
family. His child and family interest
fre-quently draws him into the families’
rela-tionships in the church, school, and
com-munity agencies. These interests pull him
into community activities regarding total
child development as he becomes a
chal-lengen and an educator.
How can comprehensive pediatrics be
made economically workable for the doctor
and the families? How can it be practiced
efficiently in the time available? I do not
have all the answers, but I have found
enough to have progressively increased my
satisfactions, income, and free time, and at
the same time I have endeavored to make
my practice more comprehensive and more
economically sound for my patients.
Since returning from the armed services
in 1946, I shifted my emphases from
“sick-call” shot and formula practice to the
corn-prehensive effort under discussion. It
be-came evident to me while in the service
that the problems of home casualties were
greater than the casualies of war. It
oc-curred
to
me that the guiding hand of aman practicing comprehensive pediatrics
could have avoided or minimized many of
these problems. The altered framework
has allowed for a much greaten opportunity
to give more “total” care, mucil more in
line with my capabilities and what I
be-lieved should be done.
Yearly budget plans from infancy
through adolescence were made available,
and as all inclusive as I could conceive.
They were spoken of as a means of
supple-menting their health insurance and were
seen as a buffer against socialized medicine.
They became the backbone of the practice
in terms of satisfactions and income. I
could introduce my patients to the best that
I knew. It shifted time spent, to a large
extent, to the side of prevention and
ful-flilment. House calls dropped remarkably,
as illness was made known in its incipiency
and people much more readily came into
the office. A comprehensive care program
formerly had been limited largely to the
first year or two and largely by default; the
older children dropped out of my practice
except when ill on they changed to
gen-eral practitioners for all or most of their
care. The budget yearly plans kept many
more coming regularly through adolescence.
These people became so well known to mc
that illnesses were much less
time-consum-ing than with the casual and sporadic
pa-tient who called only when ill.
This program was buttressed with good
laboratory facilities for routine procedures.
It was also buffered by a comprehensive
program of parent classes oriented toward
both physical and emotional development.
During the past 12 years, hundreds of
pan-ents and adolescents have attended these
question and instructional sessions. Another
format has been to use “buzz” sessions,
in-cluding older children and their parents,
followed by panels made up of
nepresenta-tives from the “buzz” groups. Tile problem
of costly psychotherapy has been alleviated
by setting up periods for group therapy,
which incidcntly often is more rapid and
more effective. We also held youth forums
for teenagers.
LETTERS TO THE EDITOR 1015
have been used. This is helpful, but only
incidental to actual individual or group
instruction. Most of it was written by
my-self or an associate in an attempt to keep
it more personal. It is a satisfactory
supple-ment but a very poor substitute.
An exciting by-product of my interest in
working with groups was the development
of an Institute of Psychology and Religion.
Dr. G. A. Young, a psychiatrist, joined with
me for all-day, monthly sessions with the
clergy, their wives and other interested
people. People traveled up to 500 miles to
attend. The project is in its ninth year and
some of the original group are still
attend-ing It has been an excellent place to spread
the gospel of comprehensive care and to
gain insight for doing a better job of
prac-ticing it.
The field of pediatrics has become so
comprehensive that it cannot be
compre-hended by any single person. As a result,
if comprehensive pediatrics is to be
prac-ticed, the team approach is necessary, with
all on most doing general pediatrics, but
with an emphasis on a subspecialty. The
team approach is also imperative if
24-hour-a-day, 7-day-pen-week coverage is to
be given.
A partial solution to these problems was
the acquisition of partners (Dr. John L.
Gedgoud and Dr. Byron Oberst).
Collec-tively we were able to practice much more
comprehensively. In addition we referred
certain patients to pediatricians outside of
our group, as they referred patients to us
if subspecialty care was indicated. We
con-tinued the oven-all care, or if we were
func-tioning in the role of a subspecialty
consult-ant, we limited ourselves to that role and
left the general care to the referring
pedia-tnician. Through the years empathy among
us increased, as did the pleasure and
quality of cane. We did not feel that we had
to confine referrals to our own group. If
special training of a fellow pediatrician
out-side of our own group made him better
qualified, we didn’t hesitate to use him.
There is a tendency in groups to become
isolated from fellow practitioners. If group
members reach out on a referring basis to
fellow pediatricians, this tendency can be
obviated. It needs to be, as comprehensive
pediatrics cannot be practiced in a vacuum.
First and foremost, comprehensive
pedi-atnics is based on a state of mind. To some
it will have no appeal, as reported by Ross
in the September 1958 Journal of Pediatrics.
Those who choose to practice “limited” as
compared to “comprehensive” pediatrics
are not to be condemned. It is only that
the comprehensive approach is also needed
so that the rapidly-unfolding new
under-standing regarding total child cane can be
assimilated and utilized. It is a phase of
child care that is not likely to be done by
social workers, psychiatrists, psychologists,
“limited” pediatricians, general
practition-ers or others. The pediatrician interested in
comprehensive pediatrics is probably the
best qualified person the culture has yet
provided to do the liaison job of funneling
the new understanding regarding total
child care from the Ivory Towers into the
stream of child life and family life.
I await with interest the revelation of the
experience of others in their attempts to
practice the new pediatrics.
CHARLES A. TOMPKINS, M.D. Tucson, Arizona
Toxicity of Phenothiazine Compounds
To i’in EDITOR:
I have been very interested in the
re-cent exchange of letters (Pimtmics, 22:
1201, 1958) regarding the toxicity of the
phenothiazine compounds. I have witnessed
many cases of typical toxicity to
pheno-thiazine drugs and have made several
ob-servations which I would like to record.
The symptoms are completely listed by
Dr. Bowen’s letter. The patients referred to
in the following paragraphs illustrate the
majority of these symptoms. It is my
im-pression that these symptoms are distinctly
not convulsive in nature, but rather are
manifestations related to the extrapyramidal
tract.
Toxicity has been observed in these
chil-then only when there was significant
