EDUCATION
Grover F. Powers, M.D., Contributing Editor
TEACHING
OF
COMPREHENSIVE
PEDIATRICS
ON
AN
INPATIENT
HOSPITAL
SERVICE
By Morris Green, M.D., and Milton J. E. Senn, M.D.
Department of Pediatrics, Yale University School of Medicine
PRESENT ADDRESS: (M.G.) Indiana University Medical Center, 1100 W. Michigan Street, Indianapolis
7, Indiana.
476
Pxawrmcs, March 1958
W
A.RD ROUNDS have been the traditionalmeans of teaching medicine in hos-pitals. The Council on Medical Education and Hospitals of the American Medical Association has stated that “The most
im-portant phase of intern instruction consists in daily, regularly organized ward rounds with well-conducted teaching at the
bed-side. By this is meant systematic instruction of the intern by the attending physician with an ample discussion of the history, the physical examination, the clinical and
lab-oratory findings, the diagnosis and the
treat-ment of each patient. The social and psy-chological aspects of the case should receive
proper emphasis.” This paper reports the
manner in which ward rounds have been conducted by the authors on the pediatric wards of the Grace-New Haven Community Hospital during the past 5 years. Particular
attention is given to the manner in which
social and pyschologic aspects of care have received “proper emphasis.”
There have been several changes in the
composition of the inpatient population on many pediatric services in recent years. While there has generally been a decrease in the number of patients with infectious disease, the number of children with chronic
illnesses, congenital anomalies, develop-mental retardation and psychosomatic
ill-nesses has demonstrated a relative increase. The total number of hospital admissions has declined, and the length of stay shortened.
The role of the pediatrician in practice has also changed. Training limited to
tradi-tional teaching on an inpatient service no longer adequately equips the pediatrician
to deal with many of the problems for which he is consulted; he is less often
con-fronted with problems of physical illness and more often with those related to growth and development and to psychosocial fac-tors. There has been a particular increase in the number of parents who want advice about child rearing and help with such problems as the child who does poorly in
school. The survey of child health services reported by the American Academy of
Pediatrics in 1949 indicated that 54% of the pediatrician’s time is devoted to well-baby and well-child care.
These changes in both hospital and pri-vate practice of pediatrics have led us to ex-plore teaching methods whereby physicians may learn how to deal more adequately with
the problems that have come with a broad-ened scope of pediatric practice.’3 In the teaching program that has evolved, primary concern with the diagnosis and treatment of physical illness has been complemented by
an interest in all factors relevant to a child’s problems.
DESCRIPTION OF INPATIENT TEACHING
PROGRAM
Ward rounds are held daily and are at-tended by the house staff, medical students,
confer-ence room on the ward. The pediatric in-tern or a medical student presents the new case, including the history, physical exam-ination, diagnostic impressions and plans
for investigation and treatment. The pres-entation is then discussed by the attending
physician with active participation of the
others. Some discussions are brief while
others may last an hour. Comments may be made concerning any aspect of the care
of the patient and are not limited to a con-sideration of the diagnosis and treatment of a physical disease. Content may come from the fields of clinical pediatrics,
pharmacol-ogy, bacteriology, epidemiology, psychiatry,
sociology and others. After the presentation of new cases is completed, children previ-ously admitted are seen on walking rounds.
In addition to the ward teaching there
have been frequent informal sessions in the offices of the attending physicians. These meetings have been tutorial in character and usually centered about a patient. This
type of personalized approach has been employed particularly to demonstrate to the house officer how to interview parents and
children. In some instances the house officer has discussed his interview with one of the
attending physicians immediately after see-ing the parents or child. More commonly, however, interviews with the parents or child have been conducted with the as-signed house officer present as an observer. At the completion of such sessions the house officer and the instructor review the tech-nique and content of the interview. Experi-ments have also been made with the use of
recorded interviews for teaching principles of interviewing to a group.
The major portion of the teaching of comprehensive pediatrics by the authors has occurred through discussion of case presentations. The sections below illustrate
the nature of the comments made in rela-tion to the following segments of the pres-entation: (1 ) the medical history; (2) the
physical examination; (3) the diagnostic study; (4) the physician-patient relation-ship; (5) the illness; (6) the pertinent
socio-economic and cultural factors; (7)
treat-ment, and (8) talking to the parents and
child.
DISCUSSION OF THE MEDICAL HISTORY
The medical history has been considered to be the most helpful diagnostic tool that the physician has, as well as an effective psychotherapeutic technique. Its
import-ance as a diagnostic tool has been drama-tized by discussing the differential diagnosis
immediately after presentation of the
his-tory, before the physical and laboratory find-ings have been given. The medical interview
serves to elicit data leading to the diagnosis of either an organic or a psychosomatic dis-ease and to establish a positive relationship
between physician and patient. It has been repeatedly observed on the wards that the intern who most often establishes good rapport with parents and wins their
con-fidence is the one who demonstrates his interest by spending time in taking a careful
and thorough history.
Very frequently on rounds the attending physician has been interested in information that had not been obtained in the first
in-terview. This has confirmed the fact that the more one knows about both organic and psychosocial aspects of disease and symptoms the more detailed the medical history becomes. It has also demonstrated
that a complete medical history cannot be elicited in one interview. History taking in many of the complex cases seen on the
in-patient service has been a progressive and continuing procedure in which information adequate for diagnosis and therapy often came after a number of sessions. Additions to and corrections of the initial history have
been part of the daily ward rounds.
Our experiences with presentations of the
medical history on ward rounds have im-pressed us with the fact that although
his-tory taking is interviewing, house officers have not learned in medical school the skill of interviewing. Many have not realized that this skill would be helpful to them as practicing pediatricians, particularly in car-ing for sick children. For these reasons, the
interviewing wherever appropriate in their
discussions of the medical history. It has been rare for an intern to integrate all etio-logic possibilities, organic and psychosocial, into the first interview. In general, house officers have been trained in medical school
to rule out the possibility of organic disease first before proceeding to a history that is concerned with psychosocial factors. This latter kind of history must be distinguished from what is ordinarily considered a
psychi-atric history. It would be a grave mistake to teach that one obtains a psychiatric history
for certain kinds of complaints but employs the more traditional type of medical history for the diagnosis of disease that has a
pre-sumed physical etiology.
When an organic etiology has been ruled out, the question frequently arises : “How do I tell the parents that this is
psycho-logic?” The optimal time for the doctor to introduce the possibility of a psychosocial
etiology is thought to be at the conclusion of the first interview. If he is not certain whether the etiology is organic or psycho-logic, he has been advised to make such a
statement as, “As you know this symptom may be caused by either organic or psycho-logic factors. From what you tell me, both
may be present here. We shall want, of course, to look into all possibilities. There is a good chance, however, that no physical cause will be found.” If organic possibilities
are then ruled out by further studies, this approach permits the physician to pursue the matter in the following manner: “As indicated in our first interview, Johnny’s symptoms could be due to some physical cause or related to some of his problems that you were telling me about. Since the
first possibility is ruled out now, I think that we ought to explore these other possi-bilities more fully.” Parents have reacted to statements of this type by regarding the
doctor as a careful, competent and compre-hensive investigator.
If the house officer has considered the problem to be psychologic in etiology, he has been advised to approach the parent
with this comment: “As we talk here, it seems that Johnny’s symptoms could well
arise from some of the problems you have
been telling me about. Since these com-plaints don’t fit into any picture of physical disease, I know that you’ll be glad to hear
that it will not be necessary to do any lab-oratory tests or x-rays at this time. I think, however, that we should talk some more
about how Johnny is getting along gen-erally.”
In discussing the house officer’s
presenta-tions, the authors have frequently asked the following questions : “What does the parent think the child has?” and “What does the parent expect us to do while the child is in the hospital?” The answer to the first ques-tion is often helpful in knowing what the parent is most concerned about. Knowledge
of what the parents expect permits one either to meet their expectation or to tell them, at the time of the first interview, why the doctor believes that a procedure need not be done. In the case of seriously ill
children these questions are also helpful in determining whether the parent has an ade-quate understanding of the severity of the
illness, the duration of hospitalization and the nature of the diagnostic and therapeutic procedures to be performed.
S.T., a 7-year-old girl, was admitted with a history of pemiumbilical pain of many months’ duration. She was also said to be very nervous and hyperactive. A roentgenographic examina-lion of the upper gastrointestinal tract and an intravenous pyelogram performed in another hospital were reported to be negative; the stool examinations were also said to be nega-tive for ova and parasites. Mn. T. had recently entered a hospital because of an ulcer and a depressive reaction. Mrs. T., also said to be
very nervous, had a history of migraine and
episodic feelings of numbness. Because of
ab-dorninal and pelvic pains that had persisted
thoughout her married life, she had undergone a series of operations in the course of which all her reproductive organs had been removed.
In the discussion of this case on ward rounds, the resident staff did not believe
that the child had an organic disease and thought that further laboratory studies were
EDUCATION
mother what she thought was wrong with
the child nor what she had expected to be accomplished in the hospital. He had not indicated to the mother what he thought might be the cause of the symptoms. The attending physician predicted on rounds that the mother would be critical of the quality of medical care when informed that no special procedures had been dime. It
was also pointed out that it would be
diffi-cult for the intern to explore belatedly the possibility of a psychologic etiology since it would seem like an afterthought.
As had been predicted the mother was
distressed to learn that no laboratory pro-cedures had been done, and she wondered
why the child had been hospitalized. The referring physician had made the presump-tive diagnosis of “abdominal epilepsy” and had indicated to the mother that an
electro-encephalogram would be obtained. At the time of the next visit, the intern was
sum-prised to learn that Mrs. T. thought her daughter’s trouble was just like her own, that is, some difficulty in her “female or-gans.” She went on to say calmly that al-thought it would be too bad, the child might as well have them removed now and
get it over with.
DISCUSSION OF THE PHYSICAL
EXAM INATION
The authors have been interested in the house officer’s description of the personality
of parents and child as part of the report of the physical examination as well as of the
interview. This interest derives from the
belief that as complete an appraisal as pos-sible is essential if the physician is to deal most effectively with parents and children.
Q
uestions such as : “What are the parents (child ) like?” have occasionally elicited aperceptive description by a house officer,
but more often the response has been a blank stare or a few nonspecific or stereo-typed adjectives. One of the educational objectives on the inpatient service has been to increase the doctor’s perceptivity of be-havioral as well as physical findings.
It has been of interest to note the different impressions that house officers, nurses and
the referring physician often have of the
same parent or child. We have been im-pressed that the young physician’s ap-praisal of behavior is as subjective as that
of a lay person and often not as incisive. This lack of perceptivity may be due to the
fact that the medical student has been taught to appraise physical findings rather than behavior. That the appraisal of parents is colored heavily by the particular outlook
of the physician was demonstrated in the following episode.
Two infants, each 6 months of age, were admitted with Hemophilus in.fluenzae men-ingitis by the same intern during 1 week. While the parents of the first child were very anxious, excitable, asked a great
num-ber of questions and did not want to leave the hospital, the parents of the second child did not demonstrate any great concern and
left as soon as they had given the history.
In the discussion on ward rounds, the in-tern felt that the parents of the first child had a normal reaction to their child’s severe
illness and were good parents. He had an opposite estimate of the second parents be-cause they had not seemed as upset as he thought they should. It was obvious that here the house officer had projected onto the parents the way he imagined he would
have reacted in the situation. He did not recognize that persons use different ways to handle anxiety and that the second
par-ents might in actuality be more anxious than the first.
The severe stress that illness places on parents already burdened by emotional and economic problems has been demonstrated often on the inpatient service. This has helped to explain why parents have often appeared apathetic, have not seemed to hear what the intern said, or even have
ap-peared to be intellectually dull. It may also account for the fact that some parents have been unable to face the prospects of coming to the hospital each day or have seemed unappreciative of the doctor’s
ef-forts.
The authors have noted a tendency for attending physicians on teaching rounds to
and to rely on that performed by some-one else. Such an attitude may be inter-preted by the resident staff and medical students as indifference to the importance
of the examination, or as careless teaching. The practice in which the attending
pedia-trician performs a physical examination on
new patients and, when indicated, on
pa-tients previously admitted, is considered to be an important aspect of the ward teach-ing of comprehensive pediatrics. These
ex-aminations contribute to patient care be-cause the greater experience of the teacher results in a more accurate appraisal of the patient. Many house officers want the se-curity offered by the attending physician’s
physical examination of their patient as well as the opportunity of witnessing a model
demonstration. The trainee’s apprehension about the results of a physical examination
is somewhat like that of the patient and his
parents. In fact, the house officer frequently acts the role of a substitute parent without
being aware of it.
The demonstration of how to perform a physical examination has provided the
at-tending physician with an excellent tool for teaching by example. Here he may dem-onstrate his understanding of and approach to children. This is accomplished in a
num-ber of ways that seem natural to the teacher. Children are addressed by their name. The doctor introduces himself and
tells the child who he is and what he is going to do. He doesn’t ignore the child while he examines him nor does he use nick-names such as “Shorty” or “Slim” or “Freckles” that are picked at random.
Re-tarded infants are not referred to as “ghorks” or “vegetables.” The doctor is pa-tient, friendly and kind. The modesty of
adolescents, particularly girls, is respected.
A sincere and personal interest in the best welfare of each child is manifested.
DISCUSSION OF DIAGNOSTIC STUDY
Special attention has been given to the
indications for laboratory and
roentgeno-graphic examinations in the discussion of
diagnostic study. The authors have stressed
that such procedures are no substitute for a good medical history or physical examina-tion and should not be done unless the house officer can indicate how they would
be helpful in the diagnosis and treatment of the patient or in the acquisition of basic
knowledge of the disease process. On some occasions the house officer had recorded a list of procedures without a critical evalua-tion of their indications.This tendency to perform laboratory studies indiscriminately was especially noticeable when a diagnosis
was difficult to achieve. The performance of tests may be the physician’s way of handling his anxiety; that is, by “doing something” he feels he is accomplishing an
important end. Unfortunately, such
un-necessary procedures may have deleterious
effects on the patient as well as increasing the cost of medical care and placing bur-dens on limited facilities.
A 9-year-old boy was admitted with the complaint of hyperesthesia over an area on his back and around his genitalia. If the child were distracted, no evidence of hyperesthesia could be demonstrated, nor did localization of the complaint follow a nerve tract distribution. On the basis of information obtained from the parents and the child, and from the physical
examination, a provisional diagnosis of hysteria
was made. Although the possibility of a spinal cord tumor had been mentioned in the initial differential diagnosis, it had been dropped from consideration after the neurologic examination. An examination of the cerebrospinal fluid was considered to be not only unnecessary but definitely contraindicated. With a change in the ward staff, however, the new assistant resident felt that a lumbar puncture should be done. As he attempted to insert the spinal needle, the patient became completely un-manageable, broke loose from the intern’s restraint and ran, screaming, down the hail. A psychotic episode followed which lasted several days.
EDUCATION
procedures are indicated, they are to be done. However, we are interested in how
they are done, that is, in the preparation of the child and the timing of the proce-dures. The following case report exempli-fies a faulty perspective in the evaluation
of a patient’s needs.
A 9-year-old boy with ulcerative colitis was
markedly dehydrated, anemic and depleted of
electrolytes at the time of admission to the hos-pital. However, because physical procedures
were thought to be upsetting to him,
replace-ment of fluids, electrolytes and blood was not begun for 3 days. Attention to psychologic factors must not interfere with proper physical care!
A type of misdirected “sympathy”
occa-sionally observed is illustrated by the house
officer who has not performed an adequate physical examination of a very sick and irritable patient because he “did not wish to disturb the child.” While there is, in-deed, merit in avoiding unnecessary dis-turbance of very sick children, it has been
the authors’ belief that no child is too sick to be examined by his physician. It may be difficult to accomplish, and may need to be
done gradually, patiently and more by in-spection than by laying on of hands, but ill-ness is always an indication for as complete
an examination as possible.
By and large, house officers on the
in-patient service have recognized the impor-tance of preparation of children for hos-pitalization and for surgery, but they have given less attention to preparation for
pro-cedures such as electroencephalogram, in-travenous pyelogram, barium enema, nose and throat examination, roentgenogram of the upper gastrointestinal tract or lumbar puncture. The importance of preparing par-ents for procedures has also been stressed. For example, they are given some idea of
what will be done and how long it will take. This preparation has helped them deal with their own anxieties as well as answer their child’s questions.
The importance of the pediatrician’s
ability to diagnose both organic and psy-chosocial disease has been repeatedly
em-phasized on ward rounds. The house officer
may often be uncomfortable in attributing symptoms such as headache or abdominal pain to a psychosocial etiology because he
is uncertain of his knowledge of organic medicine and has been concerned that he might be overlooking some disease. Rather than include both organic and psychologic factors in their diagnostic appraisal, house
officers have commonly considered the
p05-sibility of a psychologic etiology only after all organic possibilities had been excluded. Then the cause has often been ascribed
by default to psychologic factors even
though data had not been obtained to sub-stantiate such an impression. It would be most unusual for an intern to make a diag-nosis of organic disease without
support-ing data.
A 1-year-old boy had been admitted to the hospital on a number of occasions because of
recurrent episodes of cyclic vomiting. Although many procedures had been performed, no
diag-nosis was established. During a discussion of the case, some of the house officers felt that
the vomiting must be on a psychologic basis since no organic cause had been found. How-ever, they could present no data to
substanti-ate the impression of a psychologic etiology other than some vague remarks about the
parents being “peculiar.” The attending physi-cian arranged to interview the parents in the presence of one of the house officers in order to explore again possible etiologic factors. He was unable to obtain any data that would
support a psychologic etiology for the child’s symptoms. On the basis of these interviews,
therefore, he believed that the vomiting was
not due to psychosocial factors but to some
undiagnosed organic disease, probably of the central nervous system. The child continued to
have episodes of vomiting following discharge.
Six months later he was readmitted in a
coma-tose state and died within 12 hours. It was then conclusively proven that the child’s symptoms
were due to a disorder of the central nervous
system and not to psychologic factors.
else-where because of recurrent abdominal pain.
Roentgenograms of the gastrointestinal and urinary tracts had been negative. Four days before admission she began to complain of epigastric distress and some anorexia. Physical examination revealed no abnormal findings.
The house officer who first saw the patient felt that the changing location of the pain, the negative roentgenographic studies and the neg-ative physical examination made it likely that the complaints were on a psychologic basis. The attending physician in his interview with the child and her parents, however, could find no evidence to indicate such an etiology. He
was, therefore, convinced that the child must
have an organic disease, perhaps hepatitis. Examination of the urine revealed the presence of bile.
The Gesell test of development has been used as a diagnostic tool with increasing frequency in the comprehensive approach to pediatrics, and reflects the increased number of children admitted to the inpa-tient service with the problem of retarded
development. The availability for consulta-tion of a pediatrician skilled in diagnosis of development has been very helpful in determining whether the retardation was due to a primary defect in the development of the central nervous system or was sec-ondary to such factors as primary muscle disease, sensory impairment, lack of en-vironmental stimulation or chronic disease. Coleman and Provence recently reported two infants, living in families, in whom a diagnosis of environmental retardation was established by the Gesell test of develop-ment.4 Other pediatricians have been stimu-lated to include an assessment of develop-ment as part of every physical examination.
DISCUSSION OF THE
PHYSICIAN-PATIENT RELATIONSHIP
Discussion of the case presentation by the authors includes the interchange
be-tween the physician and patient and be-tween the parents and the child. The former
has received considerable attention in the literature. Since positive interpersonal re-lationships are a basic factor in good
medi-cal care and knowledge concerning such relationships are important to the
pedia-trician practicing comprehensive medicine, emphasis has been placed on the
develop-ment of skills in this area. Frequent con-tacts between doctor and parents have been fostered by liberal visiting hours, daily
be-tween 2:00 and 7:00 P.M., which may be extended by special arrangement. There are also limited facilities for the parent to re-main with the child throughout the hos-pitalization.
By providing each child with his own doc-tor, both are afforded continuity of care.
Continuity is also provided by linking hos-pita! care with aftercare at home. Each pediatric trainee has one morning or one afternoon each week free of ward
respon-sibilities. During this time he has an office available in the outpatient department which may be utilized to follow his patients
who have been discharged from the hos-pital. Furthermore, this arrangement per-mits all the resident physicians to follow concurrently a number of patients through various phases of acute and chronic illness and convalescence.
In our experience, house officers
fre-quently have seemed unaware of any psy-chologic interaction between the patients and themselves. Therefore, they have been encouraged to observe how they relate to
their patients and how their patients in turn relate to them. An effort has been made to have the house officer understand there are reasons for human behavior, and that
such activity is not a matter of chance. For example, house officers are unaware that they often spend more time talking with parents who are in the same social class as
themselves than with those of a lower soio-economic status. In a recent study the length of time spent discussing a standard-ized list of topics with mothers on the new-born service was shown to differ signifi-cantly depending upon the mother’s social
class.5 That the physician’s management
may be influenced by the socio-economic
status of the patient is illustrated by the following experience:
Dis-EDUCATION
cussion on ward rounds included comments
about the reaction of the parents and
physi-cians to the situation in which a child was not doing well and was likely to die. The attending physician suggested that a referral to social
service might be helpful to the parents. The
intern replied that he would be very uncom-fortable in making this referral because the
parents were professional people, and of
su-penior intelligence, and might resent the
sug-gestion. One of the authors then arranged to
interview the parents with the intern. During
the interview the parents mentioned the
ten-sions, problems and “tiffs” that had arisen
be-tween them over the management of the patient. When the physician suggested there might be other ways of dealing with these tensions, the mother interrupted to say, “Do you mean talking to a social worker? You know, I also thought that I needed some help, so I made an
appointment this morning with a social worker at the Family Service Agency.” The resistance
to referral had been more a factor in the intern
than in the mother.
It has also been impressive to see the
frequency with which house officers have become aware of their own feelings toward
parents and patients. The most common
mechanisms are projection and identifica-tion. They have assumed that the parents
feel the same as they would in a similar
situation. This has been evident in ward
discussions concerning the management of a retarded child. Some house officers have been vociferous in their belief that such a child should be institutionalized at once without appreciating the fact that the par-ents may not feel the same way, and that immediate institutionalization might be a
serious mistake.
In addition to an interest in the feelings
of the doctor, ward discussions have in-cluded attention to the feelings and atti-tudes of parents and children. House offi-cers have demonstrated varying reactions to anxiety in parents and children. Some have been able to identify anxiety and to
deal with it effectively while others have not recognized it or have been abrupt,
dis-gusted or overly involved with such pa-tients. One major accomplishment of this period of ward teaching has been to have
some of the house officers develop greater understanding and acceptance of parents and their feelings. It has been demonstrated on many occasions that the patient comes to the hospital with “an attitude that has a history,” often based on previous experi-ences with doctors and with hospitals. A knowledge of the nature of these prior
ex-periences permits a better understanding of
the parents’ behavior in the current situa-tion.
P.Z., a 14-month-old infant, was admitted
to the hospital with a history of recurrent
spitting up and of passing foul stools since
brth. The house officers found the parents
very difficult to work with. They stated that
if the residents did not find an organic cause,
they would go elsewhere until someone did. In an interview with one of the authors, the mother reported that early in her marriage she
had had some abdominal complaints. Studies
were made at an army hospital where the
doctors told her that her symptoms were due to pelvic pathology and that her reproductive
organs would have to be removed. On the advice of her mother she refused the operation,
went home and in time recovered completely. She had not been able to trust doctors since that experience. The mother’s attitude toward her own doctors explained her lack of accept-ance of her child’s doctors. She continued to
carry over her own doubts as to their corn-petence.
DISCUSSION OF THE ILLNESS
Comments on ward rounds have also dealt with the reaction of children of vari-ous ages and of parents to illness in general and to specffic disease states such as
rheu-matic fever, malignancy, diabetes, epilepsy, hemophilia, poliomyelitis, cerebral palsy, congenital anomalies, tuberculosis, allergy, convulsions, retardation, accidents, obesity and congenital heart disease.
In these discussions the authors have
at-tempted to deal with the doctor’s role in
484
fever, ulcerative colitis, asthma, eczema and
epilepsy. Discussions have included the fre-quent discouragement of the parents, the child and the physician in these situations, especially when there is no specific medic-ma! treatment. Whether specific
medic-inal therapy is available or not, other ele-ments in patient-management are always
important. This has been seen, for example, in adolescents with diabetes. Here the pre-scription of insulin has often been the easi-est part of the treatment. Maintenance of the child in reasonable control has
fre-quently been dependent upon the presence of a positive relationship between the child, his parents and the physician. Similar
ex-periences have been noted in patients with
rheumatic fever. Whether or not the child and family co-operate in a program of bed rest or penicillin prophylaxis has been de-pendent, in large part, upon a satisfactory relationship between patient, family and physician. Adequate management of chil-dren with idiopathic seizures has necessi-tated attention to psychologic,
socio-eco-nomic, cultural and educational factors in
addition to drug therapy.
DISCUSSION OF SOCIO-ECONOMIC
AND CULTURAL FACTORS
The effects of economic privation and poor housing on the growth, development and other potentialities of children are fre-quently manifest in the study of hospital-ized children. Although the house officer
as an individual has been able to do little
about such harmful influences except to write letters to housing authorities, we have
felt that caffing the attention of young physicians to these deficiencies in com-munity responsibility has been an impor-tant part of medical teaching.
Through the development of an interest in the behavior and feelings of persons of various socio-economic classes, cultural
backgrounds, races and religions and an awareness of their reaction to illness in
gen-era! and to specific disease states, the physi-cian becomes experienced with the back-ground and natural history of patients as
well as that of disease. More and more,
the social sciences are providing the physi-cian with systematized knowledge in this
area. That the cultural background of the patient influences both his behavior and that of ‘the physician has been pointed out many times on our rounds. For example, Negro parents and children have found it more difficult to verbalize to the doctors
than have white patients. They have not asked many questions, have been apologetic for “bothering” the doctor and have often found it difficult to believe that the house officer was sincerely interested in them.
Frequently patients have come from homes disrupted by death or illness of a
parent, by divorce or separation and by service in the armed forces. As ‘time has permitted, problems of these children have been discussed on ward rounds. Other areas of concern to pediatricians, such as the subject of adoptions, have also received comment.
A 3-month-old infant with acyanotic con-genital heart disease was transferred to this hospital from a foundling home. The tentative
diagnosis was either a defect of the septum or
a patent ductus arteniosus. As part of the ward round discussion a question was raised concern-ing plans for adoption of this infant. The in-tern assigned to the baby stated that he did not see how the patient could be adopted be-cause of the cardiac lesion. He was surprised to learn that a number of prospective adoptive parents were willing to take an infant even with a cardiac anomaly. With this in mind the house officer, aided by the pediatric social worker, explored the possibility of adoption. He was surprised when the baby was placed with prospective adoptive parents rather than returned to the institution.
DISCUSSION OF TREATMENT
Much of the discussion on ward rounds has dealt with treatment of patients. While predominantly concerned with the use of medicinal agents, attention has also been given to other aspects.
children at the time a child is hospital-ized. In his work on the inpatient service the pediatrician has had to deal skillfully with many symptoms of a psychologic na-ture including guilt, anxiety, depression,
de-pendency, grief, denial and hostility. We have attempted to demonstrate how the
physician deals with such behavior by
skill-ful use of the usual tools : ‘the medical inter-view, the physical examination, and talking with parents and children.
In addition to the attention given to the psychosocial aspects of organic disease,
there has been an attempt to define the role of the pediatrician in the management of disease states in which psychologic ele-ments play an etiologic or contributory role. Such elements have been found in patients with ulcerative colitis, anorexia nervosa, encopresis, psychogenic abdominal
pain, feeding problems, hysteria and autism. Discussions have pointed out how the pedi-atrician often works collaboratively with the
psychiatrist or, in the absence of such help, is able to offer the psychotherapeutic skills available to the non-psychiatric physician.
Although there have been exceptions, on
this service the house officer has generally done the interviewing, evaluated his data and developed a plan of management. The
attending physician and the psychiatric
consultant have been available for super-vision and consultation concerning both physical and psychologic problems. In both situations they have worked through the in-tern and have not assumed the management of the patient. Occasionally the house offi-cer has given premature advice or advice that the patient could not possibly follow.
A 9-month-old Negro baby was admitted
be-cause of severe eczema. The plan of therapy outlined by the intern on rounds the next day included an elimination diet, dust-proofing of
the home and the other measures usually em-ployed in the treatment of allergic states. The attending physician sensed the
inappropriate-ness of such therapy in this situation and asked the intern for more information about the home. It turned out that the mother, whose husband had deserted her, had four other chil-dren, the oldest of whom was 5 years of age.
They lived in a two-room tenement apartment. It was suggested to the house officer that he might wish to make a home visit and together with the mother try to figure out realistic ways of making the environment better for an a!-lergic child. When this was done, the intern returned impressed with the personal resources of the mother and with the number of things that could be done even in a limited environ-ment by active co-operation between the mother
and the doctor. The physician also saw that
accurate diagnosis, therapy and advice can
only derive from a doctor’s familiarity with a
patient’s total life situation.
CONTRIBUTIONS OF ANCILLARY
PERSONNEL
In order to implement comprehensive
care and teaching on the ward, ancillary professional and nonprofessional personnel
have been included in the total planning. The social worker has been of great help, and indispensable in the management of the problems of many patients. Information ob-tamed from the parents by the social
worker often supplemented the house offi-cer’s history and assisted in arriving at a comprehensive medical plan. Social service has also been helpful in learning about
parental concerns, in helping parents un-derstand hospitalization and the nature of
illness, in making plans for such environ-mental changes as housing, in making re-ferrals to community agencies and in in-creasing the parents’ understanding and ac-ceptance of the doctor’s recommendations. The nurse has played a significant role in comprehensive inpatient care and has been an important participant in ward rounds. Her observations about the child in the hospital and the information she received from parents and children have often been
important contributions to patient care. The important role of the child psychiatrist
in the diagnosis and treatment of children on the inpatient service has already been mentioned.
TALKING TO PATIENTS AND PARENTS
often been unclear, and may even produce
anxiety, in their discussions with parents.
Rather than make use of simple statements,
they have often presented a detailed dif-ferential diagnosis replete with many
mysti-fying and ominous-sounding words and phrases. The technique of reassurance has also been overused; there has been a tend-ency to give unwarranted assurance and to promise too much.
A 9-year-old boy, admitted to the inpatient service with fulminant ulcerative colitis, had lost considerable amounts of fluids, electrolytes and blood. When the child’s parents asked re-peatedly about his condition, they were assured” that everything would be all right. With a change in the ward staff the attending physician met the parents and told them that their child was dangerously ill. Immediately, the parents breathed a sigh of relief and said,
“We’re so glad you think so! We know our
boy is critically ill, ‘but no one else seems to
think so except you. We have been wondering if the doctors here really know how sick he is and whether he is ‘being treated vigorously enough.” In this instance so-called reassurance actually increased the parents’ anxiety.
House officers have found it difficult to explain to parents why a patient’s symp-toms sometimes remain undiagnosed for a time. There has been a tendency for them to talk too much in such circumstances, to share unnecessarily their own anxieties about the diagnosis with the parents and the child and to give the impression that the staff is indecisive. Then, too, hostile parents have been difficult problems and
almost without exception house officers have tended to react with counter-hostility.
FACTORS WHICH FACILITATE
COMPREHENSIVE TEACHING
A number of factors have seemed to
fa-cilitate comprehensive teaching on this service:
1. One of the most important of these has been the example set by the attending physician. Highly signfficant in this regard
has been the demonstration of his respect
for patients, parents, house officers and
ancillary personnel. Questions he has asked
and the content of his discussions have also been helpful in indicating what he
consid-ers to be of importance in child care. 2. Teaching has been fitted to the pro-fessional and personal readiness of the house officer. We have been interested in the house officer’s attitudes and feelings. These
have been gauged in part by his answers to such questions as, “What do you think is going on here?” ‘How does that strike you?” “Why do you feel that way about it?” “What do you plan to do about it?” What was in-cluded or omitted in his case presentation has also been indicative. Sometimes it has been possible to identify specific situations
which are difficult for individual house officers. One intern did poorly whenever he dealt with a parent whom he thought ques-tioned his knowledge. Another did not do well in situations in which parents did not follow his directions implicitly. Still another became jittery whenever a diagnosis was not immediately established. An occasional resident had particular difficulty in his re-lationship with the private referring
physi-cians or with the nurses. One intern became upset when the attending physician did not give a definite and immediate answer to
every question. Another had difficulty in dealing with parents who did not seem
in-telligent. A number of interns were highly motivated whenever a patient had an acute organic illness but not when he had an
emo-tional problem or a chronic disease. Knowl-edge of these variations in house officers’ reactions have facilitated and helped define
our teaching approach.
3. Comprehensive teaching has also been made easier by provision for sustained long-term care and responsibility by one house officer. Each child admitted to the hospital is assigned a doctor who remains his chief medical attendant during the hospital stay and for follow-up visits if indicated. Re-sponsibility for a patient’s care which is shared with other interns, medical students
EDUCATION
doctor must be the person carrying major responsibility for a number of patients.
Multiple responsibility permits a house
offi-cer to avoid dealing with many of the ques-tions and problems of parents and children and gives the patient the uneasy feeling of having no one person responsible for his care. When, because of rotation to another
ward, the admitting doctor must transfer his role as the child’s physician to another house officer, he is asked to prepare older
children for the change, introduce the new doctor, and continue to visit the child when his duties permit. Rotation of interns and
assistant residents is staggered so that all
those familiar to the child do not leave the ward at once.
4. Teaching of comprehensive pediatrics has been facilitated when the attending physician has been readily available to as-sist the house officer in a difficult situation.
A 14-month-old infant was admitted with a history of persistent spitting up of food and
passing foul smelling stools. The work-up on a
previous admission had been negative for
organic disease, and the symptoms reported in
the history were not observed in the hospital. The parents insisted that the infant had some physical illness which a series of doctors had not been able to discover. The mother was
especially concerned about the possibility of
cancer. The house staff, however, did not be-lieve that the symptoms were those of an
organic disease and were reluctant to do
pro-cedures without clear-cut indication. This was
a situation in which both the parents and the house staff were at an impasse, and nothing
positive was being accomplished by the hos-pitalization.
The parents were then interviewed by one of the authors who attempted to determine the
parents’ real concerns and the reasons for their behavior, particularly their distrust of doctors. He attempted to convey to them the fact that the staff members were considering physical illness in their child to the extent indicated by the history, but that it was very likely that no physical cause would be found. He then met
with the house staff and helped them work out a plan of management. The resident who sub-sequently spoke with the parents found them to be no longer querulous and demanding but
appreciative of the doctor’s interest and
under-standing. Rather than take the baby to another
clinic, they wanted to know where the resident was planning to practice so that they could have him as their pediatrician.
5. The effectiveness of the teaching of comprehensive pediatrics has also been in-fluenced by factors such as the experience of the house officer with illness in himself or his family, his marital status and whether he is a parent. House officers who have had children have often been much more aware of the feelings and concerns of other
par-ents and children.
On ward rounds one morning the head nurse asked an intern what she should do about a mother’s request to “room-in” with
her child who was to have an elective
op-eration. The intern dismissed the question promptly by saying that he couldn’t see much importance in having the mother stay with the child. He became very defensive
when one of the authors questioned his judgment. It was quite a different story, however, when the intern’s own child
b-came ill about 1 year later. Not only did his wife stay with the child, but the grand-parents also were called from out-of-town.
This personal experience increased the in-tern’s awareness of the importance of other
factors in good medical care besides those concerned with the diagnosis and treatment of disease.
6. The teaching of comprehensive pedi-atrics was enhanced when the teacher was recognized by the house staff as one
com-petent to deal with organic pathology and with aspects of the physical care of
chil-dren. Discussions about disease and disease processes justifiably continue to rank high in interest and concern of the well-trained resident, and he is more apt to listen to a teacher who continues to be well-informed in the traditional areas of medicine despite his new interest in the psychologic and
so-cial spheres.
7. Another important factor which has promoted the teaching of comprehensive
physi-cian to demonstrate how information re-garding human behavior and socal and
economic influences is helpful in the care of
patients. The following case reports em-phasize the fact that the pediatrician who knows what to look for and how to look for it will be able to make a diagnosis in a
situation no matter whether the etiology is organic or psychosocial and to make
prac-tical suggestions which work.
A 13-year-old girl was referred to this service because of recurrent fever of undetermined origin. The child had also complained of head-ache, dizziness, abdominal pain, fatigue, ano-rexia, episodes of diarrhea and the passage of large amounts of mucus in the stools. She had not attended school for 4 months. An extensive work-up at another hospital had failed to estab-lish a diagnosis. Fever was not present when the child was seen here. In addition to con-sidering certain organic possibilities such as a
specific enteritis or recurrent respiratory
in-fections, the attending physician suggested that
attempts be made to obtain data about possible psychosocial etiologic factors. He was able to demonstrate what to look for and how to ob-tam pertinent data in the first interview. Briefly he inquired about the presence of someone else ill in the household, the child’s adjustment to school, why the mother was
working and the child’s preparation for puberty
and the menarche. In these four areas the large
amount of significant data obtained suggested that much of the child’s symptomatology could be attributed to psychosocial factors. A thorough physical examination was negative as were examinations of the urine and stool. On the basis of these findings the doctor, child,
parents and school authorities worked out a number of modifications in the environment. Coincident with these changes the child’s symptoms disappeared, and she returned to school. There has ‘been no recurrence of symptoms.
R.M. was admitted at the age of 10 months because of regurgitation after each feeding. A
number of ‘regimens, including frequent small
feedings, phen#{244}barbital, atropine, homogenized milk, soybean milk and thickened feedings had been tried at home without success. The at-tending pediatrician noted on ward rounds that the child would place his thumb or small toys
in his mouth and suck before each period of regurgitation. Spitting up occurred almost
con-tinuously. On the basis of the history and these
observations, a diagnosis of rumination was made. The attending physician postulated that the infant had not received adequate environ-mental stimulation at home. In additional inter. views this was confirmed. Since he was said to be content to sit in his crib or high chair most of the day and play by himself, the parents rarely held the baby. The mother was de-scribed ‘by herself and by her husband as a very nervous, meticulous person. She appeared fatigued and depressed. Her father had died of cancer a few months before, and vomiting had been one of the major symptoms. Mrs. M. was fearful that her baby also had cancer. Al-though she spent some time on the ward, she
rarely held the child and played with him from
afar. She seemed ill at ease with the child and very annoyed when he would regurgitate on her.
An effort was made to provide adequate stimulation for the baby during the period of hospitalization. His crib was placed so that he could observe the activities of the staff and children on the ward. He was given shiny and brightly-colored toys, and a radio was placed in his room. Physical handling by the nurses in the form of rocking and holding was increased, and he was permitted to crawl around the floor. The mother was encouraged to play with and feed the baby. During the 2-week hospitaliza-tion period, the infant gained about 1 kg.
Regurgitation became much less frequent. When seen on a follow-up visit 1 month after discharge, he had continued to gain weight and would spit up only occasionally.
8. Comprehensive teaching is also more readily accomplished if the attending phy-sician is able to acquaint house officers
with the common questions that parents and children have about specific illnesses, their reactions to illness and their feelings about what happens to them in the hospital. The authors have discussed often the doc-tor’s role with parents whose child is cri-tically ill or has died. Many parents have later expressed their appreciation of the
comprehensive pediatrics permitted the house staff to carry out urgent diagnostic
and therapeutic procedures.
J.H., a 2-year-old boy, was admitted to the
hospital because of increasing proptosis of the right eye. His mother had signed the child out of another hospital where a presumptive diag-nosis of brain tumor had been made and an im-mediate operation advised. In his presentation on ward rounds, the intern described the mother as one of the most hostile persons he
had ever met. The other house officers agreed.
She told the intern that if a diagnosis was not made within 48 hours, she would take the child home. The house staff were very upset
with this woman and thought she must be a
terrible mother.
In his comments the attending physician pointed out the importance of establishing rapidly both a diagnosis and a more positive
relationship with the mother. If the latter was
not accomplished, the former would be to no avail. A differential diagnosis for the proptosis and for the mother’s behavior were then ex-plored. The most likely cause for the proptosis
was considered to be gliosis of the optic nerve;
the most likely cause for the mother’s behavior
was thought to be anxiety and guilt. On the
basis of these presumptive diagnoses, a plan for total management was discussed. It was sug-gested that the doctor share with the mother
his understanding of the anxiety and worries she must have and of her disappointment in
doctors and hospitals since they could not promise that the child would be all right. When the house officer did this, he found much to his surprise that the mother was responsive to his interest. Over a period of time she ac-cepted further work-up and the neurosurgical procedure. The house staff then saw her to be what she had always been-a terribly harassed woman. When the child first became ill, she did not take him to a doctor because she was afraid he would confirm her worst fears. Her husband had blamed her completely for the child’s illness and had told her that it would not have happened if she had been a better mother. She assumed that doctors also thought that she had been a bad mother.
DETERRENTS TO TEACHING OF
COMPREHENSIVE PEDIATRICS
There have been a number of deterrents to the teaching of comprehensive pediatrics
on our service, and it seems important to discuss them here.
1. From the resident’s point of view, the factor of time has been an important
con-sideration. It takes time to conduct inter-views with parents and children, to discuss the findings with the attending pediatrician
or the psychiatrist and with the nurses, so-cial worker, family physician and other per-sons involved.
2. It must also be recognized that the house officer can think actively about only a certain number of things at one time. If he is still unskilled in the diagnosis of
or-ganic disease and properly concerned about not overlooking important facts relating to such illness, he does not easily think about
other phases of patient care.
3. It is difficult for the resident to do good work when he is tired, worried or otherwise preoccupied. In addition to the
stresses associated with caring for sick in-fants and children, the inpatient house offi-cer must also deal with parents who are often distraught, almost always anxious and
at times difficult. It is more than a truism that in pediatric practice the attention of the pediatrician must be directed as much
to the parent as to the child. The continued impact and stress of dealing with both parents and children can be cumulative and overwhelming.
4. Another deterrent is the “double standard” applied to the nonorganic and the organic aspects of a medical problem. House officers have been impressed with
the importance of not overlooking organic pathology; they have been less concerned about missing important factors in the psy-chosocial sphere. Mistakes in organic
diag-nosis and treatment are pointed out in din-icopathologic conferences, but, unfortu-nately, there is no mechanism for critical
review of the other aspects of patient man-agement except on ward rounds of the type described here.
were not suggestive of organic etiology. Both parents gave evidence of severe emotional ill-ness. After completion of the diagnostic studies
the house officers continued to be concerned
that they might ‘be missing some physical dis-ease. The fact that they had not concerned themselves enough with other potential causes such as psychosocial ones did not disturb them even though these could have provoked a psychosomatic reaction in the child.
5. Because of the nature of the material it may be expected that resistances will de-velop when the attending physician talks
about reactions of people to illness and to each other, when he refers to feelings and
behavior, and when now the house officer has to look at himself and to think about
some of the reasons for his actions and de-cisions. The house officer is often not aware of these resistances nor of the reasons
be-hind them. This is usually not the case, however, with physical or organic factors.
Here the doctor can be impersonal and dis-agreements are conscious and intellectual.
6. Another impediment to learning about comprehensive pediatrics has been the rela-tive brevity of the contact between teacher and house officer due to the system of rota-tions of attending and house staff on the
wards. Since one of the most important processes in such teaching is that of
identi-fication of the house officer with the teacher, this has been a serious handicap, particularly because of the variation in in-terest and attention which different
attend-ing physicians give to the matters discussed in this paper.
7. Another significant hindrance to the teaching of comprehensive pediatrics has
been the fact that many house officers do not believe that information about the
psy-chosocial aspects of pediatrics will be of importance in their practice of pediatrics
or research careers. The fact that they
de-cide this without having had the
oppor-tunity to know just what will be required of them as a practitioner or as a teacher is probably attributable to the fact that the
prototype of the pediatrician in their mind is one who is concerned with physical dis-ease alone.
CONCLUSION
Despite the frequent lack of integration of psychologic and social considerations in the medical care of patients, it has seemed
to us that, more and more, medical gradu-ates are seeking pediatric training that goes beyond the traditional. The authors have
described the manner in which they have attempted to incorporate social and psycho-logic considerations into day-to-day teach-ing on an inpatient hospital service.
Solu-tions to many of the remaining problems in providing experiences from which the trainee may learn attitudes and techniques
easily applicable to private practice may be
achieved through further experiments in
pediatric education.
REFERENCES
1. Solnit, A.
J.,
and Senn, M.J.
E. : Teachingcomprehensive pediatrics in an
out-patient clinic. PEDIATRICS, 14:547, 1954.
2. Senn, ‘M.
J.
E. : An orientation forinstruc-tion in pediatrics.
J.
M. Educ., 31:613, 1956.3. Green, M., and Stark, M. : A postgraduate program for the longitudinal health super-vision of infants. PEDIATRICS, 19:499,
1957.
4. Coleman, R. W., and Provence, S.: En-vironmental retardation (hospitalism) in
infants living in families. PEDIATRICS, 19:285, 1957.
