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greater economy in contracting for printing services and paper supplies.

With the July 1973 issue, steps to

imple-ment prudent management objectives, as

authorized by the Executive Board, were

initiated. Most obvious was the limited

in-terspersion of advertising. Interspersed

ad-vertising pages are being grouped in four

positions in the text pages in addition to

the traditional sites in front of and behind

the text pages. A more flexible policy was

defined to attract more advertising without significant interference to reading the

scien-tific pages. A recent survey of a number of

major specialty journals shows that several

are now interspersing advertising in

vary-ing degrees. Binding techniques have

im-proved over the past decade and rather

than continue the expensive Smyth-sewn

technique, PEDIATRICS is being “perfect”

bound, a technique whereby pages are

glued in place. Advertising pages can be

easily removed at the time of binding, and

articles can be torn out for filing. A policy

for makeup of the journal which avoids

backing up of advertising and text pages has been established.

Other changes have included greater

re-liance on FDA standards for advertising

copy approval, rather than establishing

and maintaining an independent standard

of acceptability. FDA standards have

devel-oped over the past decade to an adequate

level of comparability to previous Academy policies for copy approval.

Lastly, it is appropriate to announce that

Dr. Clement Smith’s resignation as Editor

will become effective December 31, 1973.

For me, and the many others who have

worked closely with Dr. Smith, he has

proved a constant source of strength and

wisdom. He has persistently challenged all

of us in efforts to develop and maintain a

distinguished journal. I have taken pleasure

and pride in the privilege of working so

closely with our Editor in a continuing

pursuit of excellence.

A vigorous search has been conducted for

the past several months for a new Editor.

The recommendations of the Search

Com-mittee have been approved by the Editorial

and Executive Boards. The new

Editor-in-Chief will be Dr. Jerold F. Lucey, with

Dr. Robert

J.

Haggerty as Co-Editor.

The Executive Board looks to the new

Ed-itors and Managing Editor to maintain and

further develop the excellence of our

offi-cial journal so that it is continually relevant

to the health needs of children and the

re-quirements of all pediatricians whether in

practice, research, or teaching.

ROBERT C. FRAZIER, M.D.

Managing Editor

PRIMARY

MEDICAL

CARE AND

MEDICAL

RESEARCH

TRAINING

Dr. Cicely Williams delivered a

challeng-ing Blackfan Lecture, reproduced

else-where in this issue of the Journal,1 at the

Children’s Hospital Medical Center on May

30, 1973. It should be carefully studied by

all pediatricians, and particularly by

pedia-tricians involved in academic programs. Dr.

Williams speaks with the experience and

wisdom gathered during more than 50

years of service to the field of maternal and

child health and with unimpeachable

aca-demic credentials. She first described

kwashiorkor in the Western medical

lit-erature in 1931.

Dr. Williams’ message to academic

pedi-atrics is loud and clear. It may be

para-phrased in the following manner: “Be off,”

she states, “with your ultrascience, your su-perspecialists and your rapt attention to the

few with so called interesting illnesses.

Give thought instead to the thousands who

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them from malnutrition of the body or the

soul, and society will reap immediate

ben-efits. Teachers, stop seducing the very best

into your snare of enzymes, isotopes and

transducers, leaving only a small group to

replace our dwindling cohort of primary

care deliveries. If you will only see the

challenge of home care and preventive

care, the bright ones will follow you there.”

Sitting later with Dr. Williams, who at

80 is remarkably more alert and energetic

than any of us half her age, I was deeply

impressed by her sincerity, and the

trench-ancy of many of her remarks. She is not an

anti-intellectual opposed to research and

development. She is the first to agree that

many of the present thorny problems in

ma-ternal and child health are more apparent

partly because laboratory science has made

it possible to eradicate many of the

scourges of infectious disease. Their rela-tive absence has made the nutritional, edu-cational, and attitudinal problems to which

Dr. Williams refers much more obvious to

the clinician who cares to look beyond his

nose. Despite the importance of research,

Dr. Williams feels strongly that it is

virtu-ally immoral for a developing nation to

de-vote its limited resources to the care and

investigation of a few patients with rare

diseases when thousands with easily

cor-rectable or preventable lesions go

unattend-ed. She is critical of many public health

plans as well. What is the use (she asks)

of dumping vast supplies of surplus food

stuffs into a community without providing

knowledgeable home visitors who can help

a mother to use them by showing her

prac-tical techniques of child care? She refuses to lay the responsibility for the

develop-ment of an adequate system of maternal

and child health on the doorstep of a

gov-ernment agency. It is, she says, the training centers themselves-the university hospitals

-which should take the lead to develop a

cadre of public health and primary

care-oriented physicians who, together with

highly trained public health nurses, can

de-liver the care so desperately needed not

only in the developing nations, but in the

deprived areas of the United States as well.

Dr. David Rogers, formerly the Dean of

the Johns Hopkins School of Medicine and

presently the Director of the Robert Wood

Johnson Foundation, has recently

ad-dressed himself2 to the vital topics raised

by Dr. Williams. He emphasizes the

well-known fact that we have clearly

overpro-duced many specialists during the last 20

years in this country.

Our laissez-faire training system, fueled

by federal grants, has in fact developed

an unparalleled degree of expertise in

the medical sciences, rightfully the envy

of the entire world. But during this

same period we have failed rather

mis-erably to supply primary care deliverers

not only for deprived areas of the

country, but in middle-class

communi-ties as well. In fact, to satiate our demand

for deliverers of medical care, we have

systematically plundered medical school

graduates in developing countries who

have left the lands where they are so

des-perately needed to seek their relatively

easily acquired fortunes in this country.

Imbued with the concept of freedom of

choice and opportunity, we have

encour-aged the cream to rise to the top, the top

defined as specialty and research medicine, without due regard for the overall benefits

to society of such a policy. Obviously it is

anathema to any independent physician to

consider the kinds of medical delivery

pro-grams utilized by many communist

coun-tries and more hard-pressed noncommunist

countries as well. Most of us would be

loath to consider an enforced period of

service for all physicians in governmentally

defined areas of need, but our current

laissez-faire system has led to such an acute

shortage of primary care personnel, that

society may have to turn to enforcement by

government in order to solve the crisis in

care which is mounting so rapidly around

us.

What does all of this mean to those of us

engaged in academic medicine, teaching,

and research; to physicians who strongly

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ma-770

jor contribution when they deal with the

vexing and challenging problems of one

very sick patient rather than devoting their

energy to many more patients with less

complex biological problems? Dr. Rogers

points out that if those of us in academic

medicine firmly believe that the ultimate

future of medicine must be based upon

rigorous scientific thought and energetic

re-search, we must devote some of our effort

toward the solution of the health care

crisis. If we do not, the academic and

governmental institutions which make our

work possible may be swept away in a

wave of anti-intellectualism born of

frus-tration.

While this actual and potential conflict

mounts, a new ingredient has been thrust

into the picture. As Dr. Rogers explains, the

new recruiting policies of medical schools

have brought for the first time into our

student ranks large numbers of medical

students whose backgrounds differ widely

from the faculty members who are

current-ly training them. Some of these students

are naively cynical about the value of the

scientific basis of medicine which we hold

so dear. They simply do not see that a

de-tailed knowledge of carbohydrate

metab-olism is really necessary to establish (and

more important, to change) a system of

care of diabetics in communities far away

from major medical resources. They agree

that a certain base of bioscience is obvious-ly important, but they argue that the scope

of knowledge need not be as great as we

believe, and that even the depth to which

we train students in clinical expertise goes

far beyond the necessary requirements for

a career in delivery of care to large

num-bers of medically deprived individuals.

They ask for an entirely different kind of

training experience from that which the

faculties of most of the prestigious medical

schools in the United States deem

neces-sary.

Here, another conffict arises. Those of us

who were trained in the 1950s and early

1960s and witnessed with our own eyes the

remarkable explosion of medical knowledge

which has occurred cannot conceive of a

training program in which those great

ad-vances are not stressed. We hold that

medi-cal school is virtually the only time in a

practicing physician’s life when he may be

constantly exposed to bioscience as it

re-lates to the care of the sick. Without that

long exposure we believe that physicians

will revert to the gold-headed cane era

when personality was in fact the only tool

of the trade. But many of our new students,

and even some from the “old-fashioned”

backgrounds, insist that our training

pro-gram is dehumanizing, that our failure to

emphasize social factors has led to the

pro-duction of doctors who have little or no

empathy toward their patients and are vast-ly overtrained for the job at hand. As to the problem of empathy, I, for one, have little confidence that a “biosocial” curriculum will

induce an increased level of sympathy and

understanding by physicians toward

indi-vidual patients. These vital human responses spring from experiences and influences which occur much earlier in a physician’s

life than during medical school. They arise

from the basic personality structure of the

physician in which both heredity and early

environment play significant roles. An amal-gam of self-confidence, security, and humil-ity together with clinical training in normal

and abnormal psychodynamics is

neces-sary for the emotional support of patients by a physician, not courses in sociology.

Thorough grounding in biochemistry and

physiology does not eliminate these vital

characteristics from a physician’s personal

armamentarium. On the other hand, careful

study of the social sciences relevant to

pri-mary care delivery must be critically

im-portant for the development of a

leader-ship group of physicians who will evolve

new methods of primary care delivery to

large groups of patients. A knowledge of

public health procedures, medical

econom-ics, basic sociologic principles, and the

in-teractions of government with society will

be of great importance to the graduates of

training programs who intend to make

ma-jor inroads into the health care crisis which confronts us.

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771 faculty members, largely trained in the

bio-sciences and clinical investigation, be

dur-ing this important period of change and

new direction? We can, of course, take the

easy road out and moan piteously that the

new student is simply an anti-intellectual

who has little interest in biomedical

sci-ences, and whose complaints merely reflect

a higher level of the usual griping that all

medical students demonstrate during the

first two years of training. In addition, we

can console ourselves by continuous breast

beating about the short-sighted policy

re-garding research training presently evinced

by the administration in Washington. We

can write speeches about the importance of

research and gloomily foretell a collapse of

clinical investigation if present federal

trends in research training continue. This

is a particularly satisfying activity if one

re-fuses to examine the basis of the present

position of the administration and fails to

review the history of the present conflict.

It is sometimes forgotten by my clinical

investigator faculty colleagues that the

present attack on research training has its

roots in events which precede Mr.

Secre-tary Weinberger and the Nixon

adminis-tration. While we correctly pursue the

res-toration of a biomedical research training

program in the United States, we should

keep in mind that federal funds must be

allocated to deal with the development of

an adequate primary care system and that

the case for federal intervention in the

de-velopment of research physicians must be

made much more clearly than we have

made it in the past. Fortunately, several

groups interested in the future of clinical investigation are now beginning to provide

the data to support the case, and it seems

likely that some sort of federally sponsored

research training program will emerge from

the current controversy.

But even if we, the present faculty

mem-bers, come to grips with the social,

politi-cal, and fiscal problems that have so

dam-aged the future of clinical investigation and

set our own house in order in a new

part-nership with government, we must go

fur-ther. We must grapple in our medical

schools and teaching hospitals with the

problem of developing new leadership in

the delivery of primary medical care. Such

leaders will be crucially important if we

hope to develop a medical care system

which is truly open to the public that

re-quires it. I believe that faculty members who are themselves trained in scientific disci-plines can, with further training in the sci-ences relevant to medical care organization, become very useful leaders for the students and residents who desire such careers. Such

faculty members provide the correct

amal-gam of discipline, inquiry, and excitement

that will stimulate the student to think

broadly and creatively in this field. But our young clinical scientists cannot be removed

from the bench-bedside interface for this

purpose. They need more than 24 hours a

day to solve the biomedical problems that

confront them. I have my eye on the more

senior members of research divisions in

teaching hospitals. Some reach a stage in

their careers when they are no longer truly excited by laboratory investigations.

Teach-ing and administrative duties pull some of

them away from the bench for

progressive-ly 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 the latter move toward a period

of retraining which would enable them to

provide expert leadership in the complex

area of medical care delivery? Department

chairmen should act swiftly when such

ca-reer changes seem propitious and urge the

faculty member in question to receive

re-schooling in the social sciences relevant to

primary medical care. He could then

as-sume new duties in an exciting frontier.

The chairman should receive the support

of foundations like the Robert Wood

John-son Foundation to provide a salary for this

new “recruit.” Such a policy would

accom-plish two feats. It would keep those with

young and recently trained minds at the

helm in research, and it would define new

challenges for older clinical investigators

who have the tough crust and the

experi-ence to plunge into icy water. There are

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investiga-tors who have turned their attention to the

development of such programs. I somehow

feel very comfortable when I see a man

who is capable of precise measurement of

the rate at which potassium enters a red

cell applying the same sort of thinking to

an estimate of the rate and extent to which

primary care physicians must be deployed

in the city of New York. It is true that there

is very little influence of ouabain on the

latter rates, and the Nernst equation does

not apply. But there are other equations

and other inhibitors which must be

care-fully considered in the planning.

Dr. Williams has asked for a major

im-provement in continuity of care to be

es-tablished between the hospital, the health

center, and the home, and for the training of personnel to meet this need. Without this continuity, hospital-based research engages

in wheel spinning and is divorced from the

realities of health problems. Dr. Rogers

points out that we must develop new

pro-grams that produce young physicians who

are devoted to this improvement in

con-tinuity. We cannot respond to these reason-able imperatives unless we develop a

facul-ty devoted to the purpose. I believe that

this faculty should be derived from the

group that is accustomed to rigid inquiry

and firm standards and will continually

em-phasize the scientific basis of medical care.

We have such individuals at hand if they

can be persuaded to change careers in

mid-stream. The change would provide

excite-ment and new challenges for faculty and

students alike, and the benefits to society would be profound.

DAVID C. NATHAN, M.D.

Chief, Division of Hematology Children’s Hospital Medical Center

Boston, Massachusetts 02115

ADDRESS FOR REPRINTS: (D.G.N.) Divi-sion of Hematology, Children’s Hospital Medical

Center, Boston, Massachusetts 02115.

REFERENCES

1. Williams, C. D.: Health Services in the Home. Pediatrics, 52:773, 1973.

2. Rogers, D. E.: The American Health-Care Scene: Eighty-third Shattuck Lecture

pre-sented at the annual meeting of the Massa-chusetts Medical Society, Boston, Mass.,

May 30, 1973. New Eng. J. Med., 288:1377, 1973.

SOME PENNSYLVANIA GERMAN FOLK

The following folk remedies to ease the

child’s pain during teething were once widely

used by Pennsylvania German families:

“Rub the child’s gums with rabbit brain before the child is six months old; rub the child’s hard palate during dentition with your thumb; grease the child’s gums with fat from the pan in which meat was fried. Rub the gums with the rattles of a rattlesnake; pass a small fish through the mouth of a child to ease pain; suspend a rabbit’s tooth

REMEDIES TO EASE TEETHING PAINS

about the child’s neck; pass the comb of a de-capitated cock through the mouth of the child before the cock is fully dead.”

NOTED BY T. E. C., JR., M.D.

REFERENCE

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1973;52;768

Pediatrics

David G. Nathan

PRIMARY MEDICAL CARE AND MEDICAL RESEARCH TRAINING

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1973;52;768

Pediatrics

David G. Nathan

PRIMARY MEDICAL CARE AND MEDICAL RESEARCH TRAINING

http://pediatrics.aappublications.org/content/52/6/768

the World Wide Web at:

The online version of this article, along with updated information and services, is located on

American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

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