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
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
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.
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
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