865
CHILDHOOD
INJURY
AND
PEDIATRIC
EDUCATION:
A
CRITIQUE
Roger J. Meyer, M.D., M.P.H.
Infant Welfare Society of Chicago, Chicago
T
HE medical school, the school of engineering, the liberal arts college, and the high school all share a common problem today: the exponential growth of knowledge and the increasingcomplexity of contemporary society have caused numerous demands for further crowding their
already crowded curriculums. Thus, there are those who believe that high school students “must” get driver education, that engineering students “must” learn something about the social sciences, that liberal-arts students “must” have a course in computer technology. Often these needs are “felt” by their proponents rather than demonstrated objectively, and often the proponents seem
unaware that the subject matter they advocate might be acquired with equal or greater effective-ness outside a formal curriculum.
The paper that follows, however, distinguishes itself in several ways from the hortatory plead-ings characteristic of special-interest groups. To begin with, it demonstrates the cost-benefits of
sound injury-control teaching in departments of pediatrics. Secondly, it points out that much
needs to be done in the development of materials and methods before a demonstrably sound
program can be proposed. ( In both these respects the author provides a sharp contrast with the
proponents of driver education, who have successfully lobbied into the American high school
curriculum a program whose methods and materials have never been subjected to systematic
evaluation and whose outcomes have been questioned by responsible research. ) Lastly, the paper does not propose that the departments of pediatrics is the “ideal” or “inevitable” site for the teaching of injury control; rather, the responsibility for the program is seen as shared among many community institutions and agencies.
The paper does not, unfortunately, address itself to the question of the role of the pediatrician in injury control, although this question needs to be answered before adequate materials and methods ca.u be fully developed. Should the pediatrician’s role be a purely preventive one? And, if so, should he focus his eflorts on the patient and his family or on environmental hazards in the community as a whole or on the broad social, cultural, and technological factors found to be related to accidental injury in children? Should he be sufficiently trained in research methodology to carry on his own investigations or should he be taught to work with other specialists in an in-terdisciplinary context? A number of papers in this volume demonstrate the methodological
inadequacies of even the most dedicated pediatrician. On the other hand, interdisciplinary
re-search, despite the lip service which it constantly receives, is beset with problems and has pro-duced few findings that can be incorporated into action programs or that offer clear guidelines for the teaching of injury control-in medical schools or elsewhere.
As the paper makes clear, the student in a medical school today learns little to make him
effectivein reducing childhood injury. But, what, when, and how he is to be taught remain un-answered questions.
C
m.u strr today bristles with gener- of death, taking a larger toll than the nextalizations; the hands of mothers and four causes combined in the
1-to-21-year-physicians are full of pamphlets, and their old age range. Mattison has indicated that
minds are full of doubt about the most ef- there is a staggering need for more trained
fective way to control childhood injuries, people in order to control injuries.2 Despite
The hospital wards of this country are filled the incredible pressure for more people and
with children who have been disabled by programs in the child-safety area, let us
injury. it is estimated that one out of every pause for a moment to ask, “What kinds of
three children in the course of a year will programs and people have actually proven
require medical attention for injuries.1 effective against this important problem?
* Rated by faculty members responsible for teaching
this subject area.
have been successful?” Regardless of the
compelling nature of the target, we cannot
justify the expenditure of large additional
amounts of money and professional time if
what is currently expended is uncertain in
effect.
Remarkably little is known about the
specific nature of the childhood-injury
problems in terms of epidemiology,
mci-dence, classification, and effective
preven-tion. Another problem which confronts the
child-safety field is the continually
chang-ing nature of the problem. As in other
dis-eases, new injury problems continually
ap-pear and require a place in the pattern of
formal instruction and the delivery of
health services. These can sometimes be
amusing-like the epidemic of contraceptive
ingestions reported from the midwest re-cently, or profoundly tragic, like the death and disability following the use of aircraft lubricant sold as cooking oil in Africa.
Because of the nature and size of the
problem, professional schools of medicine,
nursing, public health, dentistry, social
work, and education, and many other
orga-nizations concerned with training for
com-munity service, must become committed to
more significant childhood-injury teaching programs. A survey of every state and terri-torial health department in this country
de-TABLE I
ADEQUACY OF CHILDHOOD-INJURY TEACHING IN 77 DEPARTMENTS OF PEDIATRICS*
Subject
Not
Taught inadequate Total
Sports injury 36 1 57
Drowning 33 4 57
Vehicle injury 30 19 49
Falls 27 15 42
Epidemiology of
injury 24 15 39
Thermal injury 21 17 38
Emergency care 12 11 23
Poisoning 8 9 17
Child abuse 6 11 17
termined that many had marginal,
ineffec-tive programs, with wide variation between
various parts of the country.2 In a study of
accident-prevention teaching in medical
schools in departments of preventive
medi-cine Top found less than 3 hours per school devoted to the problem.
The American Academy of Pediatrics has
for many years been sigificantly involved in
promoting childhood-injury control. It has
pioneered in the preparation and
distribu-tion of materials, the development of
com-munity programs, and the encouragement
of children’s physicians to take a personal
part in injury control. Because of the lack
of information about the teaching of
child-hood injury in medical schools, the
Acci-dent Prevention Committee of the
Amen-can Academy of Pediatrics undertook a
detailed study of the nature, extent, and ade-quacy of childhood-injury-control teaching
by pediatric departments in the United
States during 1967. Medical education was
studied because this represented a critical period in the physician’s life with respect to developing attitudes, beliefs, and practices. Precoded questions on the childhood-injury
teaching plan asked about the adequacy of
the instruction for each method of injury
(
burns, poisoning, child abuse, sports and recreation, etc.)
, the professional identityof those responsible for the instruction, and
the teaching methods and materials used.
Specific inquiry was made about the
useful-ness of literature from the American
Acad-emy of Pediatrics and other publications.
The majority of schools (77/89)
re-sponded with usable replies to the
ques-tionnaire. Thirteen schools did not include childhood injury in their pediatric
curnicu-lum. Two thirds of the schools (38/64)
which taught students about childhood
in-jury emphasized only descriptive
informa-tion about the problem; only a few (9/64)
included primary prevention of injuries,
and 14 departments felt that students
should be taught about treatment as the
central approach to the problem. There
ap-peared to be no relationship between the
rat-TABLE II
NUMBER OF Houu.s OF CHILDHOOD INJURY TAUGHT BY 77 DEPARTMENTS OF PEDIATRICS
Hours 0-5 6-10 11-20 20 plus Unknown
Number of Sehool.i
80 18 8 8 13 Material TABLE III
Not Useful Useful
Epidemiologic material Bibliographic material Pamphlets on prevention Film lists, etc.
Very Useful 11 12 26 16 Unknown 41 44 89 42 Total 22 16 S 15 3 5 9 77 77 77 77 SUPPLEMENT
ing. Respondents were asked to rate the
ad-equacy of teaching by methods of injury, as
illustrated in Table I.
Methods of injury for which pediatrics
had a large share of clinical responsibility
were considered more adequately taught.
Programs beyond medical school
(intern-ship, residency, and postgraduate
)
werenot evaluated. Child abuse teaching was
rated very adequate by many who felt this
was due to the widespread publicity about
this problem in recent years.
An interdepartmental plan for teaching
childhood injury was reported from 14
schools: 4 of these plans were with
preven-tive medicine, 1 with surgery, and the
re-mainder with a variety of other medical
school departments, including psychiatry,
pharmacology, biochemistry, pathology,
and others.
TEACHING METHODS
Most departments (58/77) relied
pri-marily upon the lecture method including
11 of 14 interdepartmental efforts. Schools devoted an average of 7.8 hours to the total
teaching coverage of childhood injury
top-ics, as shown in Table II.
Seminar teaching was used by 48 schools,
while case presentation was reported as a
method used by 60 schools.
Emergency-room assignment was used in 30 schools,
with various other methods reported in 21
schools. The usefulness of prepared
mate-rial varied widely. The American Academy
of Pediatrics pamphlets and other
nation-ally available materials were used by many
schools, but views as to their usefulness
varied as indicated by Table III.
Accident References and Accident Notes,
published by the American Academy of
Pe-diatrics, proved useful to fewer than half of
the schools; the Obedience pamphlet was
useful to even fewer. Insurance company,
National Safety Council, federal
govern-ment, and Boy Scout information materials were also cited. There was no significant
as-sociation between what the faculty
ex-pected students to learn and the method
(i.e., seminar, lecture, and so forth) used or the degree of success reported. Most replies reported lack of confidence in the
effective-ness of the published material in either
teaching about the accident problem or in
preventing accidents, yet their use contin-ued.
RESEARCH IN CHILDHOOD INJURY
The relationship of research to the
ade-quacy of instruction was interesting; 15
schools cited 19 projects completed or in
process at the time of the survey, as listed in Table IV. Schools reporting specffic
re-search invariably considered the injury
studied more adequately taught than all
other areas or in schools without ongoing
research.
TABLE IV
RESEARCH AREAS IN CHILDHOOD INJURY
Study Area I Number of Schools Reporting Poisoning Child abuse Thermal burns Vehicular Falling injury Emergencies Recreation, sports Total 9 5 I 1 I 1 1 19 DiSCUSSION
The role of pediatrics in the teaching of
childhood injury appears to be poorly
de-fined or ineffective in many medical
schools. The few interdepartmental efforts
were usually limited to joint lectures.
Sig-nificant efforts to provide the student with
a broad working knowledge of the problem,
its prevention, and management were
rarely reported. This state of affairs may be
explained by the complexity of the
prob-lem, the multidepartmental issues involved,
and the lack of sound data or proven
con-trol measures. The multispecialty nature of
many injuries, involving contributions by
the epidemiologist, the surgeon, public
health authorities, and many others make a
representative coverage of the child with
burns, vehicular, and other injuries difficult. Backett notes that “the traditional methods of the public health team, with their ready access to the home and their ability to
rec-ognize danger, will pay large dividends by
the application of relatively simple injury control measures.” The pediatrician’s
rela-tionship with families, community
re-sources, and other specialists thrusts a
coor-dinating role upon him as a member of this
team. How should he be trained for such a
role and what help is available? Very few de-partnients of pediatrics were able to provide
students with such a coordinated model.
The available materials in the field
pre-pared by the American Academy of
Pediat-rics and the National Safety Council, and
other widely accepted publications, would
appear completely unproven in their effect
upon the problem. The close correlation
be-tween research and improved
childhood-in-jury teaching may represent part of the
an-swer to raising the quality of effort in this field. The most serious deficit in the
child-hood-injury teaching survey concerned
pre-vention. Although the contributions of the
developmental, behavioral, and other
human factors to injury pathogenesis have
been clearly demonstrated,#{176}8 environmen-tal factors received almost exclusive
empha-sis. A body of scientific knowledge
com-parable to other diseases is also limited for childhood injury. This in turn must hamper the educational efforts of pediatric
depart-ments who are confined to description of
the problem and demonstration of injury
management due to the lack of proven
pre-ventive methods.
Despite the very few instances of mutual
efforts between preventive medicine and
pediatric teaching reported in the present
study, the findings were very similar to
those reported by Top3 in a survey of 87
departments of preventive medicine in the
United States, Canada, and Puerto Rico.
Top noted that the lecture method by a
fac-ulty member heavily predominated. The
average number of hours devoted to the
teaching of accident prevention was 2.7,
considerably less than the 7.8 hours repre-senting the average in departments of
pedi-atrics in the present study. Coordination of
medical education would appear vitally
im-portant if the teaching of childhood injury is to move forward.
A more critical analysis of teaching methods and preventive measures should
also be stressed. Zimmerman9 and others have noted that the lecture form of medical education is one of the least efficient forms of education; they indicated that seminar
and other more active approaches are more
effective than the traditional lecture
ap-proach. More information about the cause
and prevention as well as management of
REFERENCES
1. Schiffer, C. C., and Hunt, E. P.: Illness among
children. Data from U.S. National Health Survey. Children’s Bureau Publication No. 6. Washington, D.C.: Government Printing
Office,p. 405, 1963.
2. Mattison, B. F.: Review of existing accident prevention programs in official health agen-cies in teaching accident prevention in schools of public health. School of Public Health, University of Michigan, Continued Education Series No. L., 1962., Ann Arbor, Michigan.
3. Top, F. H.: A survey of the teaching of acci-dent prevention in departments of preven-tive medicine. J. Med. Educ., 35:1152, 1960. 4. Selected References on Accident Prevention,
Accident Notes, and Obedience Means
Safety for Your Child. Evanston, Illinois:
American Academy of Pediatrics.
5. Backett, E. M.: Domestic accidents. WHO Public Health Papers Publication No. 26, 1965.
6. Behavioral Approaches to Accident Research. Association for the Aid of Crippled Chil-dren. New York, New York, 1961.
7. Mellinger, C. D.: Family studies of accidents.
Proceedings, Childhood Accident Injury
Symposium, April 21-22, 1966. Charlottes-ville, Virginia: University of Virginia, pp. 121 and 129, 1966.
8. Rattner, W. H., Meyer, R. J.,and Bernstein,
J.:Accidental Injury to the preschool child.
J.Pediat., 63:93, 1963.
9. Zimmerman, J.M., and King, T. C.: Motiva-tion and learning in medical school. III. Evaluation of the student-centered group. Surgery, 54:152, 1962.
10. Childhood Accident Injury Symposium, April
21-22, 1966. Charlottesville, Virginia: Uni-versity of Virginia.
ACCIDENTAL
FALLS
FROM
ELEVATED
SURFACES
IN
INFANTS
FROM
BIRTH
TO
ONE
YEAR
OF
AGE
Harvey Kravitz, M.D., Gerald Driessen, Ph.D., Raymond Gomberg, M.D.,
and Alvin Korach, M.D.
From the Department of Pediatrics, Northwestern University School of Medicine, Chicago;
Children’s Memorial Hospital, Chic”go; Department of Pediatrics, Luthern General
Hospital, Park Ridge, Illinois; and National Safety Council, Chicago
T
ms work is typical of the efforts of the gifted practitioner concerned with an importantprob-lem encountered in pediatric practice. It has all the limitations which time and sampling impose and does not satisfy the more precise investigative criteria for control populations, sta-tistical treatment and other considerations which further studies by this group may encompass. It represents an effort which seeks a practical solution and it enlists allies in a well known safety
organization. It is the method of collaboration and the clues that are developed which makes this
paper a vital contribution. The practitioner requires supportive workers in this type of investiga-lion, but is in a superb position to give additional information about the child and his family, and to implement findings that might be related to prevention. The “event tree” method of study and action which is proposed and illustrated offers a model for injury control of many types.
Community workers who are concerned about the problem of falls as the leading method of
childhood injury are hereby offered a useful method of study which does not require extensive or
complicated efforts. The leads that the paper offerswith respect to cultural diflerences in types
of fallsand circumstances should be explored. It is unclear either in this work or in the litera-ture whether the method of control posters, campaigns, etc. are indeed effective or not. All
existing methods of fall control should be encouraged as they raise the level of awareness of
the hazards to children, but a number of investigators have indicated that it is the mother’s
atti-tude and distractions from childbearing which offer a strong current of causation. Approaches
with the same population using evaluated techniques suggested by the authors are a next step.
T
problem of injury caused by falls tual frequency of falls in this age group andfrom elevated surfaces in infancy is the associated injury pattern has not been
