193
PEDIATRICS, February 1963
Ped (uI rics
VOLUME 31 FEBRUARY 1963 NUMBER 2
COMMENTARY
MISSION
AND
MANPOWER
INTRODUCTION
T
IlE SPECIAL ARTICLE by Stewart andPennell, “Pediatric Manpower in the
United States and Its Implications,” is
in-teresting and timely. It will be viewed
dif-ferently by various readers, by some as
seen from their personal perch, by others
in terms of the broad reaches past and
present of pediatrics as a discipline.
The purposes of the Special Article are
to highlight the manpower situation and
to point out long-term trends and
implica-tions in the light of the growing
responsi-bility of pediatrics. The authors say that
one requires a “delineation of the role of
the specialty of pediatrics in child health
care,” and “while this role may be shared
by other types of physicians, the responsi-bility for the development, maintenance, and improvement of child health services was clearly assumed by pediatrics when, as a specialty, it adopted as its objectives
the protection and promotion of the health
of children.”
SOME
HISTORY, PAST AND PRESENTIf this mission of pediatrics strikes some
tyro as new deal, new frontier, or new
pe-diatrics, he is surely unacquainted with
medical history. Let him read Gardner’sl
charming note on the role of Jacobi, often
called the father of American pediatrics.
If he prefers an earlier reference, let him
read Dewees’ century and a half old
Phil-adelphia text, “Treatise on the Physical
and ledical Treatment of Children”2; half
of it devoted to child health counselling. Dewees knew not how to advise parents
about skin diving or football, as these
thrills did not then exist; however, he
coun-seled that “equitation for children is an agreeable way to quickly acquire
intrepid-ity and that children should commence
soon after their sixth year.” (He recom-mended a riding master by name, perhaps the first printed commercial in American pediatric literature.)
Should even earlier points in time be
wanted to draw the line which represents
the direction of pediatrics’ mission, our
reader could see that Underwood’s
“Trea-tise on the Diseases of Children,”3 most
noted for the initial description of polio-myelitis in 1784, also contains chapters on food, air, sleep, and exercise for children, and a section on “the passions of the mind,”
a discourse on childhood behavioral
disor-ders of the eighteenth century.
Were the reader to reject all this as ante-diluvian and wish to move on in time, he
could read: “In the twentieth century,
pe-diatrics was elevated from its ancillary sta-tus as a dependent dwarf of ordinary med-ical practice into the larger atmosphere of
social medicine of which it is now one of
the most important independent branches,”
Field-194 MANPOWER
ing H. Garrison, M.D.,4 one of America’s
most distinguished medical historians and
analysts who recognized the comprehen-sive nature of pediatrics. Of no little
inter-est is the 1934 paper by the great Dr. C. A.
Aldrich, “The Composition of Private Pe-diatric Practice,” reporting many interest-ing data, including “40% of the time in this pediatric practice is devoted to preventive
work.” Dr. Robert A. Aldrich has the
de-tailed cards from which his father’s paper
was based; his own survey of pediatricians in 1959 reflects a similar pattern.
DEVELOPMENTS AND GROWTH IN
PEDIATRICS
Stewart and Pennell have reiterated the
challenging comprehensive nature of
pe-diatrics’ mission. The details of form and
of content are changing constantly and
im-portantly as in all Medicine; “to promote
and protect the health of children” has
al-ways been and remains the goal of
pedi-atrics. This has included specialized and
constructive supervisory health care as we
have noted. The pediatrician has never
done this job alone but rather has led the
way and pointed out this goal to all
con-cerned with children.
The pediatrician is likely to feel divine discontent so long as current and important
needs call out for new achievements. Aware
of a partial vacuum in the special needs of
children in radiology and pathology,
sev-eral pediatricians personally engaged in
these fields and nursed them along until
they were secure. The pediatrician’s tender
loving care of pediatric surgery snatched
that rejected baby from near infanticide;
witness the now lusty Section on Surgery in
the American Academy of Pediatrics.
Thus pediatrics grows and, more to the
point, develops, a fitting state of affairs for
a discipline whose chief concern is
maxi-mum development of children. Diseases of
the mind or body, whether genetic,
infec-tious, nutritional, or behavioral, are
re-garded as barriers to full maturation, each, when possible, to be anticipated and pre-vented. A small percentage of
pediatri-cians have and will elect to pursue special
areas of clinical practice or research with
resulting contributions which have
en-riched and embellished the entire field. Our fundamental interest in development
was recently recognized when the 87th
Congress established a new National
Insti-tute of Health and chose to call it The
In-stitute of Child Health and Human
De-velopment. Congressional committee
testi-mony in connection with the formation of
the Institute was presented by
organiza-lions and persons identified with all
seg-ments of pediatric teaching, research and
practice. All reflected the very bed-rock
concern with human development which is
at the centrum of pediatrics.
Stewart and Pennell ask: “Has the
growth in the number of pediatricians kept
pace with other physician manpower?”
Their own numerical reply is a
resound-ing affirmative as they go on to say that
between 1923 and 1962 the total number
of physicians increased 76%, all full-time
specialists 743, and the number of
full-time pediatricians 1,423%. They further
state that “the proportion of specialists who
are engaged in pediatrics appears to be
levelling off at about 8%.” The most recent
survey of 2,162 American rotating interns
(1961-62) planning to enter a specialty
in-dicated a healthy increase with a choice
for pediatrics of 11%.6 As to internships, it may be noted that the number of straight
internships in pediatrics matched via the
National Intern Matching Program rose
threefold in the decade between 1952 and
1962. The latest published figures show
that there were, in addition to an uncertain
number of fellowships and special program
trainees, a total of 1,776 first and second
year pediatric residents at work as of
Sep-tember 1, 1961.8 Approximately
one-quar-ter of these are from foreign countries; at
present about one-third of all hospital resi-dents are foreigners, i.e., 9,935 out of 29,494 in all branches of medicine.
Recent data for Board candidates and
for medical school faculties show
by the American Board of Pediatrics to
646 American candidates in 1962; the
num-ber estimated for written examination for
1963 is 790 candidates.#{176} The number and the size of medical schools is increasing, per-haps not as rapidly as might be desirable. Full-time members of pediatric departments come to 817,11 with an estimated 2,100 serv-ing part-time. As a point of interesting con-trast, departments of internal medicine had 2.5 times as many full-time faculty, and psy-chiatry departments 50% more than those full-time in pediatrics.1’
THE POWER OF WOMEN
The Special Article on manpower
natur-ally calls to mind womanpower. Why is it
that the percentage of all women medical
school graduates in the United States
(in-cluding the Women’s Medical College of
Pennsylvania) numbers just under 6%,12
while in Canada (virile and outdoorsy) it is
12%,13 and for Great Britain (a man’s
coun-try) 24%?’ Let speculation run rampant
on these figures! Is there an inverse
rela-tionship between the degree to which a
so-ciety is matriarchial and the emergence of
women physicians? It is always interesting
to give the same data to several students
and note the variations in their inferences
therefrom. The women medical student
picture will doubtless evoke various conclu-sions.
One clearly erroneous one, however,
would be to say that present-day
Ameri-can girls are not sufficiently interested or
intelligent. Quite the contrary. Of the 945
scholars of the 1961 National Merit
Schol-arship Program, 5.5% of the 641 boys and
8.5% of the 304 girls gave medicine as their career choice. Of the 10,542 semifinalists,
8.5% of 6,823 boys and 9.6% of 3,717
girls listed medicine.15 Do professional
coun-selors discourage them? Will our girls find
it necessary to go to neighboring Canada
or to Great Britain for a welcome reception
into schools of medicine? The differences in
cultural, social, and economic forces
be-tween Canada and the United States, and
indeed Great Britain, could scarcely
ex-plain the marked variations noted in
per-centages of women medical students
en-rolled.
It would also be erroneous to conclude
that all this is a new phenomenon,
ascrib-able as we are wont to do, to television,
sputnik, automation, the National Health
Service, or the atom bomb. In 193816 there
were as many women medical students in
Great Britain (having only one-third the
then population of the United States) as
in the entire United States in 1961-62! My
personal view is that the ladies are not
re-luctant to enter the medical profession. Have medical schools developed an
uncon-scious reluctance over the years? The
neg-lect of this important source of physicians has gone on far too long.
PARAMEDICAL AID
The data cited for interns, residents, and
pediatric physicians show increases which exceed those of all other physician groups.
This is especially brought out in Table V
of the Special Article. But is this adequate in the face of a rising percentage of
child-hood population, and a decline in general
practitioners? The increasing demands for
and ability to pay for medical care in all
age groups strains available medical
man-power in every field. The Special Article is
essentially one of challenge which must and
will be met. In so doing, we shall, as in the
past, assume a leadership role, working
with and cultivating other
disciplines-med-ical and paramedical-to do the job.
De-veloping additional forms of paramedical personnel to operate as extensions of
pedi-atricians in practice is a paramount
con-sideration, and the pooling of fresh ideas on
this subject is needed. In recent decades
such individuals have become identified
and integrated into personal care in
institu-tional pediatric ambulant and inpatient
services; these have largely been profession-als such as public health nurses, social work-ers, psychologists, home-visitors, and health
educators. There may be means of
develop-ing nonprofessional workers skilled in
TABLE I
LOCATION OF PHYSICIAN VISITS OR CONTACTS
(BASED ON 1960 CENSUS DATA AND THE NATIONAL HEALTH SURVEY CAIcrLkTIoNs)*
Total 257.3144.0 47.0 41
#{149}
14.
15.
196 MANPOWER
,
Age .\ umber
(troop Ut Group
Office % of No. Total Home % of No. Total
Telephone Clinic and Other
% of % of
No. Total No. Total
0- 4 5-14 126.O 131.3 69.5 55 74.5 57 10 8 14 11
5.5 ‘20 20 16
1.5 16 21 16
* All numbers are in millions; percentages are approximate.
child development. Training needs in this
area are, alas, restricted to nonprofessionals.
CHALLENGE AND OPPORTUNITY
Whatever new avenue of assistance may
be developed, it will need to be applicable
to children seen in practice, be it solo,
group, closed panel, or other, for that is
where the vast majority of American
chil-dren are seen. Table I gives estimates for
the location of physicians’ contacts as based
upon the 1960 Census data and National
Health Survey calculations. The percentage of visits is not quite the same as percentage of children, but the indications are clear that
the bulk of care is rendered via personal
practice avenues. With increasing economic security, prepayment, and related programs,
this will become all the more so. Just as
pediatrics has nursed and fostered various
related medical fields needed to insure the
best care for children, so it will need to do
for paramedical fields to facilitate and
extend each physician’s delivery of
serv-ice.
Stewart and Pennell have stated the
mis-sion of pediatrics and reminded us all that
despite the continuous rise in the number
of pediatricians, we shall not only have to
continue to grow but to develop in a fashion
permitting maximum effectiveness in
prac-tice. To achieve this will require
thought-ful innovations and proposals, clearly
de-scribed, on the part of all enterprising
readers.
P.O. Box 1035
Evanston, Illinois
ALEX
J.
STEIGMAN, M.D.REFERENCES
1. Gardner, L. I.: Abraham Jacobi: pediatric
Pio-neer, PEDrmIcs, 24:282, 1960.
2. Dewees, W. P. : Treatise on the Physical and
Medical Treatment of Children, Ed. 5. Phila-deiphia; Carey, Lea & Blanchard; 1834.
3. Underwood, M. : Treatise on the Diseases of Children. London; J. Mathews; 1784.
4. Garrison, F. 11. : In Abt’s Pediatrics, Vol. 1.
Philadelphia; Saunders; 1923, p. 130.
5. Aldrich, C. A. : The composition of private
pedi-atric practice. Amer. J. Dis. Child., 47:1051, May 1934.
6. Association of American Medical Colleges Data-gram, J. Med. Educ., 37:240, 1962.
7. Darley, W., et al.: The tenth and eleventh na-tional intern matching program ( 1961-1962).
J. Med. Educ., 37:1105, 1962.
8. Medical education in the United States. J.A.M.A., 182:735 (Table 26, p. 765), 1962.
9. Medical education in the United States. J.A.M.A., 182:735 (Table 16, p. 737), 1962.
10. Mitchell, J. McK.: Personal communication. 11. Medical education in the United States.
J.A.M.A., 182:735 (Appendix Table 1, p. 789), 1962.
12. Medical education in the United States. J.A.M.A., 182:735 (Appendix Table 10, p. 800), 1962.
13. Medical education in the United States. J.A.M.A., 182:735 (Canadian Table 12, p. 808), 1962.
Lancet, 2: 295, 1962.
National Merit Scholarship Corp. (Evanston,
Ill.) Annual Report 1961, Table 8, p. 34.
