Pediatrics
VOLUME 2 OCTOBER 1948 NuMBER 4
SPECIAL
FEATURE
SECTIONS
THE
PEDIATRICIAN
AND
THE
PUBLIC
EDWARDS A. PARK, M.D., Editor, PAUL HARPER, M.D., Associate
INTRODUCTION
F
OUR pediatricians, all members of the Academy, are deans of important medicalschools: Dr. Vernon W. Lippard, Dean of the University of Louisiana School of
Medicine ; Dr. Wilburt C. Davison, Dean of Duke University School of Medicine ; Dr. John McK. Mitchell, Dean of University of Pennsylvania School of Medicine ; and Dr. Francis Scott Smyth, Dean of the University of California School of Medicine. I thought it would be interesting to obtain the answers of these four important administrators to the question of the acceptance of federal funds for the advancement and extension of
pediatric education.
The letters from these pediatricians are complemented by one from Dr. George S.
Stevenson, who is medical director for the National Committee for Mental Hygiene, Inc., and so is in a strategic position to have observed the operation of Federal grants-in-aid to educational institutions under the National Mental Health Act. His observation that
in the administration of this program the U.S. Public Health Service has tended to bend over backwards to avoid unnecessary supervision is worthy of record.
The letters follow:
EDWARDS A. PARK
June 21, 1948 DEAR DR. PA1tK:
I am glad to answer the questions presented in your letter of June 9th. These answers
are, of course, expressions of my personal opinion and do not necessarily reflect the
opinion of the faculty which I represent.
I would favor Federal grants for the improvement and expansion of pediatric education
if they could be made available without the restrictions sometimes associated with grants from Federal agencies. Improvement in the quality of medical care for children or for
any other group will be dependent, to a large degree, upon the type of instruction our
physicians receive as medical students, house officers, and practicing physicians.
De-ficiencies in their instruction in pediatrics in many schools are referable to lack of qualified,
salaried teachers and indirectly to inadequacy of the budget for instruction in this field.
Your second question relates to the use which would be made of a grant for pediatric
education if it were received. I shall assume that a grant of fixed amount would be
guaranteed for a period of five years and could be used at the discretion of the dean and professor of pediatrics. It would make possible the appointment of a larger number of
experienced and well qualified instructors so that our system of instruction in small
groups could be further improved and students would receive more individual attention
in the wards and out-patient services. Members of a larger staff would have more time free
from routine responsibilities for research and study. It would also make possible the payment of more adequate salaries to younger men so that competent physicians would
be encouraged to remain in academic medicine.
As you know, there is under consideration provision of Federal funds to cover partial
operating expenses of medical schools. Although interested in pediatrics, I am also aware of the needs of other departments in the school. I believe that fluid funds, available for distribution throughout the entire teaching and research budget, could be used more effectively than those which must be designated for the development .of in-dividual departments of psychiatry, cancer, pediatrics, etc. Quality of instruction in pediatrics is closely related to availability of good instruction in the basic medical sciences
and other clinical fields. Furthermore, in some schools, individual departments are well
endowed yet fail to function to greatest advantage because they are not surrounded by
equally well-supported units. Perhaps the answer should be more adequate support,
through Federal grants, of medical education in general.
Sincerely yours,
(signed) VERNON W. LIPPARD
EDITOR’S NOTE : Dr. Wilbert C. Davison, Duke University, in a letter to Dr. Park dated June 29, 1948, stated that he had seen and thoroughly agreed with Dr. Lippard’s
letter, He continued as follows:
“I am in favor of a Federal grant for the purpose of improving and expanding pediatric
education. If we receive such a grant, we shall increase the size of the pediatric department and also assist with the postgraduate teaching of pediatrics in the surrounding hospitals.”
August 18, 1948
DEAR DR. PARK:
Your inquiry concerning my position with regard to receiving federal grants for the
improvement and expansion of pediatric education raises a question which should receive our careful consideration. Indeed it is already merging into the larger issue of whether
or not federal support should be sought for medical education as a whole.
There is no doubt of the need for additional funds for the teaching of medicine. This
has been clearly indicated by a recent statement from authoritative sources. The problem revolves solely around how and where the needed funds should be sought.
‘T’o show the nationwide character of the problem, it may be of interest to cite a few
of the findings of the Academy study of pediatric education which show the present
situation in that field. In 21 of the 70 medical schools, the total amount available to pediatric departments from all sources is less than $10,000 annually. In nine of these
schools it is less than $5,000. Three departments have virtually no funds. In addition
a number of departivients are precariously financed by short term grants. It is a safe
At the present time the federal government makes grants directly to medical schools for
purposes of teaching and research under the provisions of the National Cancer Program,
the National Mental Health Program, and the National Tuberculosis Program. The
eagerness with which these aids are sought does not indicate undue restrictions. On the
basis of these facts I can personally see no objection to the extension of federal aid to include the field of pediatrics.
On the other hand, if specific legislation is to be enacted for the support of pediatric
or general medical education, great care should be exercised that it should contain no restrictions on university freedom. To this end it would be well if representatives from
the educational and general medical fields could participate in its preparation.
The following are items which I think should be included among those designed for
the protection of medical education:
1. There should be appointed a National Council with supervisory powers. This
Council should indude medical educators and members of the medical profession at
large as well as representatives of the government services.
2. A large proportion of the annual appropriation should be for current expense with no further restrictions on its use.
3. The number of students to be admitted and their selection should rest entirely with the medical school.
4. The selection of recipients of national scholarships should rest with the National
Council. The holders of such scholarships should have free choice of schools and the schools should retain the right to accept or reject the applicants and tQ dismiss them for due cause.
5. In view of the present shortage of physicians in the government services, it is probable that a law would provide scholarships which include an agreement by the
ap-pointee to serve, after graduation in governmental health activities (Army-Navy-Air
Force-Public Health Service-Veteran’s Administration) or in areas of physician need.
This agreement should also permit this service to be rendered through teaching or
re-search in the medical school attended by the appointee, upon request by the faculty of that school. This clause would allow for the retention of students with exceptional
qualifications for teaching or research and it is anticipated that it would be invoked but rarely.
As indicated above, the great need is funds for current expense. In the main this means salaries for teachers, research workers and administrative staff. Many able part-time
teachers would gladly devote more time to their medical school duties if they were paid
a reasonable sum for their services. As it stands at present, they are paid nothing or a
mere token and cannot afford to take the additional time from their practice. This single
provision would immeasurably improve the situation in many schools.
A budget which would provide salaries for investigators should result in an active
research program, with benefits which need not be developed here.
Some departments lack the funds to pay a single full-time secretary. When it is
realized that full-time heads of pediatric departments average 60% of their time in administration and usually have reasonable clerical help, the difficulties in the situation
faced by part-time heads with no secretarial assistance, can be understood readily. The effect on the teaching program of the administrative disorganization, which sometimes
THE
In summary I might say, that it is my firm conviction, that most of the ills which
plague pediatric education today, stem from lack
of
funds.Sincerely yours,
(signed) JOHN MCK. MITCHELL
June 16, 1948
M DEAR DR. PARK:
Here are my personal views in answer to your questions:
The acceptability of federal aid for pediatric education would depend on the manner,
conditions, or restrictions which accompanied the subsidy.
(1
)
With the continued growth of medical science and with the present inflatedeconomy, the costs of maintaining schools of medicine have risen to the point where
most schools are having financial strain. Pediatrics is but one segment of the professional
discipline and I would much prefer to consider the whole rather than a restricted or
limited portion.
(2) There is a strong tendency to link responsibility for extension of medical service with educational programs. While there is inherently an area of service connected with
the educational programs in clinical medicine, I believe medical schools can best serve in their primary function of education and research, if they are not forced to accept an extension of service less obviously educational.
For example, there are those who believe that the medical schools should assume a
much broader responsibility in the certification program. The present increase in
resi-dency training is partly due to government subsidy (G.I. Bill) . In the case of selected veteran’s hospitals, there have been set up committees to direct the training program for
residents and ample funds to meet the costs of the educational program.
For many of the private hospitals, however, the desire for the residency training
program is not met by an adequate budget and facilities to provide a training comparable
to that given in medical school centers. The impression one gets is that these hospitals are
primarily interested in getting the help of good housemen. In such instances,
involve-ment of the medical schools would be equivalent to extending budget and personnel to
hospitals not controlled or directed by the schools, for residents not of their selection,
and for a professional certificate, not a university degree.
The implied increase of cost would not be confined to the medical schools, but would
ultimately be passed on to the consumer: the trainees charging higher fees, thus increasing
the cost of medical care.
All of us want to see the best medical service widely distributed within economic
prac-ticability. How then is the problem of rural health going to be met ? On this, there are
two differing ideas:
(1
)
There should be more emphasis on training the general practitioner. (Universityof Colorado)
(2) There should be an increased number of specialists.
Both have cogent argument. Both affect the role of medical education. I have already
mentioned the costs inherent in specialization. But, with the building of centralized rural
hospital facilities, the specialist’s role is already weighted, as for example in radiology,
profession itself should reaffirm its tradition and help solve the problem. The Boards
issuing certification could require a period (after hospital training in a medical center)
of rural experience. This would gradually acquaint the profession with the problem and would have a leavening effect on the present differential between rural and urban
pediatric programs. And, any corrective measures undertaken by the profession would,
I think, prove more effective than that based on legal mandate.
The University of California has a precedent for three types of federal subsidy.
(1
)
Building facilities and capital expenditures. In the past, these were W.P.A. andP.W.A. programs.
(2) Hospitalization of certain types of chronic or crippling diseases. Usually the
subsidy came from a fund allotted and matched by local and state funds.
(3) Research. At the present time many medical schools are enabled to carry on some
very important investigations, largely on federal contract. It is, however, true that many
of these research programs are technologic, rather than basic and that many schools would
prefer a more fluid research subsidy. Some of the programs involve tedious red-tape
con-tracts for obvious utilitarian significance. I must add, however, that pediatrics has not fared so well as other departments in the matter of opportunity for subsidies.
While, of course, I cannot speak for the Regents of the University of California, I
believe they would accept subsidy for buildings, for hospitalization costs, and for some
research programs. Beyond that, I believe they might be cautious with regard to programs
which might dictate curriculum, or threaten independence in the conduct of the school.
There is something to be said against stultifying standardization and there is an inherent ineptness in large administrative units.
Sincerely yours,
(signed) FRANCIS SCOTT SMYTH July 13, 1948
DEAR DR. PARK:
In July 1946 the National Mental Health Act became law as an amendment to the
authority given the U. S. Public Health Service. This Act authorized the establishment of an Institute of Mental Health, the granting of funds for research and training and
grants to states on a matching basis for preventive activities in the field of mental health.
Such funds are not useable for the care of patients in mental hospitals.
While the focus of this Act is psychiatric and the Advisory Council so created is
com-posed largely of psychiatrists, the activities supportable under this Act extend far beyond
the customary scope of the psychiatrist. Were this not the case it could hardly be
pre-ventive, for the early stages of psychiatric disorders are not found as much in the practice
of the psychiatrist as of other physicians. Almost every other specialist and general
prac-titioner encounters psychiatric disorders before they are seen by the psychiatrist.
The early treatment, to say nothing of prevention which must antedate early treatment,
calls for increased competence on the part of all physicians and prevention itself lies
also within the scope of several non-medical groups, such as teachers, clergymen, social
workers and public health personnel.
This Act permits grants to strengthen the preventive competence of all these groups
of this competence. Recent appointments to chairs of psychiatry in medical schools have
recognized the growing theory that the role of psychiatry in undergraduate medical
education is not to produce more psychiatrists, but physicians of all sorts who will have
knowledge and skill in handling the personal problems and distorted attitudes of all
of their patients. They must know anxiety in all its disguises and how to make it work
for the patient rather than against him. They must be skilled in talking with a patient
so as to use this as a technical resource as powerful and as revealing as gadgets and
drugs. They must know the subtle inter-relationships within ‘a family and how they may build up or tear apart a personality ; and they must know the resources of a community to help patients and how to use them.
It is the intent of those administering this Act to strengthen both undergraduate and postgraduate medical education so as to accomplish these aims and to see to it that every
section of the country has at least one medical school with a strong department of
psy-chiatry focused on these’ objectives. It has set aside a stipulated number of stipends for
training in child psychiatry and there is no reason within the law why a pediatrician
concerned to strengthen his competence on the psychiatric side could not be granted a
fellowship for this purpose.
As the National Mental Health Act is set up the relation between the U. S. Public Health Service and the educational institution is an entirely voluntary one, but even
beyond that acceptance of federal support has not in my experience carried with it in the
least any arbitrary control. To be sure there are regulations in which a recipient of support
must frame his program, but these regulations have been set up by a panel composed largely of faculty members of educational institutions and actually include some of the
recipients. Were I to make any criticism it would be toward the tendency of the Public
Health Service to bend over backwards and avoid supervision that is necessary to insure an adequate carrying out of a high quality of work under the program submitted. This
puts upon an organization such as the National Committee for Mental Hygiene the task
of maintaining a close watch on the operation of such activities in order that it may use
whatever resources it has to stop or forestall unwise use of public funds.
The importance of this law to the relatively normal child is evidenced by the fact that
the state department through which the state grant aspect of this law operates is, in most
cases, the state department of health, which in the past had little psychiatric responsibility. Under these funds the state may select a staff or prospective staff member in the field of child hygiene and place that person in special training in order that the mental hygiene elements may be strengthened.
Sincerely yours,
