THE
PRACTICE
OF
PEDIATRICS
CHANGING
TRENDS
IN
PEDIATRIC
PRACTICE
Robert W. Deisher, M.D., Alfred J. Derby, M.D., and Melvin J. Sturman, M.D.
Department of Pediatrics, University of Washington School of Medicine
CONTRIBUTORS’
SECTION
711
PEDIATRICS, April 1960
A
LETrER written in 1957 by apediatni-cian from time State of Washington expressed a very pessimistic future for pediatnics.I In fact, the writer eventually left time field of pediatrics. In his letter he indicated that improved feeding, anti-biotics, corrective surgery and other mod-em trends have eliminated the need for large numbers of pediatricians. He believed that the general practitioner, social agencies and lay publications were doing much of what the pediatrician formerly had done. His letter stimulated a great deal of dis-cussion about time rewards of pediatric prac-tice and the new areas in time field that were developing. Fischer’ pointed out some of the new areas such as accidents, allergy, school imealtim, adoptions, handicapped chil-dren and juvenile delinquency.
Time changing nature of pediatric practice imas been further illustrated in a recent article on time types of cases seen in practice oven the past 25 years.3 This report indicates that well baby cane, general health confer-ences and psychologic problems have ne-placed the treatment of infections, such as lobar pneumonia, empyema, cellulitis and diphtlmeria, to a large extent.
With timis information in mind time Pedia-tnic Department of the University of Wash-ington School of Medicine wisimed to as-centaiim what time pediatricians in the state were doing, wimether timey were satisfied with their practice, and if time training now being provided to pediatric residents is ade-quately preparing them for the present-day practice of pediatrics. We also wished to ascertain time nature and extent of pedia-tnic care (lone by the general practitioner in
ADDRESS: Seattle 5, Washington.
order to compare pediatric cane given by the specialist with pediatric cane given by time general practitioner.
PROCEDU RE
Informatioim was obtained by subrnittiimg a
questionnaire to 91 of the 113 pediatricians in the State of Washilmgton, excluding those in teaching or work other than practice. The
ques-tionnaire was developed with the help of the
University of Washington Public Opinioim
Labo-ratory. It was pretested using those pediatri-cians who were engaged in part-time teaching and certain pediatric residents. A list of pedia-tricians practicing in the State of Washington was obtained from the records of the Washing-ton State Medical Society-pediatrician mean-ing anyone who limited his practice to pediat-rics exclusively; there were 1 13 of these, all in practice. Two fourth-year medical students
iilterVieWe(l all pediatricians to obtaiim the in-formation. Almost all meim iiiterviewed were contacted during June, July aimd August of 1958. Pediatricians interviewed represented 41 different medical schools and were from 44 different pediatric residency programs. A letter explaining the study was sent to the pediatri-cians by Dr. Robert Aldrich, Head of the Dc-partment of Pediatrics. The pediatrician was then contacted, usually h’ telephone, and an appointment made. The interview lasted from 20 minutes to an hour.
Information about general practitioners ‘as
obtained from a survey of 123 general
practi-tioners done in 1957, using similar methods.
RESULTS
TABLE III
SUBSPECIALTY EMPHASIS
19.6%
1.1%
2.2%
4.3%
2.2%
1.1% 1.1%
TABLE V
PERSONAL PROBLEM AREAS IN THE PRACFICE
OF PEDIATRICS
(Subjective Answers)
2% (2)
12% (11)
712
TABLE I
PEDIATIiui.Ns HAVING HAD OTHER TYPES
OF PRACTICE IN THE PAST
(;eneral practice
Public health service
Both general practice and public health service
Military general practice Military pediatrics
Military l)sYchiatO Military surgery
Years iii pediatric practice, Average-li .45 (Ratige,
0.67-35)
anotimen branch of medicine prior to their pediatric practice. The average length of time in pediatric practice was 11.4 years (Table I).
Of the men interviewed, 100% had an urban practice; 56% had centrally located offices and 44% had suburban offices.
Fifty-eight pen cent of the men were in practice by themselves while the remaining 42% were in some type of group on partner-ship arrangement with other physicians or other pediatricians (Table II).
None of the men practiced a pediatric subspecialty to the exclusion of general pe-diatrics. However, 30% of the men empha-sized some subspecialty of pediatrics while doing general pediatrics (Table III).
A question was asked about the number who did some type of surgery (Table IV).
Eacim pediatrician was asked what he considered to be Imis greatest personal prob-1cm related to the practice of pediatrics. He was directed to avoid problems of an aca-demic or medical nature, such as problems concerning the diagnosis or treatment of disease. The most frequent reply to this
TABLE II
PRACTICE ARRANGEMENT
Sole 58% (54)
Partnership with pediatrician(s) 18% (17)
Group part nership vith pediatricia 11(s) and
other physicians 10% ( 9)
Group partnership with other physicians
(no other pediatrician)
Other
Allergy 14% Surgery 1%
Allergy & Surgery 1% Emotional
disturb-ances 1%
Adolescents 3% ENT 1%
Cardiology 3% Diabetes 1% Mental retardation 2% Prematurity 1% Neurology 1% Rheumatic fever 1%
TABLE IV
PEDIATRICIANS DOING SURGERY
Lacerations 89%
Fractures (minor) 48%
Tonsillectomy 43%
Abdominal 8%
Fractures (most) 7%
Insufficient time for self and practice 39%
Telephone, and telephone therapy 36%
Poor remuneration 20%
Inadequate or anxious parents 16%
Lay publications 11%
Volume practice necessary to make practice
economically sound 10%
Patient’s inability to pay 8%
Unnecessary calls or night calls 8%
question was the lack of sufficient time for himself and his family. A close second was the problem of having to treat patients oven the telephone. A smaller percentage felt that pediatricians were not paid well enough. Allied to this complaint was another com-plaint-that the pediatrician had to handle a large volume of practice to meet the de-mands of economics (Table V).
The pediatricians interviewed were asked to estimate the major subdivisions into which their practice fell. Well-child care and ill-child care seemed to be about equal in the overall average (Table VI).
Well-child care
Ill-child care
TABLE VIII
\\‘EEKLY PATIENT LOAD: AVERAGE TIME
SPENT WITH PATIENTS
49.0% 15-90%
51.0% 10-85%
(Information was taken from secretary, nurse, or
Respiratory illness Upper respiratory illness
Lower respiratory illness
Diagnostic studies
Diarrhea, vomiting, & G.I. complaints
Surgery (including T & A)
Fluid & electrolyte therapy
CNS (convulsions, meningitis, etc.)
Infections (of a nonrespiratory type) Accidents & poisoning
16%
7% 24%
1%
15%
12%
11%
7%
7%
6% 6%
TABLE VI
PltAcrIcE SUBDIVISIONS
(Physicians’ Estimate)
Av. Range
with very few in the 12- to over 16-year raimge (Table VII).
(
Correlative data obtained from the office secretary or nurse and taken from the phy-sicians’ records support this information.)Time average pediatrician saw appnoxi-mately 100 patients weekly and spent an average of 173k minutes with time well child aimd 163 minutes with time ill child (Table VIII).
Time average number of imospitalizations in the pediatrician’s practice was found to be 11 pen month. The most common cause for lmospitalization was respiratory illness (Table IX).
In order to find out how closely the mcdi-cal interests of time pediatrician correlated with time problems on which he spent most of his time, eaclm man was given a list of conditions and asked to mate each according to his interest, and then to mate each accord-ing to the frequency with whicim it occurred in imis practice. A scale of 1-7 was used with 1 indicating little or no interest and 7 a great deal of interest. The same scale was used to indicate time numbers of cases seen, that is, 1 indicating something occurring infrequently and 7 indicating a very com-mon occurrence.
Sucim items as viral diseases, rheumatic fever, prematurity, adolescence, allergies, dermatologic disorders and feeding
prob-TABLE VII
AGE DISTRIBUTION OF PATIENTS
}ears
0- 1
.4,’. Range
35.7% 10-73%
- 6 34.2% 15-65%
6-12 21.4% 5-40%
H-16 7.3% 0-20%
16-f- 1.3% 0-10%
An average week:
No. ill patients 53
No. well patients 45 Average time with ill child 16.6 minutes
Average time with well child 17.6 minutes
records.)
lems were most liked. Of this group only allergies and feeding problems ranked among the most commonly seen items. Well-baby cane, respiratory infections, vomiting and diarrhea were most commonly seen by the pediatrician although of only moderate interest (Table X).
Among the items seen least, it was found that cancer, collagen disease, rheumatic fever, renal disease, cardiac, hematologic and neurologic disorders, mental retanda-tion, congenital anomalies and fractures are least often encountered. Correlation with items liked least is closer imene (Table XI).
In an attempt to find out in what areas medical school training was lacking, timose interviewed were asked in what areas more training emphasis seemed indicated from their experience in practice (Table XII).
Comparison of information gatlmened in the State of Washington in 1953 by the Washington State Sickness Survey (WSSS)4 with information reported by Boulwarei
from his records covering 25 years of
pediat-TABLE IX
hospITALIzATIoNs
Average/month, 10.9 Range, 1-38 Mode, 4-6
7 4
7 1
7 4
7 3
7 7
7 5
6 7
Items Seen Least in Pediatric Practice
nics (1930-1955), and with Aldnich’s report
of his practice in 1934, shows us certain differences in the nature of changes in pediatric practice. Health supervision and respiratony problems have remained rela-tively unchanged from 1934-1953. Judging from the Washington State Sickness Survey, diseases of the central nervous system,
mal-2 1 formations and accidents all have shown
2 1 some increase (Table XIII).
2 1 If one considers the total problem of
2 1 pediatric cane, one must consider time
gen-4 era! practitioner as well as the pediatrician,
;
::
because he cares for a larger proportion of2 4 the children in the population. The
sum-I 7 men before undertaking a survey of the
I 1 pediatricians of Washington State, we had
I I used similar methods to obtain
infonma-tion from general practitioners concerning
I 2 their pediatric practice. While the primary 1 2 purpose of the survey was to obtain specific
information about their pediatric medical
1 1 education and how well it had prepared
I 2 them for their practice, there was also some
1 4 information obtained about the type of
pediatric practice being done.
From a total of 123 general practitioners
interviewed it was found that
approxi-Items Like(i Lea.1 in Pediatric Practice
tFractures
tMiIIOr surgery
tCongenital aflOIIIalies
.t
Cancer and leukemia fCollagen diseasetMental retardation
Orthopedic problems
* Direct correlation with like or interest in item.
t 1)irect correlation with volume of item seen in prac-tice.
TABLE X
(;ISEATEST INTEREST IN, AND F1IEQtTENY OF, ITEMS IN PEDIATRIC PRAcrIcE
Mode Rating Volume
Items Liked Most in Pediatric Practice
Viral exanthems
Rheumatic fever
Adolescence
Prematurity
*Allergies I)erinatology *Fee(liIIg problems
items Seen Most in Pediatric Practice
Well-baby care 7 (49%) 5
URI 7 4
l)iarrhea 7 4
Vomiting 7 4
fFeeding problems 7 6
tAllergies 7 7
* I)iret correlation with volulne of iteIll in practice.
t 1)ired correlation sitli like or interest in item.
TABLE XI
LEAST INTEREST iN, AND FREQUENCY OF, ITEMS IN PEDIATRIC PRACTICE
*Fractures \hirior surgery
*(‘ollgellital anomalies
*4$IeIItal retardation
Cardiac disorders
Neurologic disorders
Hematologic disorders Renal
Rheumati fever *(‘ailcer and leukelnia *(ollageII (lisease
Mode Jolume Rating
TABLE XII
MEDICAL SCHOOL T1IAINING (More emphasis dssired, in order of preference)
Basic Science Clinical
Virology Adolescence Psychiatry Newborn physiology Genetics and teratology Behavior problems
Physiology Accidents and poisoning
Hematology Normal growth and devel-opment
Neurology Fluid and electrolytes
*Bihemistry Prematurity *pharmacology Allergies
Mental retardation Nutrition
Inborn errors of metabolism
Dermatology Infectious diseases Collagen diseases
* Significant to the s% level.
TABLE XIII
COMPARISON OF PEDIATRIC PRACTICES
Jvs&sS (1953)
(Rank in (Rank in All Pediatrics) Ages)
Boulware
(19.90-55)
Aldrich5
(1934)
health supervision I 40% 1 40% 39%
Respiratory prol)lems 2 22% 2 24% 23%
Nervous system-special senses 3 7% 5 2% 0.5%
Allergies 4 6% 12 2.5% 2%
Infant diseases and malformations S 4% 16 0.5% 0.25%
AccidelIts 6 4% 3 ‘2.5% 1%
lIlfeetiollS and parasitic diseases 7 4% 15
Sylliptolns alal ill-defined disorders 8 3% 10
skin 5111(1subcutaneous tissue 9 3% 9 4% 3%
Gastrointestinal 10 2% 7 5% 4%
Cardiovascular 11 2% 4
(ieIIitt1riIIar 12 1% 6 1% 1%
Blood diseases 13 1% 17
Metabolic & nutritive disorders 14 1% 14 0.5% 1%
Neoplasnss 15 1% 11 0.2% 0.05%
Mental 16 1% 13 2% 0.5%
Musculoskeletal 17 0.5% 8 0.5% 0.25%
29%
71%
mately 34sf of timein patients were in the pediatric age group (Table XIV).
If one compares this witim the figures ob-tamed by the American Academy of Pediat-nics’ Study of Child Health Services in 1948, the results are surprisingly similar. In timat study time general practitioners’ case-load was 30% child patients, with 30% of these being well and 70% ill.
DISCUSSION
It is interesting timat the incidence of well-and sick-child visits imas remained relatively constant over the past 10 years in the gen-era! practitioner’s practice. However, there imas been some change in time type of pnob-1cm coming to time pediatrician. Treatment of diseases of time nervous system, allergy, congenital deformities and accidents has increased on an average of about 4% in the last two decades. Time spent in well-child
TABLE XIV
CENEIIAL PRACTITIONERS’ PEDIATRIC PRACTICES
Total nuIul)er interviewed 123
\Vell-child visits
Ill-child visits
care and health supervision has increased by 9% oven the figure given in 1953 by the Washington State Sickness Survey.
Many factors may contribute to time ap-parent increase of certain kinds of pnoblcms in pediatric cane. Among these are: in-creased diagnostic proficiency due to better knowledge about the nature of certain dis-eases and physical anomalies; increased medical practice of preventive techniques, such as vaccination, preventive serums and early treatment of orthopedic defects; in-encased public awareness of psyclmologic components of behavior and development, and correspondingly an increased desire for medical advice in the area of well-cimild cane. The public has been educated to mc-spect and to make use of medical special-ists, and because of the dissemination of knowledge about child development, hotim physical and psychologic, parents incneas-ingly are coming to the pediatrician for ad-vice formerly given them by relatives, friends and clergy.
consultative practice, another example of
in-creasing specialization within a specialized field of medical practice.
When one compares the information mc-garding the items liked least in pediatric practice (Table XI) with the information ob-tamed relating to more empimasis in medical school training (Table XII), one finds a con-relation between least-liked items and little emphasis in medical school training. Possi-bly these items are least-liked because the pediatrician’s training in fields relating to the management of these areas is scanty, and therefore he is unsure of himself in their treatment. Comments obtained in the questionnaire about the relationship of em-phasis in medical school training to actual pediatric practice can be used as guides in the evaluation of the efficacy of present pediatric training programs of medical schools.
SUMMARY
In order to gather more information about the current trends in pediatric prac-tice in one locality, a study was done in 1958 to ascentain what the pediatricians in the State of Washington were doing; whether they were satisfied with their prac-tice; and if their training had adequately prepared them for practice. Information about the nature and extent of pediatric cane done by the general practitioner, which was available from a 1957 study in the State of Wasimington made it possible to compare certain aspects of pediatric care as practiced by the general practitioner
with those same aspects of pediatric cane as practiced by the pediatrician.
Some attempt was made to try to com-pane the findings of this study with relevant information given in other studies.
In general, it was found that in time State of Washington well-child care and the treatment of upper respiratory infections occupies much of the pediatrician’s time. Time spent in well-child care was approxi-mately equal to that spent in sick-child care -a contrast to the experience of the present-day general practitioner and to pediatric practice in former times. Treatment of cer-tam kinds of diseases has ostensibly in-creased somewhat in the past two decades, and treatment of accidents is now part of pediatric cane. Some conclusions about the adequacy of medical school training are also presented.
REFERENCES
1. Tabrah, F. L. : The pediatrician’s role in society (Letter to the Editor).
J.
Pediat.,51:745, 1957.
2. Fischer, C. C. : The pediatrician and his changing world.
J.
Pediat., 51 :593, 1957. 3. Boulwane,J.
R. : The composition of pri-vate pediatric practice in a small corn-rnunity in the South of the United States; a 25-year study. PEDIATRICS, 22:548,1958.
4. Standish, S., et al.: Why Patients See Doe-tors. Seattle, Univ. Washington Press, 1955.
5. Aldrich, C. A. : The composition of private pediatric practice. Am.
J.
Dis. Child., 47:1051, 1934.
6. American Academy of Pediatrics: Child Health Services and Pediatric Education.
