PEDIATRICS
AND
SOCIETY
SOME
OBSERVATIONS
ON
THE
SOCIOLOGY
OF
PEDIATRIC
EDUCATION
AND
PRACTICE
By Julius B. Richmond, M.D.
1)cjwrtmcnt of Pediatrics, State University of New York, Uprtate ?mfcelical Ccntrr
CONTRIBUTORS’
SECTION
PEDIATRICS, Jumne 1959
A
recemit editoriaP emititled “Can the newpediatrics 1)e pract:ced? raised many
sigmi ificant issumes which deserve elaboration.
The “new” pediatrics has been developing
over a period of years and it might be
ad-vamltageo)ums, therefore, to view the
develop-ment of current pediatric practice and
edu-cation in tile somewhat broader historical
perspective of social process. Since each
person views social process from the
van-tage point of his own background and
ex-penience, these observations are not
pre-sented with the thought that they are a
consensus of pediatricians generally. I
SllOtmld emphasize at the outset, however,
that I am not presenting value judgments,
I)Ut rather that I am making an effort to
record certain trends of which we should
take note. For if we are aware of social
process, we are in a better position to direct
it in the interests of progress rather than to
drift randomly.
Changes in American pediatrics have not
occurred in isolation. The rapid
industniali-zation, urbanization and subumrbanization,
and rapid population growth of the past
several decades, are known to all. The in-crease in the child population from a total
of 40 million in 1940 to 57 million in 1957 is in itself a figure of considerable significance
for American pediatrics. The considerable
and continuing mobility of oumr population
-and particularly young families-has no
parallel in other parts of the world.
Perhaps of most immediate relevance to
pediatric education and practice are the
rapid advances in medical knowledge which
have niade SO great an impact on the
im-ADDRESS: Syracuse 10, New York.
1)rovememlt of health of our yoimmig
I)oPull-tio)n. Certainly many practicing
pediatri-cians can recall all too vividly tileir great
preoccupation with the severe infections
and nutritional diseases which were so
prey-alent in the early decades of this century.
These rapid advances have made it clear
that the one thing above all else which
pediatricians (and all enlightened citizens) need to be prepared for is change. Much
of the concern about education generally in
this country stems from the fact that we
have been relatively complacent with things
as they are, rather than facing up to the
challenge of the future.
What have been some of the implications
of our increasing knowledge for pediatric
education and practice? Certainly it is
be-coming increasingly evident that we need
to clarify the role of various groups of pediatricians we are educating in order that
we may be clear about the objectives of our
educational programs. As a consequence
of increasing knowledge and specialization,
it woumld appear that pediatricians can be
classified into three main groumps as follows:
1) Practicing pediatricians (the group
re-ferred to by Shaw2 as “journeymen
pediatni-cians”). This is undoubtedly the largest group
in terms of numbers. Certainly this is the group
called upon to practice “the miew pediatrics.”
2) The subspecialists in pediatrics. These are
the pediatricians who remain in academic centers or in hospitals or clinic groups. This group is increasing in numbers and it is from
this group that most pediatric education
de-rives.
1176 EDUCATION AND PRACTICE
involved in institutional programs in child care. This is a very influential group in determining patterns of care and public policy related to the medical care of children.
Some comments on the implications of this career grouping and its significance for edumcation are in order. We note that each group has very specialized activities. There
are many who nostalgically long for the day
when all pediatricians cared for all of the ills of children. It is appropriate to note that this pattern would no longer be compatible with providing the highest quality of care. For specialization in any scientific field is not just a sociologic accident; rather it represents a logical development.3 Indeed, this development has completely changed the role of the consultant. The individual as a consultant has largely been displaced
by the medical center or the clinic as a
con-sultant. Thus the pediatric cardiologist,
en-docrinologist, virologist, psychiatrist, etc.,
could hardly function any longer without the supporting staff and facilities of the medical center or clinic. Remove the sub-specialist from his institutional setting and his role as a consultant becomes reduced or impossible.
In the light of such specialization, it is
interesting to note that the journeyman
prac-titioner often minimizes his role as a
special-ist. In the modern American community (with the exception of some pediatricians practicing in rural areas where the pattern of practice may be similar to that prevalent in the country at large 25 years ago in that
he is concerned mainly with pathology) the
pediatrician is, indeed, a speciahst in
growth and development as well as in diseases of children. Since definitive care of complex disease often requires collaborative care with the staff of a clinic, his primary role becomes more and more that of pro-viding guidance for the growth and
develop-ment of children along with caring for
acute and transient illness. Since his
edu-cation has in the past not prepared him adequately to assume this role, the corn-rnunity’s expectations of the pediatrician
in guiding growth and development are
often beyond those which he feels prepared
to fulfill. Herein lie some of the core prob-lerns for pediatric education.
Because of the diverse careers which
pediatricians pursue it would seem
appro-pniate to continue the 2 years of residency as a generic, common educational core for all pediatricians. Following this period
fur-ther
training
might
be
acquired
to
meetthe needs
of the
individual. Thus, the pedia-trician going into academic medicine or the practice of a subspecialty would-as he now does-seek a fellowship for furthertraining.
The length
of the period
of
fellow-ship training would depend upon individual
needs and objectives. The pediatrician
in-terested in a career in public health or
in-stitutional work might seek further training
in a school
of public
health
or in specialized
programs for institutional care. The larger
numbers of pediatricians would become
practitioners after the 2 years of residency. There has been considerable discussion
recently concerning the fact that
pedia-tricians as a group may not have a high degree of satisfaction in their work. The
question has also been raised as to whether
as many highly qualified candidates are seeking pediatric training in comparison to previous years. However, the question might
be raised
as to whether
some
of the
dis-satisfaction stems from the educational
ex-peniences of the pediatrician.
Pediatric residency training programs
de-veloped during a period when there was
heavy emphasis on the care of the sick child
and on inpatient pediatrics, and this has been the continuing emphasis of pediatric
training. In years gone by, such training
corresponded closely with what the
pedia-trician was called upon to do in practice. However, as has already been indicated, the pediatrician is currently called upon to pro-vide guidance for the growth and
develop-ment of children. If in his educational
ex-penience he has had little preparation for
1177
Most pediatricians have had to undergo a period of rapid self-education following their embarkation on pediatric practice.
The problem is miot exclusively one of inadequate preparation for practice. If the
model which attracts the trainee to
pedi-atrics is that of inpatient pediatrics, it may well be that a significant number of people are attracted to this training on the basis of a model which bears very little resem-blance to pediatric practice. It is perhaps small wonder that there is considerable
disillusionment when the trainee finds that
there is little in the way of major pathology to be observed in practice. To illumstrate this point I have in recent years surveyed some
of
the
recent
graduates
of our
residency
program concerning the numbers of patients
they have hospitalized in a year of practice.
The figure has ranged from a low of 6 to
a high
of
28 patients in a year. This is,in-deed, a far cry from the pediatric practice of yesteryear! I wish to make it clear that I am not being critical of pediatric trainees. They have good reason to feel that what they see as pediatric training should bear some resemblance to the realities of pedi-atric practice. Those of us who are pediatric
edtmcators perhaps have not been sufficiently sensitive to the changing nature of pedi-atnics in the modern American community.
Whenever one raises the question of edu-eating stumdents for the management of
problems in growth and development (and
I include physical as well as intellectual, social and emotional development), one is stmbject to the accusation that there will be a diltmtion of the quality of scientific train-ing or that the pediatrician will have no
competence in the care of the sick child.
In our experience it has been entirely
feasi-ble to empilasize both growth and develop-ment and the understanding and care of the sick child without doing a disservice to
either. Furthermore, the teaching of growth
and development offers jumst as significant an opportunity to provide scientific
back-ground as does the teaching of pathology.
Certainly the teaching of biochemical and physiologic growth can be just
is
exciting-and no less scientific-as the teaching of
dis-ease. The teaching of the management of
problems in psychologic and social growth,
which constitute such a large portion of
office practice, can also be presented in a
disciplined and critical fashion. Washburn has elaborated on this approach in his pro-posal for the teaching of “medicine as human biology.” In our experience the in-terests in the sick and vell child are parallel.
A few words are perhaps in order on the distribution of pediatric care in the United States. The best figures available to me
mdi-cate that there are in pediatric practice in the United States approximately 8,100
physicians of which approximately 5,500
have obtained the certificate of the Amen-can Board of Pediatrics. If we accept the figumre of 57 million as the child population in the United States, we would find that
the pediatrician to child population ratio
is approximately 1 to 7,000. Obviously this
is an impossible task. Since the number of
pediatric trainees is not increasing, it is unlikely that this ratio will become a more
favorable one in the relatively near future,
as the child population continues to
in-crease. Inevitably much pediatric care is
being rendered by general physicians or through public health programs. Certainly this problem emphasizes the importance of the pediatrician who is engaged in planning public health programs.
In the United States much of private pediatric practice has centered in the corn-mumnities in which families are of reasonably
good economic circumstances. However,
even in families of reasonably good
circum-stances, there may be some difficumlty in
financing the kind of pediatric care which
is anticipated. This is one of the questions
raised in the editorial, “Can the new
pedi-atnics be practiced?” It would seem that, if pediatricians are to provide the kind of care which is expected, prepayment plans or instmrance provisions for comprehensive
medical care may be necessary. That
pedi-atricians and other medical specialists have
pro-1178 EDUCATION AND PRACTICE
visions for such care in insurance plans
sponsored by the medical profession, such
as Blue Shield plans. Any evaluation of these plans reveals that they make provisions pre-dominantly for surgical procedures or other “catastrophes.” Although it may be argued that low premiumms can be offered only by
such plans, this is not
the
primary
need
of
many families. Witness the fact that the
commercial insurance companies are finding
their way into this field with a considerable degree of success. Pediatricians and other medical specialists will need to become more articumlate as advocates of the interests
of the young families for whom they are
providing cane. Certainly the pediatrician is
entitled to compensation for time expended in patient care at a rate comparable to other specialists. Some of the job to be ac-complished is educational; just as significant,
however, is the need for imaginative
ap-proaches to making adequate care possible
economically.
In a society which is destined to be
under-going rapid change we have the
responsi-bility for bold and imaginative thinking in
the planning
for pediatric
edtmcation
and for
care
of our
young
population.
The
pedi-atrician, because of his identification with all aspects of the interests of children, is in a position to be a most effective advocate for children. In order to fulfill this obliga-tion he needs to be sensitive to the
implica-tions of
the advances
in medical
knowledge
for the increasingly effective care of
cliii-dren
in our population.
REFERENCES
1. Ma, C. D. : Can the mu’v l)1ittrics lw
practiced:? (Editorial). PEDIATRICS, 23:
253, 1959.
2. Shaw, E. B. : Appemidicitis in children
(Edi-tonal). PEDIATRICS, 22:235, 1958.
3. Frankel, C. : A philosopher looks at
medi-cine. To be published in Proceedings of
the First Institute on Clinical Teaching, American Association of Medical Col-leges,
J.
M. Education.4. Washburn, A. : Growth: its significamice in medicine viewed as humman biology.
