PEDIATRICS Vol. 63 No. 6 June 1979 935
nopathy induced by oxygen in newborn kittens,’8
thus supporting the need for clinical trials of
tocopherol in preventing RLF. Currently,
John-son, Schaeffer, and Boggs’9 are conducting a
randomized double-blind clinical trial of
paren-terally administered tocopherol in quantities
sufficient to raise the serum levels of premature
infants to 3.5 mg/dl. Their preliminary data,
obtained at serum levels of 1.5 mg/dl, suggest a
lower incidence of acute RLF in infants whose
birth weight is under 1,500 gm.
CONCLUSION
Patients with prolonged fat malabsorption and
some premature infants receiving iron must be
given vitamin E. Use of tocopherol therapy in
BPD
and RLF, while promising, is unproven andshould be used only . in a controlled study.
Research on the role of vitamin E in human
physiology is entering a rapid-growth phase. I feel
certain the near future will see scientifically well
founded uses for this “vitamin without a
disease.”
Los Angeles, CA 90024
DALE
L.
PHELPS,M.D.
Division of Neonatology,Department of Pediatrics,
UCLA School of Medicine
REFERENCES
1. Melhorn DK: Vitamin E: Who needs it? Ohio State Med
I 69:899, 1973.
2. Oski FA: Metabolism and physiologic roles of vitamin E.
Ho Practice 12:79, October 1977.
3. Bieri JG, Farrell PM: Vitamin E. Vitam Horm 34:31,
1976.
4. Stuart MJ, Oski FA: Vitamin E and platelet function.
Ani I Pediatr Hematol/Oncol, in press.
5. Dormandy TL: Free-radical oxidation and antioxidant.
Lancet 1:647, 1978
6. Cross 5: The antioxidant relationship between selenium-dependent gltitathione proxidase and tocopherol.
An I Hematol/Oncol, in press.
7. Horwitt MK, Harvey CC, Duncan GD, Wilson WC: Effects of limited tocopherol intake in man with relationships to erythrocyte hemolysis and lipid
oxidations. Ani I Clin Nutr 4:408, 1956.
8. Oski FA, Barness LA: Vitamin E deficiency: A previous-ly unrecognized cause of hemolytic anemia in the premature infant. I Pediatr 70:211, 1967.
9. Ritchie JH, Fish MB, McMasters V, Grossman M: Edema and hemolytic anemia in premature infants: A vitamin E deficiency syndrome. N Engl I Med 279:1185, 1968.
10. Roselil)lt,m JL, Keating JP, Nelson JS, Prensky AL: A progressive neurologic syndrome in six children with chronic liver disease and alpha-tocopherol deficiency. Pediatr Res 12:555, 1978.
11. Hillman RW: Tocopherol excess in man. Am I Clin Nutr
5:597, 1957.
12. Comgan
JJ,
Marcus Fl: Coagulopathy associated withvitamin E ingestion. IAMA 230: 1300, 1974. 13. Corrigan JJ: Coagulation problems relating to vitamin
E. Am I Pediatr Hematol/Oncol, in press.
14. Ehrlich HP, Tarver H, Hunt TK: Inhibitory effects of vitamin E on collagen synthesis and wound repair.
Ann Surg 175:235, 1972.
15. Levy L: The anti-inflammatory action of some compounds with antioxidant properties. Inflamma-tion 1:333, 1976.
16. Ehrenkranz BA, Bonta BW, Ablow RC, Warshaw JB: Amelioration of bronchopulmonary dysplasia after vitamin E administration: A preliminary report. N
Engl I Med 299:564, 1978.
17. Northway WH Jr: Bronchopulmonary dysplasia and vitamin E. N Engl I Med 299:599, 1978.
18. Phelps DL, Rosenbaum AL: The role of tocopherol in oxygen-induced retinopathy: Kitten model.
Pediat-rics 59:998, 1977.
19. Johnson L, Schaffer D, Boggs TR Jr: The premature infant, vitamin E deficiency and retrolental fibro-plasia. Am I Clin Nutr 27:1158, 1974.
The Task Force Report
The Future of Pediatric Education, ‘ a report by
a special Task Force under Dr. C. Henry Kempe,
has been widely circulated to practitioners and
academicians since its publication in the spring of
1978. Dr. Kempe summarized its
recommenda-tions in his presidential address to the American
Pediatric Society.2 The Task Force consisted of 17
members representing most of the constituent
societies responsible for pediatric education,
research, and service in the United States. They
worked for two years, commissioned two
surveys-one of parents and one of 7,000 recent
(
since 1964) graduates of pediatricresidencies-and met with numerous consultants.
Of the 1 1 recommendations, most have resulted
in little disagreement, perhaps in part because no
single group was forced to change its behavior as
a result of the study. The recommendations that
have been agreed upon would:
1. Require a periodic assessment of the health
status and needs of children and adolescents
in the United States
2. Base pediatric education upon the health
needs of children rather than on service
needs of tertiary care hospitals
3. Require the medical student’s clerkship to
be of equal length in medicine and
pediat-rics and that the pediatric experience
emphasize growth and development
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936 TASK FORCE REPORT
4. Emphasize continuing education in
pediat-nc departments
5. Require that family practice training
pro-grams offer a minimum of six months under
pediatric supervision during the three core
years
6. Maintain the present number of graduates of
pediatric residencies and develop a plan to
assure access to excellent pediatric health
services in all underserved areas of the
United States
7. Urge society to fulfill its “obligation to
muster all those services required to meet
the health needs of all our children,” and
point out that “pediatric education can no
longer be dependent upon antiquated
in-hospital reimbursement mechanisms.”
These sound recommendations, when, and if,
implemented, should improve child health.
The recommendations relating to pediatric
residency training, which will probably have less
impact on child health but more on the way
residency programs are run, have occupied the
bulk of the time of pediatric faculties in response
to the Task Force report.
What are these recommendations? They have
been incorporated into the requirements of the
AMA Pediatric Residency Review Committee,
thus ensuring some action. They include requiring
a third year of core residency; apportioning time
in the program to meet the criterion of
compe-tence in both the biomedical and biosocial aspects
of pediatrics (usually resulting in increased time
in biosocial pediatrics); establishing increasing
levels of supervisory responsibility; and
stipulat-ing that education take place in a variety of
settings, including ambulatory and community. In
addition, pediatricians should be educated as part
of a health team, legitimizing the role of allied
health workers.
Finally, in the major recommendation about
academic programs (eg, research and preparation
of faculty as compared with practitioners), there
was vigorous support for existing areas and
recommendations for an increase in biosocial
aspects.
While we have heard little public discussion,
we can assure readers that there has been plenty
of private discussion among faculty over these last
aspects of the report. Their concerns need to be
addressed. First, why do we need special
empha-sis on biosocial, developmental, and ethical
issues? Are not these areas covered in the context
of nearly every patient encounter? Do we need
special rotations or faculty devoted to these
issues? Doesn’t the present ambulatory rotation
meet these needs? Does this require expanding
the core residency for all to three years and, as a
corollary, guaranteeing that all who start a
resi-dency will have a slot available for them to finish
(eliminating the pyramid system)?
The Task Force drafted its recommendation on
residency programs after analyzing the long list of
problem areas, the skills needed by practitioners,
and the results of the survey that showed that 54%
of recent graduates felt their residency had given
them insufficient experience in
biosocial-behav-ioral problems. The fact that nearly half of the
recent graduates felt that their training time in
neonatal intensive care units was excessive led to
the recommendation for a “forceful measure” to
correct this imbalance. Since the report was
released, residency directors have been occupied
with juggling schedules to reduce the time
resi-dents spend in neonatal intensive care units, with
abolishing the pyramid, and with creating a
three-year residency.
Honorable people will have disagreements on
this aspect of the report-probably based upon
their own experience. It is hoped that the Task
Force has been able to see the big picture. But the
problem with big pictures is that good local
variations are sometimes ignored.
For instance, some neonatal intensive care
units have staff who are especially oriented to
biosocial issues and follow-up. It is inconceivable
that a resident working for six months there
would not learn more about these areas than in
many outpatient departments. While I personally
believe that more time in biosocial aspects and
community settings can be an excellent
educa-tional experience, I also know that if residents are
unsupervised there or are with faculty who do not
have special skills, there is danger that the time
spent may actually be counterproductive. There
is also a great lack of skilled faculty with
knowl-edge in these areas. The recent program in
Behavioral Pediatrics offered by the William T.
Grant Foundation and the General Pediatrics
Academic Development Program of the Robert
Wood Johnson Foundation should help overcome
the current shortage of skilled faculty with a body
of knowledge from which to teach these subjects.
With such faculty in place, education in these
areas should be expanded. A premature
require-ment merely to spend more time in a subject area
without concern for its quality should be avoided,
however. In addition to the biosocial aspect, most
graduates have large gaps in their experience in
other areas of importance such as adolescent care,
chronic illness, dermatology, orthopedics, and
prevention, hence the recommendation for a
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PEDIATRICS Vol. 63 No. 6 June 1979 937
three-year residency for those going into practice
makes sense. But I hope the Residency Review
Board can monitor the quality of that experience
to ensure its adequacy.
The second major issue, which concerns the
report’s impact on the education of academicians,
is more controversial. I have no quarrel with the
need to impose more rigor on fellowship
programs, to reduce the dependence of hospitals on these services, and to increase fellows’ research
skills. But I worry that, after three full years in a
core residency, for some the spark of creativity
will be diminished. For most, two years in a
fellowship is probably not adequate preparation
for a career as an independent faculty member.
However, if we add three years of fellowship
training to the three core years of general pediat-rics, we shall be creating a “soil bank” of pediat-nc trainees; more seriously, we shall possibly be
restricting entry and limiting the research drive at
the very tilDe in a person’s career when he or she
should be host productive. It appears that the
report does not fully address these issues of
fellowship training. The recommendation for
flex-ibility does not seem to be followed through here.
The needs of children dictate that some residents
become experts in a particular area of need;
however, most medical students, particularly
those who plan to practice, will choose programs
that offer the full range of proposed three-year
experiences. Those who wish a career in
investi-gative medicine may be better served by having
an opportunity to work in a relevant special clinic
during the third core year, as is now often the
case, and to devote most of the following two
years of fellowship to research.#{176}
The Task Force has defined very well a track
for the ftiture practitioner, although I worry
about quality. I hope that under the flexible
clause other tracks will be judged acceptable,
especially for some future academicians. Such
flexibility will require taking more responsibility
for the quality of these tracks by the faculty and
for monitoring
by
the Residency ReviewCommit-tee. This seems preferable to the single-track,
rigid system that has been proposed.
ROBERT
J.
HAGGERTY, M.D.#{176}Since writing this, I have heard that exceptions for research-oriented fellowships can be made in which two core years of residency are followed by two, or preferably three, years of fellowship. These will be exceptions, however, requiring special approval.
REFERENCES
1. Task Force on Pediatric Education: The Future of Pediatric Education. Evanston, Ill, American Acad-emy of Pediatrics, 1978.
2. Kempe CH: The future of pediatric education: 1978 presidential address to the American Pediatric
Soci-ety.Pediatr Res 12:1149, 1978.
Future
Events:
Pediatrics
in Review
Beginning in subsequent volumes of Pediatrics,
readers will find a new section, PEDIAmIc5 IN
REVIEW, a major activity in continuing education
of the American Academy of Pediatrics. This
32-page supplement will be included with all
copies of Pediatrics for the next two issues. After
that, only those readers who subscribe to PREP
(
Pediatric Review and Education Program), orwho elect to subscribe to PEDIAmIc5 IN REVIEW
alone, will receive this within their copies of
Pediatrics. This “introductory” offer is designed
to acquaint all readers with the continuing
educa-tion program in the hopes that they will be
interested in subscribing. Each issue will contain
four to six review articles and several abstracts,
together with questions that will allow the reader
to determine whether he or she has retained the
main points of the article. In addition, members
who subscribe to PREP and return the coded
answer card will receive continuing education
credit.
The continuing education publication is one of
the major parts of the Academy’s program to
assist the practitioner in obtaining information
helpful to his or her clinical practice. Most of the
information in each ‘ issue of PEDIATRICS IN
REVIEW has been selected on the basis of
educa-tional objectives developed by joint task forces of
the American Academy of Pediatrics and the
American Board of Pediatrics. These task forces
are composed of practitioners and teachers. The
educational objectives will also be used as the
basis for the certification examination, thus tying
the educational program to the recertification
program. Try it, we hope you will like it!
R.J.H.
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1979;63;935
Pediatrics
Robert J. Haggerty
The Task Force Report
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Pediatrics
Robert J. Haggerty
The Task Force Report
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