PRIVATE
PRACTICE
FOR
CHILDREN
P
RIVATE practice as it applies to children has been influenced in a very fundamental manner by the recent trends in medicine reviewed in the foregoing chapter. Preventive measures have virtually eliminated many illnesses which formerly made up the physician’s daily work. At the same time new therapeutic measures such as chemotherapy, the anti-biotics, and refinements in the use of blood and blood substitutes have brought to the general practitioner methods of curing many diseases which formerly were apt to be re-ferred to the specialist because of their severity.Another significant change is that which has taken place in infant feeding. Formerly, infant feeding was a very complicated procedure requiring specialized knowledge of for-mula adjustments. But infant feeding is no longer an esoteric mystery. Commercial prepa-rations for formula feeding have been so widely advertised, and are so commonly available that the ant of infant feeding is in danger of being lost altogether. We have the definite opinion, however, that there is still no substitute for the knowledge and experience of the well trained physician in supervising the nutritional needs of the individual infant.
As a result of many years of effort on the pant of pediatricians and other leaders in child health, parents have learned to appreciate the actual value of having their children under continuous and skillful medical supervision. The public has come a long way toward a realization of the fact that immunizations and regular visits to the physician not only result in a greaten measure of health but have definite economic value as well. To the ex-tent that sickness may be avoided, the family budget is not drained by the heavy costs of unexpected medical care.
INCREASED NUMBER OF PEDIATRICIANS
An awakened public interest and increased popular demand have, at least in part, been responsible for the tremendous increase in the number of pediatricians which has occurred during the past generation. In 1910 there were only a few pediatricians in all New York State; today there are approximately 700. In 1930, when the American Academy of Pediat-rics was founded, there were less than 1,000 pediatricians throughout the United States. Now there are about 4,000.
Is the rapid increase in the number of child specialists to continue? Should it continue? Should all children be in the hands of child specialists, or is it better that children should be the responsibility of the family physician who has taken care of their parents and grandparents?
RELATIONSHIP WITH THE GENERAL PRACTITIONER
Important as we who are pediatricians may think ourselves, and great as is our re-sponsibility for children, we play a comparatively small role in the total volume of child
care. Specialists in nearly all fields include children among their patients. Many obstetricians continue to take cane of the newborn infant; orthopedics, as the name implies, is very largely concerned with the care of children; pediatric patients are also a part of the prac-tice of ophthalmologists, otolaryngologists, cardiologists, and one could continue through the whole list of specialties with the exception of geriatrics.
It is, however, the general practitioners who cane for seventy-five pen cent of the children in comparison with eleven per cent of child cane attributable to pediatricians and fourteen per cent to other specialists. Three out of every four children who are receiving any medi-cal attention from private physicians are getting it at the hands of the general practitioner.
The family physician is thought by some to have disappeared with his horse and buggy,
to have been squeezed out by the specialist on the one hand, and the public health official on the other. The buggy has disappeared, but the family physician has not. Fortunately,
he is very much with us, travelling greater distances in his car, seeing more patients and working just as many hours as his predecessors. Despite the increasing momentum in the trend toward specialization the general practitioner, fan from being extinct, is alive and thriving and doing most of the pediatric practice throughout the land.
However rapidly the number of pediatricians has increased and continues to grow,
there is every indication that the bulk of child care will continue to be done by physicians in general practice. The reawakening of interest in preserving the dignity, integrity and training of the general practitioner is in evidence everywhere-a reaction perhaps to the pronounced swing toward specialization. Several factors have had a part in bringing this to pass. In the Armed Services, a general practitioner was at a disadvantage beside a fellow officer who had been certified by a specialty board. Board certification in itself was usually worth at least one rank higher. For example, a well-trained and experienced general prac-titioner might find himself serving under a junior and less experienced Board member in internal medicine, or perhaps pediatrics. After returning from military service, the
gen-eral practitioners protested, more vigorously than ever before, against the importance being
placed upon Board certification and against policies which excluded them from certain hospital privileges enjoyed by the Board members.
One result of the activities on the part of the general practitioner was the organization
of an American Academy of General Practice, which held its first meeting in Cincinnati in March, 1949. Attendance at this meeting was more than twice the nurriben that had been expected. Subsequent meetings of various state chapters have also stimulated great interest.
PEDIATRICIANS AND THEIR PRACTICES
In the light of such changes, the function of the pediatrician should be carefully re-viewed if the specialty of pediatrics is to continue to grow in an orderly fashion. Without a clean concept of the pediatrician’s place in the increasingly complex structure of medicine, without a well understood picture of the work for which pediatricians are being prepared, their training must inevitably be confused and lacking in direction.
The function of a pediatrician may be considered under certain broad headings: consul-tation practice, general practice for infants and children, academic and public health ac-tivities. A pediatnician* may develop a careen along one of these lines, or he may choose to spread his interest over any combination.
516 THE AMERICAN ACADEMY OF PEDIATRICS
CONSULTATION
By fan the majority of pediatricians make their living in pediatric practice, in which
general cane is given to infants and chldren in health and disease. It was found impossible to determine how much of the practice of these physicians was made up of consultations. The definition of consultation is too loose and variable. Clearly, if a specialist is called
in by a general practitioner to see a patient with him and to advise on diagnosis and treat-ment, the service can be considered as a consultation. But if the patient is referred by the general practitioner to the specialist, if the general practitioner calls the specialist on the telephone for advice about the dose of streptomycin in the treatment of tuberculosis, are such situations to be classified as consultations ? Many similar equivocal cases could be cited, from which it is clear that no statistically reliable count of consultations can be made.
In addition to the 3,500 pediatricians listed in the study as having at least some private practice, there was a smaller group of about 400-not in practice, but on a full time basis in research, public health or administrative positions. Those in academic positions account for a very considerable part of all pediatric consultations. The pediatric professor is in a particularly favorable situation to have problem cases referred to him, on to see pa-tients in consultation with other pediatricians or general practitioners. Not only does he enjoy the reputation afforded by his academic position, but, if he is among those receiving
a full-time salary, he is not in competition with physicians in private practice.
The extent to which practicing physicians refrain from calling upon consultants who
practice in closely related fields and who are competing in the same community has an important bearing upon the nature of pediatric practice. If we consider that pediatric prac-tice is general practice for a limited age group, the pediatrician is in direct competition with the general practitioner.
Let us suppose, for example, that a severe diarrhea occurs in an infant belonging to a family that has always had a general practitioner for the children, as well as the adult
members of the family. Perhaps the general practitioner needs help in restoring the baby’s electrolyte balance, and would like to have a pediatric consultation. He may be reluctant
to call in a pediatrician who practices in the same community, for it is not unreasonable that he may be fearful that thereafter the parents may wish to have the baby continue in
the hands of the specialist. The result is that he may either go without the consultation, or send the baby in to a pediatric hospital service from which his patient will eventually re-turn and still be under his supervision.
Similarly, the general practitioner who practices obstetrics will naturally be inclined to continue to take care of the newborn baby rather than refer him to a pediatrician. It is from obstetricians and not from general practitioners that a pediatrician may expect to
have newborn babies referred to him-one of the factors which tends to keep pediatricians
in urban centers where most of the obstetricians are also to be found.
Since consultations form such a small part of pediatric practice, it is not surprising that
pediatricians cover an increasingly broad field. The survey shows that about one-half of the pediatricians cared for their own patients for minor surgery, 16 per cent set fractures rather than referring such cases to a surgeon, and 12 per cent did tonsillectomies. It may also be noted that pediatricians are inclined to extend the upper age limit of their practice.
To an increasing degree the problems of adolescence are coming within the pediatricians’
TEACHING
One of the outstanding findings of the study of pediatric education was the amount of
teaching done by practicing pediatricians. Of all pediatricians in private practice, 36 per cent reported that they spent some time in teaching, averaging about 9 hours a month. These are the part-time teachers whose instruction contributes so much to the pediatric
education of the undergraduates, interns and residents. Pediatricians who give less than one-quarter of their time to teaching comprised more than one-half of the entire teaching
staff of pediatric departments ; and, as a group, account for about one-third of the aggre-gate teaching hours in undergraduate pediatrics. In addition to this time given to under-graduate teaching, these part-time teachers are responsible for an important part of gradu-ate training by virtue of their service as attending physicians on the staffs of hospitals
ap-proved for pediatric residency.
Also included in the group of practicing pediatricians are the many who give much
more than the average nine hours to teaching activities. Under our present system a number of those who shoulder the responsibility for undergraduate and graduate training find it necessary to do some practice in order to augment totally inadequate academic salaries. Almost one-fifth of the members of pediatric departments who give one.quarter
or more of their time to the department derive their entire support from private practice. Furthermore, half of all the staff members serve on a part-time basis and, if they receive any pay at all, it is usually so meager that it represents a very small addition to their
in-come from private practice. In reality the teaching done by these men is paid for by their
private practice. In addition to teaching interns and residents, the pediatrician has an opportunity to teach parents singly and collectively as to physical, mental and emotional development of their children. Child training begins with training the mother, not for-getting father and grandparents. The pediatrician also frequently teaches on a larger scale, talking to parent groups and taking part in school and other community activities concerned with the health and welfare of children.
PREVENTIVE CARE
We have also shown the extent to which pediatric practice is preventive medicine con-cerned with the supervision of well children in comparison to the care of the sick. During
the course of the study, more than half of the pediatricians’ daily visits were for well children defined as those seen for health examination, immunization, advice on feeding and the like. On an average day, 54 pen cent of the pediatricians’ visits were for health super-vision and 43 per cent for the care of sick children, the remaining 3 per cent being for persons aged 15 on older. From one point of view the percentage of well child visits in a pediatric practice may be considered as an index of the importance which a pediatrician places on health supervision and preventive medicine. On the other hand, it may be that a high percentage of well child visits reflects a practice in which a pediatrician sees a large number of children with only a few minutes given to each for routine checkup and
regu-lation of feeding. In such a practice a sick child in need of time-consuming examination may actually interfere with the office schedule and be given too little consideration.
The average number of visits per year for practicing pediatricians lies between 5,000
and 6,000.* Some pediatricians report that they made 16,000 to even 18,000 visits a year,
* The term visits includes patients seen in office, home or hospital. Since pediatricians see most of their patients several times a year, the patient load (actual number of patients) would be
two or three times the average number. These heavy loads mean an average of 40 to 70 patients a day. Undoubtedly such practices are made up very largely of children seen for routine checkup and immunization. But even so, it is hard to see how a pediatrician can
do justice to so many patients. He spends but a moment with each child and leaves the mother with a diet slip, printed instructions and a host of unanswered questions. At the
end of the day he is plenty weary, but he can have little satisfaction from the contribution
he has made to his individual patients.
If this study were to be repeated today, it is likely that an even greater proportion of
the pediatricians’ daily work would be concerned with preventive medicine. Three years ago, when the survey was made, many physicians were not yet released from military
serv-ice. Consequently the “home front” physicians had not recovered from the abnormal con-ditions of the war years, when there were fewer doctors for the civilian population and when, therefore, they were too busy taking care of sick patients to give much time to health
supervision.
Similarly the 14 per cent of pediatricians who took part in school health services and the 28 per cent who attended child health conferences are probably underestimated. With the slackening of the abnormal pressure of the war years, pediatricians have again been able to find the time for the public health aspects of child care. They are to be found stimulating
community action for the improvement of child health, organizing programs for the care of rheumatic fever patients and premature infants and sitting on the advisory councils or
even the boards of health departments. The very fact that practicing pediatricians played such a large part in the conduct of the study of child health services is evidence of their awareness of the importance of the social and environmental factors which influence the
health of children.
CONCLUSION
In the future as at present, the majority of child care can be expected to be furnished
by general practitioners, while pediatrics continues to consist of a blend of consultation practice, general practice among infants and children, and teaching not only in medical schools and postgraduate programs, but also for parents and the lay public. The balance
between these several factors will depend upon the pediatricians’ own interests and the nature of the community in which he practices. But, although pediatricians give a much smaller proportion of medical care to the nation’s children than the general practitioners, their influence undoubtedly extends much farther than indicated by statistical percentages.
Through their contacts with general practitioners, through their position as teachers and child consultants, pediatricians have opportunities for informed leadership in regard to all matters pertaining to child health and safety. And in respect to his individual patients,
both the pediatrician and the general practitioner are in a favorable position to mold life while it is still pliable, to prevent illness or if illness does occur, to restore a young
