Comments on the Contents of PEDIATRICS OT any topic of general interest are invited. Queries
and answers may be exchanged between correspondents. Letters accepted for publication will
not be subject to editorial alteration except as to proper form. The Editor reserves the right to publish replies to letters and to solicit responses from authors and others.
This column has been established to provide a forum for all members of the profession for
exchange of information and views. Statements and opinions expressed in letters are those of the authors and do not represent the official position of the American Academy of Pediatrics, Inc., or its Committees.
LETTERS
TO
THE
EDITOR
The Private Pediatrician’s Role in
Head Start and Other
Health Services
To THE EDITOR:
It was interesting to IlOte in Dr. Richmond’s
article Oil Project Head Start (PEDIAmIc5, 37:
905, 1966) that they have found that one of the great difficulties in the health aspect was
integrating the various community health fa-cilities. Dr. Richmond went on to enumerate
these various facilities, mentioning the Aid To
Dependent Children program, the health
de-partments’ infant and child health clinics, the
school health services, the university clinics
and hospitals, immunization clinics, etc. It strikes me as a glaring omission that in this
lineup Dr. Richmond did not mention the pri-vate pediatricians and general physicians. Are
they not part of a community’s health services?
This omission may reflect an attitude in the Head Start Program and other similar
pro-grams-namely, that these programs cannot or
should not be handled through the private
physicians in their offices in the same manner
in which the physician looks after other chil-dren.
In our own area we took the position that that is just the way this program should op-erate-that the children who are part of the
program should be brought into the general
pattern of medical care, that they should be seen in tile offices of the local physicians and referred OIl by them where the need for
refer-ral existed. In attempting to work out this
pro-gram with the Head Start personnel we met a
blank wall, not at the local level, which is
where Dr. Richmond says tile programs are
run, but at the Federal level (where the rules are made).
A very disturbing aspect of the health phase
of Head Start is that extensive medical reports
are now placed in the hands of teachers,
ad-miriistrators, and probably many other
person-nel connected with the Head Start program.
There seems to be no effort to preserve some
modicum of privacy in the doctor-patient
rela-tionship. And there is little effort to insure that
medical decisions are made by medical people and not by lay persons.
Because of these and other defects in the health phase of Head Start, it seems to me
that the long range effect of this health
pro-gram may well be a negative one. It would
seem that the logical solution would be to
sep-arate tile health phase from the program. If
there is a group of children in the country who are not receiving adequate medical care
be-cause they are not quite poor enough to be on
welfare, but not quite rich enough to afford
private care, the solution of this should not de-pend upon their being involved in a pre-school program for cultural and educational
enrich-ment.
R.
J.
DASCHBACH, M.D.Baywood Avenue, San Mateo, California
EDITOR’S NOTE: Beside Dr. Richniond’s response,
below, attention is called to Dr. Yankauer’s Corn-mentary and Dr. Toll’s letter in the July issue of this journal. Dr. Diamond writes:
I appreciate tile opportunity to respond to
Dr. Daschbach’s letter concerning my
presen-tation of the Head Start program to the
Acad-emy’s membership (PEDIATRICS, 37:905, 1966).
Dr. Dashbach’s comments illustrate the main
thesis of my discussion: that it is indeed
difficult to develop a program with a high de-gree of local autonomy without encountering
many variations. Certainly practicing
pediatri-cians are not monolithic in their view of the
LETTERS TO THE EDITOR 691
therefore, that there would not be universal
acceptance of the pattern whicil develops in
each community. I will comment sequentially on the specific questions raised by Dr.
Dasch-bach.
1. Concerning my apparent omission of the
private pediatrician in the enumeration of
health services : since the entire presentation was aimed at the Academy’s membership, I
suppose I thought I would be stating the obvi-ous to dwell on the practicing pediatrician
in-asmuch as his participation was the major
theme. The problem of integrating all of the
community health services for children is one
which is not my exclusive concern, obviously, since, at the forthcoming annual meeting, the
Academy is sponsoring a 2-day program on
various health services for children. Also, this has been the subject of several presentations in
the Academy Newsletter recently and is not unique to Project Head Start. Our executive
director, Dr. Christopherson, has phrased this
aptly in a recent comment in Modern
Medi-cine (July 4, 1966) as follows:
Governmental child health services have been
segmented so that no one is really responsible.
2. Concerning the matter of the examination of the children in the offices of local
physi-cians: In spite of Dr. Daschbach’s comments,
there never has been any national policy
against the examination of children by
physi-cians in their offices. In many communities this
has been the pattern. I would emphasize that
tile Head Start guidelines make the following
suggestion:
The Center should engage a physician in consul-tation with the local health department, medical
society, hospital, medical school or other
appropri-ate agency. One of these agencies or the local
section of the American Academy of Pediatrics ma’ assist in recniiting. If possible, the Center should engage a pediatrician or other physician particularly interested in child care.
Thus, insofar as it is possible we have
at-tempted to ensure that whatever program
evolves locally will reflect a consensus of the local health agencies and practitioners. If
Dr. Daschbach can present any evidence that there has been a national position against the
examination of Head Start children in physi-cians’ offices, I would certainly like to be made
aware of it.
I would, however, add that, for those
pedia-tricians who have insisted that the only way to
have Head Start children examined is in the
practitioner’s office, local communities have
experienced great difficulty in finding
pediatri-cians’ offices in Watts, Harlem, and Chicago’s
South and West sides, and Appalachia, to
mention but a few areas.
3. Concerning the matter of Head Start
medical reports being placed in the hands of
teachers, administrators, and others-I would again emphasize that the medical director of
the local Head Start program has the
responsi-bility for ensuring appropriate confidentiality of records and privacy in the doctor-patient
relationship. I would also mention that our problems in this connection are no different
from those of long established school health
programs. If local physicians involved in the
program do not make appropriate provisions,
this represelltS a failure at the local level. It is
true that we do endeavor to involve the staff
members in observations concerning the health
of the children. This emphasis is consistent with efforts in school health programs over
many years. Certainly those who are familiar
with the Astoria Program of the ‘30’s will find
this no new emphasis. It is hard for me to
be-lieve that any pediatrician today would dis-agree with the following quotation from the
medical publication on Project Head Start:
The physician’s comments will assist teachers in
their daily work with children; the range of
infor-nlation gathered by teachers vili aid the physician
in making diagnoses, particularly in the detection of sensory and neurological abnormalities.
It is very surprising to me that a
pediatri-cian would take tile position that a child
de-velopment program for young children should
have tile health phase divorced from the
re-mainder of tile program. For those of us who
have learned during the course of our pediatric
training over many years that the education
and welfare of children are intimately tied to
their state of health, the child development center concept certainly seems logical.
Particu-larly for one-quarter of our children reared
under the adverse circumstances of poverty, it
would be difficult indeed during the preschool
period to separate these three aspects of the life of the child. Indeed, it is the fragmentation
of such services which has, in part, worked against the development of desirable services
for poor children in our society. Again, Dr.
692 LE11ERS TO THE EDITOR
1966) emphasizes: “. . . that greater
organiza-tion with a health team approach to providing
child health services will apparently be the
fu-ture trend.”
J
ULIUS B. RIcHMorm, M.D.Program Director Project Head Start
Should Additional Training be Required
for Board Certification?
To THE EDITOR:
As a young academician I hesitate to be critical of the Board of Pediatrics’ recommenda-tion that additional training be required for
certification. (PEDIATRICS, 37: 861, 1966). The points I wish to raise were certainly discussed and were likely omitted from publication for
the sake of brevity.
However, the addition of an entire year of
training in problems of behavior, school-life,
etc., as recommended, may well be patchwork
of old problems rather than insight into the
future. The critical decision is: who vill
be-come the patient’s primary medical contact of the future? In the majority of American urban areas, the pediatrician has replaced the
gener-alist as the primary contact, with many assists
required from general surgeons and internists
so that needs can be met. It is unlikely that
this state of affairs will or should continue. A critical shortage of pediatricians already exists which, according to a modestly reliable but probably exaggerated report, may reach
3-4,000 by 1970 (Hosp. Physician, March,
1966, p. 39). Additional length of training will increase this shortage. The shortage can be
al-leviated if an acceptable and successful
substi-tute can be provided as the primary medical
contact, whether this be a generalist, specially trained nurse, or a computer.
The public is presently not prepared to uti-lize or accept a more elegantly trained
pedia-trician. His fees will necessarily increase. But is
there any assurance that he will have the
addi-tional time necessary to counsel families with behavior problems?
The Board of Pediatrics suggests that “many
skills are needed beyond those which are
gained in the 2 core years of hospital care of the sick.” Which skills? If skills in care of
be-havior problems and scllool life, then the
pedia-triciall has them but lacks sufficient time to put
them to use. If skills in cardiac catherization,
neurology, and other subspecialties, then
ad-mittedlv he has not acquired them, nor will he
but rarely require them as a general pediatri-cian in suburbia.
One might consider decreasing the length of training for general pediatrics to a straight in-ternship plus 1 year of residency. Until we, as
well as the public, can train and accept
some-one other than a pediatrician as primary
medi-cal contact, then we must continue to accept that responsibility. To do this properly we
need more pediatricians.
Should we not provide two residency
pro-grams? Our present program might be revised
to provide 1 year of training in care of the sick
(
internship) and a second year in the care of ambulatory, chronically ill, behavior problems,and preventive pediatrics. This physician
would continue to be certified as a general
pediatrician. The alternate program might be a
similar year of training for care of the sick, fol-lowed by 2-3 years of subspecialty training. This would seem to be a more realistic ap-praisal of the future needs in pediatrics,
in-crease the pediatrician’s status in the medical
society, and provide more extensive pediatric
coverage to a clamoring public.
C. VAN LEEUWEN, M.D.
Assistant Professor of Pediatrics
University of Missouri School of Medicine
Colunibia, Missouri
EDITOR’S Nom : Dr. F. Howell Wright commented
as follows:
As Dr. Van Leeuwen suggests, the points
made in his letter were considered in some
detail before and during the Institute on Resi-dency Training held by the American Board
of Pediatrics last September in Atlanta. A
sum-mary of these deliberations appears as the
Oc-tober supplement to PEDIATRICS. The following
rejoinder to Dr. Van Leeuwen’s letter is a
per-sonal rather than an official interpretation of
the “sense of the meeting.”
The impending shortage of pediatricians in
this country is recognized. It is true that any
increase in the length of training will
tempo-rarily slow tile production of finished
pediatri-cians. However, two points should be empha-sized. (1) Men taking extended training in
fel-lowship or residency capacities are not
corn-pletely removed from service to the pediatric
