EDUCATION
537
Grover F. Powers, M.D., Contributing Editor
NEW
PEDIATRICIANS:
NEW
PEDIATRICS
By Park Jerauld White, M.D.
LL OF US who are concerned with
train-ing pediatricians for the practice of
pediatrics must agree that the time has
come to say with Browning’s Rabbi,
“Something is wrong: there needeth a
change.
But what? On where? At the last on first?”
The answer is : at both first and last. I
write witil whatever authority may have
been conferred by 35 years in the private practice of pediatrics, plus a fair amount
of pant-tune clinical teaching. As I retire
from private practice (but not yet from
clinic and wand work) I lay down my
tele-phone and say, “For this relief much
thanks.” Thirty-five years of night-and-day
pediatrics, with the endless raucous
oh-bligato of the telephone, have led inevitably to reflections upon certain obvious trends
in pediatric education as well as in
pedi-atric practice, reflections based upon happy association with young pediatricians in and
out of hospital training.
ON HOSPITAL OR INTRAMURAL PEDIATRICS
At St. Louis Children’s Hospital-for
ob-vious reasons-we speak of the Lactate
Ringers and the Doorbell Ringers, in
dis-tinguishing full-time from part-time faculty.
The doorbell ringers are and should be
among the first to proclaim that full-time
investigators are essential to the teaching of
the fundamentals of biochemistry and
hac-teniology as applied to pediatrics. It is they
who can teach students and intennes the
iiiathemnatics involved in the accurate
con-From the I)epartnient of Pediatrics, \Vashington University School of Medicine, St. Louis, Missouri, and the St. Louis Children’s and Homer G. Phillips Hospitals.
rection of such-and-such degrees of alkabo-sis or of acidosis; the intricacies of Rh-in-compatibilities and of safe
exchange-tnans-fusions; the determination of sensitivity of micro-organisms to various antibiotics, etc.
And it is they who deserve to share the
thrill of students, internes and parents when certain infants, otherwise doomed, respond
to treatmemit with rapidly or gradually
ne-stored health. It is they whom we
part-timers consult on our most difficult prob-lems.
Of course, we pant-time clinicians are
often important as “local doctors first on
the scene.” We like to feel reasonably sure that by early diagnosis and proper treat-ment, we have kept many an “interesting
case” out of the hospital. But of course
there is always the mother who “didn’t
realize in time (Consider how we rail
at the “worry-warts” who make much ado
about nothing!) Verily, that’s pediatrics!
And it is clear evidence that hospital and
“outside” pediatrics are very closely related, and should be so in pediatric education.
Here let us not belittle “the Boards!” A
young man or woman going through a year
of internship, 2 years of pediatric residency,
plus 2 years of pediatric practice, must then
look forward to the severe test of a series
of written and oral examinations, before
being certified by the American Board of
Pediatrics. He knows that such certifica-lion is requisite to the better positions in teaching, in research, and! even in part-time
jobs of desirable stature. He knows what
it takes to master the details of child growth and development, of diabetes, of water amid! mineral balance, of all the laboratory tests. (Let not one of them be omitted!) Verily, straight is the gate and narrow the way!
whose training has cost so much time,
money and effort show signs of resenting
2 obvious facts:
1. That other specialties provide far
greater economic security with less
noctun-nai harassment.
2. That their years of hospital training
have indeed equipped them for the care
of seriously sick infants and children-”that
vitally important tell per cent”-and for
certain types of research, but not for the
care of the nun-of-the-mill well-babies, nor of those with sniffly noses, bronchitis,
“strep” throat, otitis, diarrhea, measles, eczema, “colic,” etc., who should never see
tile inside of a hospital, and who comprise
the great majority of private practice.
THOSE HOUSE-CALLS!
In tilese latter days of highly trained young specialists in diseases of children,
a natural temidency has developed which
does not endear them to the anxious parents
of ailing children-the tendency to avoid
vastimlg rne(hcally and financially valuable
time in the traffic jams which are
increas-ingby common in every city large enough to
support pediatricians and other specialists.
Now, more tilan even, this is what
house-calls involve. Yet many parents select their
pediatricians according to whether or not
they will come to their homes when the
children are sick.
Here we have the chief-nay, the
sole-disadvantage of house-calls: the waste of
the doctor’s tune-waste, incidentally, which
is usually increased by the thrifty mother’s
“Now you’re here, I wish you’d just look
at Johnny, Linda, Karen, etc,” when such
extra siblings chance to exist. The
pedi-atnician knows that parents are quite
will-ing to take their offspring to the offices of oto-lanyngologists, and to pay higher fees.
That, you see, is customary.
The matter of making house-calls in the
suburbs must be taken seriously if we are
to expect or to encourage young doctors
to become pediatric practitioners. But in
considering the disadvantages of
house-calls, let us not overlook their advantages
to the patients:
1. They avoid spread of infections in
cnowded offices.
2. They keep parents-and grandparents
-from remarking, “Say what you like, but
that child shouldn’t have been taken out to the doctor’s office.”
3. An occasional house-visit enables the
pediatrician to perform better his
increas-ingly exacting duty of child guidance. In
the home he can tell whether the mother
is a neat and orderly perfectionist (perish the thought!); or whether she is so sloppy
as to pile an electric hot-plate on a ‘phone-book by the baby’s bed to boil some water
when he has croup (perish the baby!); on
whether daddy reads the paper or watches
television while the doctor examines his
sick baby; or, per contra, whether daddy is the bossy, interfering type. Yes, house-calls
may reveal whether the home is a
matni-anchy, a patriarchy, a gerianchy, or, as is
now practically the rube, a “pediarchy”
(
ruled by the child or children).Let the pediatrician with children of his
own decide what he should think of a
col-league Wilo refused to cross the street one evening to see a child with a fever of 105#{176} and a convulsion. (He “didn’t make
house-calls.”) Let him also decide whether he
should like his child to sit in a waiting-room
crowded with sick (and well!) children.
THE REMEDY
Some home-visits, then, should be made.
To reduce them to a minimum satisfactory to parents and to pediatricians, 3 remedial
procedures at once suggest themselves, and
indeed are already being carried out in
some areas:
1. “Districting” of pediatric practices.
“Subunbias” are everywhere round about
metropolitan areas. They exist largely
be-cause of the children. “Regional” private
p(liatnic practice should nowadays be
re-ganded as well-nigh inevitable. When we
oldsters opened our offices a generation ago, pediatricians were few, and patients
came from “all over town”; and when they
5,39
wide, early and bate. This no longer needs
to be the case, if pediatricians will but col-laborate in “resonable self-limitation to
cer-tam districts.” Parents will see that this
works out to their advantage and to that
of their children.
2. Attaching offices to homes, in the case of pediatricians, or having them quite near
by. This has long been done in the East,
but not in the West. I used to think it a
barbarous custom, for one could “never
get away from one’s practice.” Never in 35
years ilave I got away from my practice
except by the device of leaving town. Evening work? Of course the check-ups,
immunizations, well-baby-work in general
can and should be done during day-time
office hours, and by appointment. But
fevers soar higher, ears ache harden,
vomi-tus shoots farther, and elders wax more
dis-tracted, iii the evening. This is pediatrics.
Blessed be the pediatrician who can say,
“To this end was I born, and for this cause
came I into the world.”
Now, inasmuch as very sick children
must be seen anyway, doesn’t enlightened self-interest dictate that it is better to have them brought to the doctor over distances
as short as possible and, of course, with
every precaution to keep them isolated one
from another?
3. Keeping overhead to a minimum. If the pediatrician’s income is inevitably less than that of his surgical or obstetrical
cob-league, so, emphatically, is, and must be,
his out-go. Nevertheless, he must provide
enough (3 or 4) consulting-rooms to keep
his patients separate from each other. Even with careful adherence to the
appointment-system-”staying off the ‘phone” while
seeing patents-there are shots to be
ad-ministered out of turn, “quick looks” to be
given-and made less quick by the
mcvi-table (often important, remember!), “Now
we’re here, doctor, I want to ask you, “. . .“
And amiother thing . .
The only less-expensive way for a
pedi-atrician to provide enough space for the
essential and difficult isolation of patients is to have his office in or near his home,
where rents are bower or property bought
more cheaply. “Downtown offices” are
well-nigh “out” for him. Here, incidentally, he
may well bethink him that elevators are
usually crowded; that they scare many
children so that they arrive in a wild state;
and that parking is difficult and often cx-pensive ill the down-town sections.
ENLIGHTENED SELF-INTEREST
Haven’t doctors always been supposed
to be self-sacrificing rather than
self-inter-ested, ever ready to travel afar in all
weather to relieve suffering? Yes, of course.
Prevention and relief of suffering are our
objectives now, as much as with them of
old times. But how immeasurably better is
the work we do for our patients in this
day and age! How much more is, and should
be, demanded of us by way of accurate
di-agnosis and efficacious treatment! Even the mother who is most afraid to take her child
out (in a heated car) would agree that if
the doctor spends less time in transit, he
should, at any rate, have a better chance
to spend more time considering her
off-spring.
A pediatrician owes it not only to
him-self but also to his patients to do certain
things which will be improving
profes-sionally, although some of them will be
interpreted as pure selfishness by anxious
parents and grandparents.
1. He should “keep up,” by attending
hospital and pediatric conferences.
(
Note:He vi1b neither give nor receive much
in-formation if, while at such conferences or
ward-rounds, he spends the majority of his
time answering the telephone!) I know a
number of pediatricians who come
con-siderable distances to conferences in St.
Louis, where nearly all of them received
their training. They and their patients-and the conferences-are inevitably the better
for it.
2. He should not yield to the temptation
to try to include every baby in town in his
practice. Only by keeping his practice
within manageable (albeit less lucrative)
and should be expected of him. This can be, and all too often is, done through
Mam-mon’s attractive device of charging high
fees, payable only by the “carriage trade.”
But the pediatrician with a social conscience will remember that it was largely his social
conscience that got him into pediatrics; that
the incomes of the majority of young
par-ents are in the lower brackets. Often these
same young parents may seem not to
ap-preciate it when the doctor tries to save
them money, attributing the honest
spac-ing of visits to indifference, to laziness, or to
overwork, and “change” to a doctor who
extracts more money from them! Well,
let the “un-avaricious” doctor take
com-fort in the dictum of no less an authority
than Cardinal Woolsey, “Corruption wins
not more than honesty.”
3. He should bear in mind that bringing
overwork, with its noctural and telephonic
harassment, on himself will keep him from
functioning humanely. And people want
their doctors to be humane.
To this end, the pediatrician should:
(
a) Have a colleague with whom he canregularly
exchange week-ends, summerva-cations, and convention-times.
(
b) Have an arrangement whereby histelephone cannot be heard during meals,
emergency calls being taken by an
“cx-change,” which can recommend a colleague
or a hospital. The tension incidental to
telephoning during meals (my record is 10
calls during one meal) must be avoided if
a pediatrician is to maintain anything
ap-proaching equanimity. Meal-time
emer-gences are few and can be dealt with as
mentioned. A card with instructions like
the following, handed to the parents of
each new patient, should not arouse
ani-mosity:
About the Telephone
Many things may be settled, and visits
saved, by telephone calls. Try to call during
office hours, when the baby’s record is availa-ble. This will avoid much cross-examination. To prevent crowding and waiting in the office,
you may be told that I am “with a patient,” in
which case you will be called back as soon as
possible. Of course, if there is a real emergency, be sure to say so.
If there is “no answer,” call my Exchange ‘phomie number
Evidence is accumulating that parents
are learning that the pediatrician’s large
volume of constant work, with low income
compared with that from other specialties,
entitles him to employ what devices he can
to preserve his sanity, and to keep him from
committing all the sins known to child
psychiatry against his own children.
Pedi-atrics, indeed, commends itself to celibacy
ratiler more than does the priesthood. And
yet-how much better a pediatrician he is
if ile has children of his own! How much
more readily can he help parents with
dif-ficult decisions if he can say with authority,
“Now, if this were my child . . .“ or even
grandchild!
IN CONCLUSION
Thus, at retirement from the private
(
nocturnal) practice of pediatrics, I am “Still witliimi this life,Though lifted o’er its strife.”
In retrospect, it is very clear that far from
being reprehensible for a pediatrician to
take steps to make his work endurable to
himself and to his family, it is essential for
him to do so. To students and internes, as
inducements to undertake the practice of
pediatrics, absorbing interest and real sig-nificance in the community, if relatively little lucre, can properly be offered. If in
later life their self-interest is enlightened but not overdone, they will deserve to find
that working with children and their
parents is as exciting and rewarding as they
thought it would be when they chose
541
Good teaching is set in many diverse frameworks; here is the framework for one aspect of
the educational program of the Department of Pediatrics, University of Washington.
PEDIATRIC
RESIDENCY
PROGRAM
By Robert W. Deisher, M.D.*
G.F.P.
D
URING the past 10 to 15 years, the typeof practice carried on by
pediatni-cians has been undergoing a change. There are fewer seriously ill children requiring
long-tenll treatment and follow-up since
many of tile common infectious diseases of
childhood are detected early and, because
of modern methods of treatment, prevented
from becoming serious. Although
pediatni-cians have fewer patients who require hos-pita! care, this is balanced by the fact that there is Il increasing use of the pediatrician for health supervision or “well child care.”
Parents are becoming more aware of the
need for supervision of tile child’s physical
and emotional growth and development
through tile extensive attention given this
in popular everyday literature and by the
fact the pediatrician himself is now
en-couraging this more than formerly.
This change in pediatric practice is being
reflected gradually in the type of pnepana-tion given the pediatrician in his residency
training. When one thinks of the
tremen-dous amount of knowledge available
regard-ing normal growth and development and
of the growing importance of the field it is
evident that real knowledge in this area
cannot be obtained quickly and without
effort. Therefore it is of sufficient
impor-tance to be included in routine residency
traimlmg. There is no question that the
resi-dent needs much more of his time spent in
the hospital caring for seriously ill
ciii!-dren than in the well-child area of
pedi-atries. It is to be hoped however that the
well-child training lie is given will be of
such nature as to provide him ample
op-Porttlnity to work Vitil well children and
parents. Thereby he may learn about
nor-0 Assistant Professor of Pediatrics and Director,
University of Washington Child Health Center,
Seattle, Washington.
mal development and behavior at various
ages and also become familiar with the
parents’ problems relating to these ages and stages of development.
If such opportunity for experience in
well-child work is provided, the
pedia-trician just beginning practice will not feel that this is of relatively little importance
nor be annoyed with the amount of time
it requires. Also he will not have a tendency
to concentrate on only physical aspects of
the well-child visit thereby neglecting a
total appraisal of the child. Likewise, the
newly established practitioner with
ade-quate background will be aware of the role
expected of him, as a specially trained
per-son, in the community. Schools, social
agen-cies concerned with children, as well as
various parent groups, turn to him very
frequently for advice and help in solving
common problems. He should be aware of
the fact that schools are concerned with
many of the same problems that he is, that
there are community agencies which deal
with children and that knowledge of them
may be extrelnely useful to him in his
prac-tice. The fact that there are non-medically
trained people such as psychologists,
teachers, nutritionists, and social workers
who have a great deal of knowledge
con-eerning children and who often can work
effectively with him is important for him
to know.
The pediatric residency program in
Se-attle, which is under the direction of the
Department of Pediatrics of the University
of Washington School of Medicine, has
tried to meet some of tile resident’s needs
in these areas by offenimig an opportunity for pediatric residents to spend 3 months,
or in selected cases 6 months, in a
non-hospital setting where the emphasis is
