874 PRACTICE OF PEDIATRICS
and 3% the need to share the load with a partner—making a total of 40% complaining about the time factor. Next in importance came income, about which 20 to 25% corn plained, 17% on the basis that the income was poor compared to the long hours, years of training, and degree of specialization and 9.8% that too many patients must be seen to make a living.
With this introduction may I then turn the discussion over to our panelists and ask Dr. Hill to first give us his answer to our questions. Each of the panelists will then present his views.
[A morecomplete
account
of theresults
of Dr. Aldrich's survey, along with an anal ysis of the results, will be published as a report of the 36th Ross Pediatric Research Conference, “¿Careersin Pediatrics,― Ross Laboratories, Columbus 16, Ohio.]rics can be done better than we're doing it now. If what we're talking about is bet ter pediatrics rather than new, the sooner we abandon “¿new―thebetter.
But it is my impression that the term “¿new―pediatrics, as was indicated by Dr. Fischer,arosein responseto the criticisms voiced by a few, that pediatrics no longer affords a satisfying professional career. The reasons cited were long hours, hard work, low pay as compared with otherspecialties, and the monotony of practiceas compared to the glamour of residency training. The young pediatrician, it was maintained, who enters practice fresh from his exciting resi dency becomes frustrated and disillusioned when he findshimself,for economic rea sons,unable to dispensethe high qualityof comprehensivemedicalcarehe isprepared to offerand which he believeshe should. He sacrificesqualityfor quantityin order to make possiblethe income he feelsen statistics that Dr. Aldrich and his group
collected, revealing that 16% of the board certified pediatricians practiced some sub specialty with allergy, cardiology, psychia try and neurology, and hematology heading the list in that order.
Finally, it is hoped that our panelists will touch upon the questions that seem to be the main source of dissatisfaction among those who are unhappy about present day pediatric practice. Here again, we might quote from Dr. Aldrich's survey and note that of the board-certified group: 12% felt that there were no problems of note; 20.2% complained that they had no time for families, friends, etc.; 9.7% that they were too busy, the hours were too long and ex hausting; 9.8% that too many patients had to be seen to make a living; 9.1% that there was an inadequate time for each patient;
D R. FIscHER has asked us to comment on threetopics:(1)the “¿newpediatrics,― (2) residency training requirements and (3) pediatric practice—in the space of 10 min utes. I can dispose of the first topic very quickly. I don't know what is meant by “¿new―pediatrics. Even after our chairman has supplied us with a nicely-worded defi nition, I still don't know what the “¿new― means. It seems to me that his definition has been applicable as the objective and goal for pediatriciansever sincepediatrics was established.If the questionbeforeus was “¿canbetterpediatricsbe practiced?― I would have a much clearerconcept of what the concern is about.To that ques tion my answer would be “¿sure,it can―and then we could go on to a discussionof methods of improving teachingof pedia tricsatalllevels,medicalschool,internship and residencyin preparationfor pediatric practice,and of how the practiceof pediat
SOLO PRACTICE
Lee Forrest Hill, M.D.
AMERICAN ACADEMY OF PEDIATRICS—PROCEEDINGS 875 titled to. It was even suggested that efforts
should be made to educate the public to a better appreciation of the superior quality of the pediatrician's services, in hopes it could be persuaded to pay fees coinmen surate with the best in training and skill.
If the term “¿newpediatrics― is intended as a solution for these complaints, it would have to be interpreted to mean that pediat nc practice should be so modified that the pediatrician would see fewer patients, have more time for each and would charge and expect to collect higher fees. Assuming that this interpretation of “¿newpediatrics― is correct, the answer to the question, “¿canit be practiced?―, in my opinion is a definite “¿no―—notif by practice we mean the type of practice developed in this country over the years, in which the pediatrician is a general physician to children. It could and automatically would be practiced, if we were to change our system to a consulta tion or referral type of practice similar to that in many foreign countries. There are some who are asking “¿whatshould be the future role of the pediatrician?―, which might be taken as an indication that they believe such a change should be given con sideration.
“¿NewPediatrics― would have a meaning if by it is meant the abandonment of the present system of practice, in which the great majority of pediatricians serve as gen eral physicians to children, to be replaced by the referral or consultant system. In this system the routines of well-child care, im munizations and care of minor illnesses, which the critics find so objectionable, would be relegated to some other group, presumably the general practitioners. The pediatrician's practice would then consist exclusivelyof referredpatients.He would have fewer patients, more time, higher fees and perhaps a more interesting practice. But if this is to be the direction pediatric practice is to take in the future, it is clear that modifications in the educational prepa ration for practice will be required. I don't believe serious consideration is being given
by anyone at the present time to abandon ment of our American system.
[Dr. Hill's views on the second topic, re quirements for residency training, were pub lirhed elsewhere.—EDIT0R]
Finally, a word about the third topic as signed us by our chairman—private prac lice. I have been greatly distressed by the adverse criticisms about pediatric practice. I have learned from several reliable sources that some medical students and interns have been steered away from pediatric ca reers by these adverse criticisms they have heard and read about. This I think is most unfortunate and I think it is high time that those of us who are not in agreement with these criticisms should make ourselves heard. I suspect that most of the critics who have found themselves unhappy in pediat nc practice shouldn't have gone into pedi atrics in the first place. I find it difficult to understand why a pediatrician who has de cided upon practice as a career does not ascertain for himself beforehand what pri vate practice is like. It seems absurd that as many as a third of pediatricians who go into practice should be so uninformed as to be disillusioned and dissatisfied by what they find. On the other hand, there may be some truth in the criticism that some resi dencies give greatest emphasis to the un usual and are inadequate in presenting the commonplace in preparation for practice. More emphasis upon the basic principles of anticipatory guidance might enable the pe diatrician to view in a more interesting light the endlessmothers'questionsin his office practice, and give him a better insight into the importance and dignityof being the purveyor of sound parental advice in build ing solidarity of the family structure throughout the period of growth and de velopment.
PRACTICE OF PEDIATRICS 876
among the pediatricians of the Middle West and upon conversations with many of them would lead me to believe that the great majority of practicing pediatricians scat tered over the country are equally satisfied with their jobs, their incomes and with the amount of work required.
In summary, I would say that the term
S THE MEMBER of this panel who repre
sents pediatric group practice, I be lieve it is for me to suggest how such group practice may aid or abet or, at least, fit into the concept of the “¿NewerPedi atrics.―
I do not believe that there is truly a “¿New Pediatrics.― I think we are simply attempt ing to define something that has been around a long time, but which has been successfully applied by only a fraction of practicing pediatricians.
Almost a year ago I gave a talk to a group of residents who had requested my thoughts on the meaning of the term, “¿New er Pediatrics.― I am not sure that I made myself entirely clear to them, which implies that I was not wholly clear myself as to all the implications in this concept. However, permit me to read to you the last paragraph of my talk. Further reflection has given me no causeto change the content.
“¿Iconceive of the ‘¿NewerPediatrics' as being an approach to practice which re quires the pediatrician not only to be well grounded in the diagnosis and treatment of disease, but to be sensitive to the psycholog ical and emotional aspects of illness and general growth and development; further more, it requires that he be able, either by his own ability, or by using the abilities of his specialized colleagues, to make availa ble to the families in his practice pediatric care•which encompasses these factors in a
“¿NewPediatrics― is so vague in meaning that it should be dropped from further dis cussions. Can better pediatrics be prac ticed, can be answered in the affirmative and offers opportunity for wide and profit able discussion. Pediatric practice does offer a satisfying professional career.
fashion satisfactory to himself, to his pa tients, and to their families. Within such a framework of practice boredom is unlikely to develop and competence in terms of what is given to the patient should be more than adequate.―
If there is a “¿NewerPediatrics,― which I doubt, and if my summary above is any where near on target, then where does group practice fit in?
Our group, and therefore the type of group I am talking about, is known as the Chestnut Hill Pediatric Group. We practice in suburban Philadelphia. The group is composed of four pediatricians and a part time pediatric orthopedist, all with separate but closely integrated practices, that is, we are not a partnership in the usual business sense.
Each member of the group, in addition to private practice, serves on the staff of the local community hospital and on the staff of either the Children's Hospital of Phila delphia or St. Christopher's Hospital for Children.
While we are all doing general pedia trics, one man has had special training and experience in hematology and one in dis eases of the chest. A previous member of the group (female), who married several years ago, later took training in psychologic pediatrics and returned to solo practice in this particular field.
Many busy practitioners feel that the con
GROUP PRACTICE
Henry F, Lee, M.D.
1960;26;874
Pediatrics
Lee Forrest Hill
SOLO PRACTICE
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