Abraham B. Bergman, M.D., Steven W. Dassel, M.D., and
Ralph J. Wedgwood, M.D.
Department of Pediatrics, University
of
Washington, School of Medicine and Children’sOrthopedic Hcepltal and Medical Center, Seattle, Washington
(Submitted December 2.2, 1965; accepted for publication February 2, 1966.)
Presented to the Western Society for Pediatric Research, Portland, Oregon, November 2, 1965.
ADDRESS: (A.B.B.) 4800 Sand Point Way N.E., Seattle, Washington 98105.
Psiwriucs, Vol. 38, No. 2, Part I, August 1966
TIME-MOTION
STUDY
OF
PRACTICING
PEDIATRICIANS
254
C
LEAN MILK, widespread immunization,and antimicrobial drugs have changed
the traditional role of the pediatrician and
have made him search for a new image.
That this image has not been easy to find is
attested to by a regular stream of letters to
the editors of pediatric journals attempting
to define the role of the pediatrician. The
term “new pediatrics” was coined to connote
increasing involvement in the emotional and
social problems in children.1
Our affluent society has brought with it
the concept, not discouraged by the
medi-cal profession, that every family should
have a pediatrician. As the World War II
bumper crop of babies now commences, in
turn, to have their babies, and the numbers
of practicing general practitioners continue
to decline,2 it is evident that either many
more practicing pediatricians must be
pro-duced, or the public must be educated to
accept alternative methods of child health
care.
A consideration of pediatric manpower
involves the question of appropriateness of
training programs for the job at hand. Are
current residency programs adequately
pre-paring pediatricians for modem-style
prac-tice? Are we conceivably “overtraining”
pediatricians? The answers to these
ques-tions presupposes a knowledge of what
present-day pediatric practice is.
Contents of residency programs are
widely known and catalogued. Contents of
pediatric practice, on the other hand, are
not as well defined. A possible cause of the
“unhappy pediatrician syndrome” is that
the expectations of prospective trainees are
not matched with the realities of everyday
pediatric practice.
Two previous studies from this
depart-ment have dealt with the characteristics of
pediatric practice. Deisher, Derby, and
Sturman3 interviewed 91 pediatricians in
the State of Washington while R. A. Aldrich
and Martinez conducted a nationwide
questionnaire survey on the content of
pediatric practice in the United States.4’5
We decided to follow up these large
sam-pies by studying in greater detail a smaller
number of pediatricians to give a more
de-tailed description of how a practicing
pedi-atrician spends his working day. This type
of study would hopefully corroborate the
physicians’ own estimates of their activities
reported in previous studies and would
pro-vide additional information about activities
not previously examined.
M ETHODS
Four board certified physicians in the
pri-vate practice of general pediatrics were
s-iected for the study which was conducted in
the summer of 1964. (Table I). The selection
was arbitrary. Men of varied ages were
cho-sen who practiced in different settings. All
hold clinical teaching appointments in the
Department of Pediatrics and are respected
by their peers. Five physicians were asked
to participate; one demurred.
The four men were followed by a fourth
year medical student (S.W.D.) from their
first hospital call in the morning until they
left for home in the evening. Paysen’s et a!.
method used in a time-motion study of
TABLE I Foui PEDIATIucIANS
I)octor -:-::-- Received Practice Location
A 37 19.54 Solo Town of 50.000
B 35 1955 Partnerlilip Suburban Seattle
C 43 1945 Solo Urban Seattle
D .54 1936 Solo Urban Seattle
days of the week were spent with each
ex-cept Dr. A., where it was possible to spend
3 days only.
Following the observation period, each
pediatrician was interviewed in the broad
areas of his own background, reactions to
the study, opinions about medical
educa-tion, and thoughts about the future of
pedi-atric practice.
RESU LTS
The working day of the physicians during
this summertime observation period was
about 83 hours long. Table II shows the
de-tails of how these days were spent and
Fig-ure I graphically portrays the average time
distribution. An average of 23 patients a
day were seen, 20 in the office and 3 in the
hospital. This ranged from 31 per day for
Dr. C. up to 18 per day for Dr. D. (All
agreed that fewer patients were seen in
summer than in winter.) On the average,
slightly less than one-half the day (48%) was
spent in the presence of patients. Of this,
3.8% of the day was spent with hospitalized
patients, and 45.6% with patients in the
office. Dr. A. saw only one hospitalized
pa-tient, a newborn, in 3 days.
The telephone plays a major role in a
pediatrician’s life, as seen in Tables II and
III. An average of 12.5 of the day was spent
on the phone. Two-thirds of the calls were
from patient families. Here, there were
striking differences between our doctors.
Drs. C. and D. spent twice as long on the
phone as Drs. A. and B. This was by design.
The two younger men took only urgent
calls while seeing patients, while the two
older men accepted calls as they came. The
two younger men seemed to resent the
phone more, while the older men seemed
more resigned to it.
Consultations took an average of 8% of
the day. This included conversation with
office staff, other physicians, drug
repre-sentatives, or conferences. (Social
discus-sion is listed under miscellaneous.)
Paper work and reading averaged 9%.
This included charting, mail, insurance
forms, and filling out camp physical
exami-nation forms, the latter being no mean task
in the summertime. Of time spent in paper
work, an average of 50% was spent on office
charts, 18% on hospital charts, and 32% on
other writing tasks.
An average of 8% of the day was spent in
personal activities, mainly meals.
Some-times lunch was combined with charting or
a conference, in which case it was counted
with those activities. Dr. C. routinely did
paper work while eating sandwiches for
lunch at his desk.
An average of 6% of time was spent in
travel, 4% by auto, and 2% by foot. Here the
range (1.4 to 13.7) was great. This was
mainly a measure of time spent between
TABLE II
Ilov PEDIATRICIANS SPEND ThEIR DAY
Doctor . Observation . Period t rj Ar. Hour., per Day Ar. Office Pts. per Day Ar. Hasp. Pts. per Day
Percentage of Day
‘. aith Patients Telephone Consult-ing Paper Work Personal Auto Travel Foot Travel . Misc. A B C I) Average 6 4.5 37..5 43 8.7 8.5 7..5 8.6 it 18 7 15 0.3 .5 4 3 49 51 49 44 9 7 17 18 12 7 .5 7 10 9 9 10 11 5 8 9 1 8 4 4 0.4 5 2 3 8 8 7 5
60
U)
I-Ui
F-30
C’):D0 Ui
z
_J
Ui
> UI
4 0
cx: U)
PEDIATRICIANS AVERAGE TIME DISTRIBUTION-FOUR
.1verage No. From
Doctor
per ay amzy
A O.3 8.6
B 16.8 11.8
C 27.8 18.6
I) 24.4 15.8
Average 1.3 15.7
Percent Others
of Day
11.6 8.8
5.0 7
I 9.2 17
8.6 18
8.6
>#{176},
0
4-0
C
a)
0
3-Ui
z
0
Q-Ui
_j :D
Ui U)
z
pj
.. .‘ n
Fic. 1.
hospital and office, and on foot between
hospital rooms and parked car. Time
walk-ing between office examining rooms was
negligible and was not counted. Since Dr.
A. had but one hospitalized patient, he
spent very little time traveling. Dr. B’s high
travel time is due to his suburban location
and because he had the most hospitalized
patients.
TABLE III
OFFICE TELEPHONE CALLS
Little time seemed available during the
working day for “continuing education.”
Dr. A. was able to spend about 10 minutes
scanning a pediatric journal before patients
arrived, but this was the only reading done
during the observation period. The
ob-server’s presence might have modified this
factor, however. Miscellaneous time not
falling into any of the above categories
av-eraged 7% of the day. This included talking
to the observer, looking at x-rays, checking
lab tests, etc.
OFFICE TIME WITH PATIENTS
Time with patients was broken down into
pre-examination, examination, and
post-ex-amination periods. Theoretically, this would
be used for history taking and
disposi-tion, but it was found that history may be
exami-PATIENT TIME IN PEDIATRICIAN’S OFFICE
Fic. 2.
TABLE IV
..lrerage
!),oease RAiflL % Rank
hy% Time Time Pt. Load by% Time
\‘ell Child I .50 46 I
Respiratory t 7
Accident S S 7 .5
Emotional Behavioral I 3 S 4 Poorly Defined Syndrome., .5 .5 4 7
1)ermatology 6 S
Allergy 7 9
Communicable l)isea.se S e s
6.!. 9 1 1 6
Other .5 5
-% Rank % it. Time Load 43 t so 6 S 7 5 9 8 0.4 C 1 C C C 8 8 B Rank by% #{176} . Time Ti rae 1 .58 C CO 4 4 5 6 7 2 .5 4 6 5 C’ Time 53 SO 10 8 S 4 C C 8 (, Rank
!)t. by %
Load Time .57 I CC C .5 5 7 6 S .5 C S !)t. Load 54 31 10 4 C 4 S 4 8 D % Time 6.5 15 4 4 8 C by % Time C 5 4 3 6 % Pt. Load .58 C4 S S 7 S
nation, particularly in well-child visits. A
fourth category, procedures, includes
im-munizations, foreign body removal,
sutur-ing lacerations, etc. Most immunizations
were done by office assistants. The average
distribution of office time with patients is
shown in Figure 2: 18% for introduction,
38% for physical examination, 4% for
proce-dures, and 41% for post-examination
discus-sion. All the pediatricians followed a
uni-form pattern with little variability in this
category. The majority of discussion took
place during and after the physical
exami-nation. A more detailed analysis of the
pediatrician-patient interaction has been
performed and will be the subject of a
fu-ture communication.7
DIAGNOSTIC CATEGORIES
Table J\T lists the diagnostic categories of
the patients seen during the observation
pe-nod, both by percentage of physician’s time
and by percentage of total number of
pa-tients. Often a patient would present with
more than a single reason for seeing the
doctor. In this case, the entire time was
awarded to that problem occupying the
most time unless a large segment Of time
was spent in each area. In such a case,
sepa-rate times were kept for each. When the
chief reason for coming to the office was a
routine examination and no other problem
was fouiid which occupied more than 45
seconds of time, the entire time was placed
nn(ler “well-child” examination.
Well-child examinations were the
great-est reason for office visits, taking on the
av-erage of one-half the pediatricians’ patient
time. This ranged from 32% for Dr. C. to
65% with Dr. D. The other large category
was upper respiratory infections, which
av-eraged 22% of the patient time. In the
hos-pital an average of 79% of patient time was
spent with normal newborns.
The pediatricians averaged 11 minutes
per patient, ranging from 13 minutes for
Dr.’s B. and D. to 8 minutes for Dr. C.
(Table V). Dr. A. spent almost twice as
much time with well-child visits than those
TABLE V
AVERAGE OFFICE TIME WITH PATIENTS (suN.)
for respiratory illness. Dr. C.
tients considerable printed
gave his
pa-material on
U) a.
0
a,
0’
0
a,
0
a,
a.
C,)
0
C
C.) a,
a-D
Fic. 3. Doctor
All
, .
Categories
Well
.
Child
Respiratory lllne8s
A B
C
I)
11 13 8 13
15 13 9 15
8 13 8 13
Average 11 13 11
well-child care and preferred to discuss
par-ticular problems rather than cover what he
considered routine matters.
The seasonal character of the observation
period reflected itself in the relatively
greater amount of accident treatment and
relatively lower incidence of respiratory
ill-ness than would be expected in the
winter-time. There was little gastrointestinal illness
in the community during this time.
AGE OF PATIENTS
These pediatricians on the average spent
most of their time with children between 1
and 6 years old, and almost equal time with
infants under 1 and school children 7 to 12.
There was interesting variation, however,
among the group (Figure 3). Dr. B., the
youngest pediatrician, and in a suburban
location, spent over two and one-half times
the amount of time with infants as Dr. D.,
the oldest pediatrician. Dr. D. spent far
AGE DISTRIBUTION OF PATIENTS
0 - I year
I -6 years
7-12 years
more time with grade school and adolescent
youngsters. Dr. A. is particularly interested
in adolescent medicine, which may explain
his percentage of time with that group. No
age group took strikingly more time than its
percentage of patient load. In the
previous-ly mentioned studies,35 infants under 1
year constituted the most common age
group.
ADDITIONAL OBSERVATIONS
No seriously ill children requiring
emer-gency treatment were seen. One patient
with croup who had not improved at home
during the day after having been seen in
the office earlier was admitted to the
hos-pital. He was the sickest patient seen in the
office during the observation period.
Each pediatrician seemed to have a
different pace, though they all worked
steadily throughout the day. The office help
played a large role in determining whether
the doctors’ time was used efficiently.
One day Dr. C. saw 42 patients with one
nurse in the office. She managed to answer
the phone, make appointments, move
pa-tients in and out, give injections and handle
payments, all with apparent ease. None of
the 42 parents seemed to be rushed through
or leave with unanswered questions. Also,
although rushed on this day, Dr. C. spent 15
minutes on a child with an emotional
prob-1cm.
INTERVIEWS
House calls were not made by any of the
physicians during the observation period.
They are a rarity for pediatricians in the
Seattle area.
Following the observation period, each of
the pediatricians was interviewed for
ap-proximately 1 hour.
None of the physicians felt that the
pres-ence of the observer modified their patterns
of practice, nor caused any resentment
among their patients. The observation
pen-od was typical of the season of the year. All
felt that the ratio of well-child cane to
respi-ratory illness would be reversed during the
winter season. They agreed with the noted
trend towards positive correlation between
age of the pediatrician and mean age of his
patients.
Two main themes emerged during
dis-cussion on preparation for practice. One
was a rather nostalgic regret at not taking
subspecialty training. The expressed basis
of this was desire for more intellectual
stim-ulation, a recurrent theme which will be
discussed later. During residency training
they had planned on being “specialists,” but
this was found to be true only to a degree.
A suhspecialty skill seemed to represent a
means to more intellectual stimulation in
practice.
The other theme was the greater
aware-ness of the effect of social environment on
illness that emerged after going into
prac-tice. The three older physicians all
men-tioned that the pediatrician is called upon
to participate in many paramedical
activi-ties, such as education, adoptions, and
hos-pital planning. They felt ill-prepared for
such areas based on their previous training.
The pediatricians felt that their
expeni-ence was put to good use in caring for
new-bonus and thought that this area deserved
emphasis. Since a pediatrician’s time is
taken up so much with well children, the
training in this area was thought to be
worthwhile. (Interestingly, they said the
well-child clinics had not been popular
when they were residents.)
Despite some reservations, all the
physi-cians enjoyed practicing pediatrics but one.
Dr. B. is planning to give up his practice
shortly to start a radiology residency.
Though he is respected by his peers and has
been very successful, he feels that general
pediatric practice offers too little
intellectii-al chintellectii-allenge.
Though pediatrics is a relatively
low-pay-ing specialty, this did not seem of major
concern to our doctors. They were aware of
it before they went into the field and were
fatalistic that pediatricians were underpaid
in relation to other specialists. They all said
that a pediatrician could make a very
regarding finances was directed towards the
procedure-oriented fee schedules. Charging
for tests and injections is allowed, but
basi-cally a pediatrician cannot charge for his
most precious asset, his time.
A steady stream of newborns into a
prac-tice insures its success. The observation that
the older pediatrician gets fewer newborn
referrals, causing a falling off in the
prac-tice, was felt to be accurate. Dr. D. pointed
out that the obstetricians who used to refer
to him are now mostly doing gynecology.
When asked about the value of well-child
visits, there was question as to whether all
mothers needed to come so often. Dr. A.
said, after much hesitation, “The same
question could be asked of pastors or
medi-cine men. People need someone to lean on,
and I suppose we are it.”
Both Dr.’s A. and C. felt that
pediatri-cians might be better off with wider public
insurance due to the failure of most private
insurance plans to cover congenital defects.
Dr. A. said, “Covemment financed
insur-ance might be a boon to pediatricians by
making them see more demanding
prob-lems such as chronic illnesses and
develop-mental defects which are now often cared
for in institutions, and thus they would not
have time to see so many trivial problems.”
COMMENT
The time-motion study was an attempt to
gain an objective profile of the
pediatri-cian’s day. Though the sample was small,
the data corroborate the statewide
inter-view survey of Deisher,
et al.
and thena-tionwide questionnaire survey of Aldrich
and associates.4’5
A medical student was well accepted as
an observer in a private practitioner’s office.
Others have found that medical students
are uniquely accepted in this potentially
sensitive situation, even more so than other
physicians, where the fear of “checking up”
might exist.8
The fact that our physicians spent no
more than half their time with patients is
interesting but not surprising, and probably
not unique to pediatrics. The large number
of telephone calls, even given the summer
season, is also not surprising and if not
unique to, at least the hallmark of,
pedi-atrics.
Well-child supervision and upper
respira-tory tract illness constitute the vast bulk of
problems seen by the pediatrician.
Inter-estingly enough, the same apparently held
true at least 30 years ago. The famous
pedi-atrician, C. A. Aldrich, who kept meticulous
records in his private practice, reported in
1934 that 39% of his patients were seen for
routine well-child supervision. He said that
these patients “took more time and effort
than those in any other group.”#{176} Similar
findings were reported by Boulware.b0 The
diagnoses in the observation period are
strikingly similar to these as well as the
cent studies of Deisher, et a!. and R. A.
Al-drich and associates.4”
The positive correlation between age of
physicians and patients was an interesting
finding. Youth does not seem to be a
handi-cap in starting pediatrics but age is in
re-taming a practice.11 Newborn referrals
en-sure an active practice. Dr. D. gets fewer
such referrals since the obstetricians he
“grew up with” have turned to gynecologic
problems. At an age when other specialists
hope to “hit their peak,” the pediatrician is
losing his practice. Additional factors might
be that young mothers prefer younger
doe-tors and that an older doctor might have a
backlog of older patients who require more
time.
Our two younger physicians spent much
less time on the telephone than the older
ones. This is probably related to the
mdi-vidual’s philosophy concerning the value of
advising over the telephone. Dr. B., for
cx-ample, was not interrupted by phone calls
when he was with patients other than for
emergencies. Messages were taken and he
called later. His older partner, on the other
hand, preferred to take calls as they came
in. The fact that there is no remuneration
for the considerable volume of telephone
practice seemed to be accepted with
resig-nation.
TABLE VI
COMPAn1S0N OF AVERAGE PATIENT LOAD
Pediatricians and Internists5
Time with Patients Pediatricians Internists
pediatrics is not that the total income is
insufficient, but rather than the pediatrician
is financially penalized for spending time
with patients. Surgically oriented third
party fee structures are the norm : doing
something to the patient pays, talking to
him does not. A pediatrician’s most
valu-able assets are his knowledge and
experi-ence. Instead of charging for time,
how-ever, he is forced to charge for visits or
pro-cedures. Any plan advocating a change in
the structure of pediatric practice must be
prepared to come to grips with this basic
problem.
A comparison of the average patient load
of our pediatricians and a group of 505
in-ternists questioned in New York State is
shown in Table VI. A considerably higher
proportion of the internists’ work is done in
the hospital. The pediatricians saw about
twice as many patients in the office while
spending less than half the amount of time
per patient as the internists.”
The expressed theme of intellectual
dis-enchantment is a serious problem.
Pedia-tricians spend most of their time dealing
jth children who are not ill or have only
minor illnesses and who, they may feel, do
not require their special talents. The desire
for subspecialty training perhaps implies
that a general pediatrician no longer
con-siders himself a specialist. The major
por-tion of a pediatrician’s day is spent on
prob-lems that he considers do not tax his
intel-Office patients/week
Hospital patients/week Hours with Office
patients/week
Hours with Hospital patients/week
Minutes/Office Patient
1o 55
3.4 4.8
19 i.6
1.6 9.9
11 4
S As reported by Altman, et al. The office practice of
internists II. Patient load. J.A.M.A., 193:667, 1965.
lectual capacity. The concepts of
intellectu-at challenge and subspecialization appeared
to be intertwined in these pediatricians’
minds.
The trend to subspecialization, though
appearing glamorous to the general
pedia-trician, is probably not the solution.
Practic-ing subspecialists outside a medical center
are a vanishing breed. Anyway, how many
pediatric cardiologists, hematologists and
endocrmnologists are needed for child health
care?
Dr. A.’s suggestion that pediatricians
de-vote more attention to the child with birth
defects, multiple handicaps, and chronic
ill-ness is a constructive alternative. Currently,
a large proportion of such children are
cared for by institutions, which have an
al-most inherent difficulty in dealing with
“whole children.” Certainly such patients do
not lack the challenging medical problems
upon which a pediatrician’s skill could
con-ceivably be brought to bear, but few
pedia-tric training programs currently emphasize
needed training for this role. Increasing
coverage of such conditions under the
pub-lie insurance programs might make
treat-ment of chronic illness by the practicing
pediatrician economically feasible.
The American Academy of Pediatrics has
for many years held as a primary goal the
provision of the best possible health care
for all the children of the nation, without
regard to economic or social limitations.
The Academy recommendation is that all
children should receive health supervision
visits from qualified physicians every 4 to 6
weeks during the first year, every 3 months
during the second year, at least every 6 to
12 months during the pre-school period,
and at least once a year thereafter to the
age of 18.” That this goal has not been
reached is clear from the most recent
Na-tional Health Survey (1964), which showed
that of the 66 million children in the United
States under the age of 17 years, 55% of
those under the age of 6 years and 69% of
those between 6 and 16 years have not had
a regular examination by a physician in the
legis-Number of Physicians (Thousands)
Pedia-G.P.’s tricians Year
1930
1940
1950
1960
Child Health
Physicians
Per 100,000 Children Number
of
Children
(Millions)
36 33
41
56
11
109
95
74
1
4 8
1970
1980
63
75
55
35 16
lation removes the economic selection
fac-tor for access to children’s health services,
the disparity between these rather idealistic
goals and available manpower will become
painfully apparent.
These manpower problems have been
clearly expressed by Stewart and Pennell,2
who calculated that the ratio of medical
practitioners caring for children
(pediatri-cians and general practitioners) to the child
population under the age of 15 years fell
from 353 per 100,000 in 1940 to 151 per
100,000 in 1961. Similar calculations for the
past four decades and projections for 1970
and 1980 are shown in Table VII. While the
numbers are approximations, the orders of
magnitude are probably correct. The
sug-gested fivefold decrease in the ratio of
mcd-ical practitioners caring for children to the
child population in the four decades
1940-1980 is occurring at a time when our
society has expressed a mandate for
broad-er child health services to include all
seg-ments of the population.
Calculated estimates of manpower needs
to provide these services are extraordinarily
revealing. Such calculations have been
presented by Stewart and Pennell2 and
TABLE VII
PHYSICIAN MANPOWER FOR CHILD HEALTH SERVICES
314
336
146
106
68
Figures derived from “Statistical Abstract of the
United States, 1964,” U.S. Department of Commerce,
Bureau of the Census. Projections for 1970-1980 made on basis of steady continuation of current trends, on expected medical school enrollment and life tables.
“Children” by definition includes all persons under 15 years of age.
more recently by Stewart.’5 In 1980 there
will be approximately 75 million children in
the United States. To maintain the 1960
ratio of 1 :685 for physicians caring for
chil-dren to the number of children in the
popu-lation, we will need by 1980 about 110,000
physicians to provide these children’s health
services.
General practitioners as a rule do not see
as many children as pediatricians, but are
available as a medical resource, and are
therefore included in child health
man-power statistics.
By 1980 the attrition of general
practi-tioners, if current trends continue, will have
reduced their number to less than 35,000.
Again, if current trends continue, the
num-ber of practicing pediatricians will have
in-creased to only about 16,000. There will
then, with current trends by 1980, be
possi-bly 51,000 physicians to provide services
re-quiring 110,000 physicians by present
stan-dards. To close the manpower gap and to
maintain the physician-child ratio, by 1980
it would be necessary to train at least an
additional 59,000 physicians to provide
these child health services. Even were it
conceivable that the majority of all medical
school graduates for the next 15 years could
be recruited for this purpose, there is
seri-ous question whether the training facilities
available could be successfully expanded to
accommodate the eightfold increase in
num-bers of trainees. Certainly the conversion of
pediatricians from generalists in child
health to specialists for referral practice,
while being attractive from some points of
view, is not going to assist in providing an
answer for this manpower need.
These manpower problems have direct
relevance to the study presented in this
paper. The American public has accepted
the practice of pediatrics in its current
form. The trained pediatrician has, for the
middle and upper socioeconomic classes,
become the arbiter in the American scene of
such things as infant feeding, clothing,
elimination, child rearing practices, and the
differential diagnosis and treatment of
the pediatrician could long remain in
prac-tice today if he divested himself of these
functions. As more of our population move
from lower socioeconomic status into the
middle class ranks, and as federal programs
erase the economic selection factor, the
pro-vision of this form of practice function is
going to be increasingly demanded. If as
would appear probable, the manpower
problem and the law of supply and demand
decree that a steadily increasing number of
American children will not have their own
pediatricians, as we view pediatrics today,
alternative patterns of child health care will
and must be developed. Should not the
pediatricians play an active role in
deter-mining what form these patterns take?
Finally, it should be readily apparent
that the questions raised in this discussion
and that the data presented on the content
of practice are not unique to the field of
pediatrics alone. As matters of the public
health become issues of public policy, each
professional group will need to assess its
own particular function in the overall
provi-sion of health services to our modern
soci-ety.
SUMMARY
Four practicing pediatricians weie
fol-lowed by an observer with a stopwatch for
a total of 18 days to gain a profile of how
their working days were spent.
An average of 48% of the day was spent
with patients, 12.5% on the phone, and 9%
on paper work. Fifty per cent of patient
time was spent with well children, and 22%
on children with minor respiratory illness.
Intellectual understimulation seemed to
arise from spending the majority of time
with children who did not require their
spe-cial talents.
In view of the alarming decline in ratio
of physicians to child population,
pediatri-cians are urged to play a decisive role in
formulating the alternative patterns of child
health care that must inevitably develop in
the United States.
REFERENCES
1. May, C. D.: Can the new pediatrics be
prac-ticed? Pimwriucs, 23:253, 1959.
2. Stewart, W. H., and Pennell, M. Y.: Pediatric
manpower in the United States and its im-plications. PEDIATRICS, 31:311, 1963.
3. Deisher, R. W., Derby, A. J., and Sturman, M.
J.: Changing trends in pediatric practice.
PEDIATRICS, 25:711, 1960.
4.
Aldrich, R. A., and Martinez, C. : Survey ofpediatric practice in the United States, 1959. Unpublished data.
5. Aldrich, R. A.: Careers in Pediatrics. Spitz,
R. H., ed Report of the 36th Ross
Confer-ence on Pediatric Research. Columbus: Ross
Laboratories, 1960.
6. Payson, H. E., Caenslen, E. C., and Star-gardter, F. L. : Time study of an internship
on a university medical service. New Eng.
J.
Med., 264:439, 1961.7. Bergman, A. B., Probstfield, J. L., and
Wedg-wood, R. J.:Content analysis of office
pedi-atnc practice. Unpublished manuscript.
8. Deisher, R. W. : Personal communication. 9. Aldrich, C. A.: The composition of private
pediatric practice. Amer. J. Dis. Child.,
47:1051, 1934.
10. Boulware, J. R.: The composition of private
pediatric practice in a small community in
the south of the United States: A 25 year
study. PEDIATRICS, 22:548, 1958.
11. Bruce, J. W.: Reflections on pediatrics as a career. Clin. Pediat., 4:548, 1965.
12. Altman, I., Kroeger, H. H., Clark, D. A.,
Johnson, A. C., and Sheps, C. C.: The
of-flee practice of internists. II. Patient load. J.A.M.A., 193:101, 1965.
13. American Academy of Pediatrics: The Health
Supervision Program Your Child Should
Have. Evanston, Illinois: American Academy
of Pediatrics, 1964.
14. Physician visits-interval of visits and children’s
routine checkup, United States, July 1963-June 1964. Vital and Health Statistics data from the national health survey. Public
Health Service Publication No. 1000, Series
10, No. 19, Washington, D.C.: U.S.
Govern-ment Printing Office, 1965.
15. Stewart, W. H.: Presentation “workshop,”
American Board of Pediatrics, Atlanta,
Georgia, Sept. 1965. Unpublished data.
Acknowledgment
We greatly appreciate the generous assistance of
the four practicing pediatricians who participated
in this study, and without whose help these studies
