PEDIATRICS (ISSN 0031 4005). Copyright :#{235}:#{149}1986 by the American Academy of Pediatrics.
COMMENTARIES
Opinions expressed in these commentaries are those of the authors and not necessarily those of the
American Academy of Pediatrics or its Committees.
Acute
Medical
Care
of Severe
Head
Injury
Is Not Enough
As
indicated by Jacobson et a! in this issue(Pe-diatrics 1986;77:236) significant head trauma is a
major and frequent occurrence in adolescents and
in younger children as well. The major advances in
emergency medical services-helicopter transport,
trauma centers, and management of increased
pres-sure-has had dramatic effects on the survival rate
and, probably, on the quality of survival of children
with closed head injury. However, discharge from
the hospital of a child who is able to walk, although often considered the end point by the surgical team,
is clearly not sufficient for the parent and child.
As Jacobson and his colleagues indicate, dis-charge is not the end but the start of many
prob-lems. The child who looks normal often has many
intellectual, judgmental, and personality problems
which, to a large extent, are related to the injury. The lack of physical evidence of the trauma
corn-plicates society’s response to these organic deficits. Many of the deficits resolve gradually with time,
usually 2 to 6 months and often more than 2 to 3
years. We know little or nothing about this recovery
process or about how it can be facilitated. As
Ja-cobson et al indicate, when the injury occurs in adolescence, it may be particularly difficult to
dis-tinguish adolescent problems from organic deficits.
The superimposition of depression, anger, and frus-tration, as well as parental guilt and frustration, compounds the problems.
Where is the family to turn for help? This is rarely the sphere of the busy neurosurgeon. The pediatrician has rarely been involved in the acute
problems of the intensive care unit and the
recov-ery. But perhaps, the pediatrician should be
in-volved while the child is in intensive care. Not
necessarily in the management of the increased
pressure but in helping the family to cope with the initial anxiety and grieving, with the ensuing hope and frustration, and with the long-term adjustment
to deficit and recovery. The pediatrician is well trained to help the child or adolescent adjust to
daily problems and to interface between the child
and family. He is also best equipped to work with the school system to design an appropriate school
program and to cope with the school’s anxiety and
restriction.
Jacobson and colleagues have pointed out a gap
in care, an important gap, that the pediatrician could well fill.
JOHN M. FREEMAN, MD
Department of Pediatrics and Neurology The Johns Hopkins Hospital
Baltimore
Academic
Hubris
Envy and pique and vanity, all the passions of
self-regard. You could not live long in a society of men and not see them weigh down the rest.
-c.p.
Snow in The MastersI have always liked the word hubris ever since I
heard it on my first day of college from a humanities
professor as he talked about the ongoing feuds
between Sparta and Athens. Professor Arragon of Reed College defined hubris as “stiff-necked.” Webster’s New World Dictionary’ defines it as
“wanton insolence or arrogance resulting from
ex-cessive pride.” Lewis Thomas2 writes that hubris
Presidential address delivered to the Ambulatory Pediatric As-sociation, May 10, 1985, Washington, DC.
PEDIATRICS (ISSN 0031 4005). Copyright © 1986 by the
252
PEDIATRICS
Vol. 77 No. 2 February 1986first turned up in popular English use as a light
piece of university slang at Oxford in the late 19th century, with the meaning of intellectual arrogance
and insolence. I define hubris as looking out of a
high turret in an ivory tower and being unable to see the ground because of the clouds.
My general theme is that hubris runs rampant in academia and is manifested by individuals in the power structure who view themselves as possessing some form of moral superiority over those who toil in the kitchen, or outside the ivory tower. Faculty
in ambulatory/general pediatrics are destined to be
chronic kitchen dwellers. (Granted, some of us
relish our underdog status and have a need to wear
hair shirts, but that is another story.)
Academic hubris creates a needless gulf between
schools of medicine and medical practitioners, re-sulting in the training of finely honed dinosaurs,
ill-suited either to meet pressing health needs of
the public or to survive themselves in a changing environment. The chasm between the practicing and academic medical communities deprives the former of potentially enlightened leadership and the latter of potential political and economic
sup-port necessary for survival.
Here are some of the manifestations of hubris as I see them: Our present form of pediatric training
was forged in the 1950s and, despite repeated calls for reform, has changed very little. Recall that the
“new pediatrics” was proclaimed by Charles May3
in 1959. The disparity between pediatric training
and the skills required by pediatricians in practice
has grown ever wider. Our vocational guidance of
trainees is abysmal. We send them, like lemmings, over the cliff into careers that are as viable as
shoeing horses.
General pediatric training, which, if training had any relation to function, would get the most
re-sources, gets the least. General academic
pediatri-cians continue to sit at the back of the bus.
Even in research, some of the most important
child health problems, like injuries, and the rela-tionship of poverty to premature birth and infec-tions, continue to be ignored. The reasons for this state of things can be found in the natural instincts of self-preservation. We medical school faculty members desire to replicate ourselves in order to justify our existences. Like any other group of more than two persons, we exist as a collection of tight guilds that wish to retain power. How else can we
explain the recent action of the pediatric residency
review committee in requiring block rotations in hematology/oncology, cardiology, endocrinology,
and nephrology? Is it just coincidence that these
are the only pediatric subspecialties with official
board certification?
In other worlds, like business or politics, working
to acquire power and wealth is considered natural and desirable. In academia, however, we cloak these
natural base instincts under our priestly robes,
point our noses skyward, and proclaim that we act on behalf of others, like students, residents, or
children of the United States.
MEDICAL SCHOOL BREEDS INSECURITY
Medical school breeds insecurity. The overriding theme is: “You have to know so much . .. especially
about my subject . . .or else you will make a mistake
and kill somebody. If you narrow your focus of
expertise, you are less apt to make mistakes.”
Stu-dents and residents are constantly influenced to lodge on “tight little islands” of expertise. For ex-ample, it is not enough to be a hematologist; one must specialize in red cells, white cells, platelets, or
clotting factors. How else is it possible to “keep up?” The above thoughts are most apt to be
pro-mulgated by those faculty furthest removed from
the responsibilities of caring for patients.
It is, of course, natural that the importance of
being familiar with the newest developments in science would be stressed by those who are im-mersed in acquiring new knowledge. Yet, all of us
former medical students who were exposed to en-thusiastic teachers proclaiming “the last word,”
know the wisdom of the wise teacher who says: “I know that half of what I teach as fact will be proved false in 10 years. The hard part is that I don’t know
which half.”
Simpson4 says:
Our “standards of excellence” have tended to be uniquely
self-satisfying. They do not seem very excellent in the
ghetto, in the rural areas, or for the homeless. Most
attempts to define thees mythic standards have proved
to be self-descriptive and self-congratulatory inventories drawn up by small elite groups.
ORIGINS OF ACADEMIC HUBRIS
One way of justifying our lower incomes to
our-selves, and our spouses, is that we have some higher moral and/or spiritual calling than our practicing
brethern. Petersdorf,5 however, says:
Academicians expect too much of academic medicine. They wish for the gentility of the academician of yester-year, the income of the cardiovascular surgeon, and the
kudos of the molecular biologist who clones a new gene
(provided that it is the right one, of course), and they
complain if they don’t get it all.”
In this discussion I am talking mostly about clinical subspecialists and I am exempting basic scientists. Perhaps the basic scientists do have a higher moral calling. I propose a trade-off. Pay
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them as much as clinicians. Their contributions to
better health doubtless will be greater than mine. But get them out of positions of influence in the
training of physicians. Basic scientists originally
were brought into medical schools to lend some
class to what, up-to-then, had been curricula filled
with witchcraft. They succeeded. Now they should
release their tentacles from the medical
students-few basic scientists have any idea of what
physi-cians are called upon to do-and concentrate on
what they truly care about, conducting research and teaching their own graduate students.
In a wonderful review of 20th-century child health care in the United States, Hugh Thompson6
recalls the golden fifties, with the burgeoning of the
pediatric subspecialties, and the succession of
won-der drugs such as antibiotics, anticonvulsants,
anti-histamines, and steroids. He points out that, at the
time, it was possible for pediatricians in practice to
subspecialize. That era is long past. Now
subspe-cialists can only exist within large medical centers.
The 1950s were also the golden years of the
National Institutes of Health (NIH), where
subsi-dies for medical education were provided indirectly
through research and research training grants. It is interesting to speculate what would have happened if there had been direct federal support of medical
education. Such a proposal, put forth in 1951 by
President Truman, was torpedoed by the American
Medical Association (AMA).
As mentioned previously our residency training
programs took their form during these years. The biggest change has been a burgeoning of intensive care, both for neonates and older children, which consumes much resident time and energy. Thanks
to modern technology, much of what now passes for inpatient wards in childrens’ hospitals are, in
fact, large chronic intensive care units. Our
resi-dents are burdened with having to make endless
moral decisions, eg, “why must I continue to obtain
blood gas levels on this tragic infant with no
func-tioning bowel or lungs?”
In the 1960s when I was involved in a health manpower study, I interviewed a pediatrician in Bellingham, Washington, Kenneth Jernberg, about how well his training prepared him for practice. I will always remember one of his responses: “I
es-pecially value the time I spent on night call at the hospital. It gave me a chance to go around the ward
and learn how to talk with kids.” Now, our harassed
residents on the ward are lucky if they ever talk
with any kids or parents. Carrying pagers that never cease beeping, they are mostly occupied as super-secretaries, scheduling tests and treatments, and staying in touch with the numerous consultants involved with their patients.
ACADEMIC HUBRIS AND GENERAL PEDIATRIC TRAINING
One of my most valuable experiences as a teacher
was exchanging jobs in the summer of 1968 with a local practitioner, Alfred Skinner.7 I learned two major lessons. The first was that management skills were more important than diagnostic skills. The
exact etiology of an illness did not matter if the
child got better the next day. The other was having to make numerous small decisions, alone. That is in contrast to the teaching hospital, in which deci-sions are usually made in groups. The British
psy-chiatrist, Michael Balint8 characterized the
multi-specialty and multilayered care in teaching hospi-tals as the “collusion of anonymity”-vital deci-sions are made without anybody feeling fully
re-sponsible for them.
Thompson6 notes that the two major changes
that have taken place in pediatric practice in the
last decade are increased attention to psychosocial
and behavioral issues and the extension of care until patients are 21. Yet, what proportion of our training programs are devoted to preparation for these two activities? What proportion of “hard
money” positions in pediatric faculties are held by teachers of behavioral pediatrics, adolescent medi-cine, or even general pediatrics?
One of my Seattle colleagues, David Shurtleff,
runs what I consider to be one of the best programs
in the world for children with multiple handicaps,
which includes an outstanding research component.
All of the fellows trained by Shurtleff have found excellent jobs. Yet, our residents and students steer clear of rotations on his service. “Too depressing,” most of them say. It is more than that. Chronic disease, in general, is not fashionable in academic
circles. At the same time, the residents flock to take elective rotations in the various subspecialty
“olo-gies” to deal with various forms of exotica that most of them will never again see. Given the enormous advances in a field like cardiology, for example, about all a primary care pediatrician needs to know
is whether a baby is blue or pink, whether his heart is beating, and where he should be referred.
ACADEMIC HUBRIS AND CONTENT OF PEDIATRIC TRAINING
It is possible to define the content of general pediatric training, as has been done so nicely by the Education Committee of the Ambulatory Pediatric
Association.9 Our students and residents must
re-ceive systematic training in development and be-havior. They should develop communication skills, such as how to talk with a family about a dying
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Vol. 77 No. 2 February
1986
sudden infant death syndrome (SIDS), child abuse,
and obtaining permission for an autopsy. They need to learn how the physician’s own feelings affect his
care ofchildren.’#{176} Our trainees should possess some
familiarity with resources for children outside the medical sphere, such as schools, the welfare system,
the juvenile justice system, and institutions for the
disabled.
Are these areas of knowledge and skills with which only a general pediatrician should be
famil-iar? Of course not. They are basic for anyone
in-volved with any aspect of child health care. I have mentioned the repeated calls for enhanced
training in adolescent medicine that are totally ignored by the pediatric academic establishment. It
is well-nigh criminal to graduate pediatric residents
who have no experience dealing with sexuality, pelvic examinations, sexually transmitted diseases, drug and alcohol abuse, school dropouts, and sports
medicine. Will we allow these areas to be the
exclu-sive province of family medicine and internal med-icine?
With a few notable exceptions, faculty in
ambu-latory and general pediatrics are recruited to
aca-demia with blocks of cement chained to their feet. They carry large clinical service and teaching loads
in clinics and emergency rooms with scant free time
for research. Whereas a superstar subspecialist de-mands and gets office and lab space with research assistants, the generalist is lucky to find a cubby-hole off the clinic waiting room to share with the
financial eligibility interviewer. At this point, I must pay tribute to my own chairman, Herb
Abel-son, at the University of Washington. His first
faculty recruit after taking the job was a general pediatrician who received a commitment of at least
50% of time to conduct research and some seed-money to get started. That, of course, is the only
way that a general pediatrician, or any faculty member, for that matter, has a chance to survive
in the academic world. There are a few universities
who possess a “critical mass” of academic general pediatricians, but they are the rare exceptions. Pe-diatric department chairmen wishing to improve the quality of their ambulatory pediatric programs must do more than wring their hands. They must match their money with their mouths.
An interesting new development is the push for health maintenance organization-type faculty prac-tice plans in order to shore-up department income. When I reflect on the number of pediatric faculty capable of providing primary care, my heart goes out to the parents and children who were inveigled into signing up. What if the T cell specialist finds
himself on call on a busy weekend?
RESEARCH HUBRIS
Hubris is never more in evidence than when
decisions are made on the types of research to receive funds or on the qualifications of individuals performing research. Much discussion takes place in medical school appointment and promotion corn-mittees and in the councils of prestigious research societies about what constitutes real research or soft research. As usual, the vote goes to the status
quo.
Befitting my penchant for hair shirts, I have been associated with two research “losers,” SIDS and injury prevention. In 1970, I submitted an abstract to the Western Society for Pediatric Research on research priorities in pediatrics. I pointed out that
virtually no research was being conducted on the two biggest killers in the pediatric age group after
the first week of life, injuries and SIDS. The gist of my message was that members of pediatric research societies should address the issue of how research priorities are set.
The president of the society called to ask, as a personal favor, whether I would withdraw the ab-stract (the paper, of course, was not accepted for
presentation), because all of the abstracts were publishedin Clinical Research, and “this one would be embarrassing.” I refused; the abstract was duly
l Unfortunately, nobody noticed.
The pediatric academic community has no cause
for pride in the SIDS story. Did the scientists push for funds to conduct research in SIDS? Certainly not! A modest research effort got underway at the National Institute of Child Health and Human
Development (NICHD) only after parents who had
lost babies raised enough hell, through their
sena-tors and congressmen, to push some money onto the research establishment.’2
As president of the National SIDS Foundation from 1972 to 1977, it was my job to go all around the country trying to establish humane manage-ment programs in each community to assist families
who had lost infants. Each of our local chapters
had a medical adviser to “run interference.” In only
two of the approximately 35 chapters at the time
were these advisers academic pediatricians. The vast majority were pediatric practitioners, usually
the busiest in each town, who shouldered this hu-manitarian job, just as they took on their
commu-nity problems.
At least there is now a modicum of research effort
in SIDS. The same cannot be said for injuries.
Parents of burn or drowning victims do not band together to plead their cases. For 15 years I, among
others, have been trying to interest the Department
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of Health and Human Services, in general, and
NICHD, in particular, to tackle the biggest killer
of children, to no avail. Although the American
Academy of Pediatrics has been supportive, the leaders of the pediatric research societies sort of mumble and shuffle their feet. Potential harm to
existing funded research by bringing a “new boy on the block” is the reason most often given. The
concern is perhaps legitimate. The unwillingness to
join in seeking alternatives is not. It is hubris.
From the testimony of the Acting Director of NICHD, Duane Alexander, to the Senate Appro-priations Subcommittee for Health and Human Services on the 1976 fiscal year budget, one might
think that lightning had finally struck. He said:
The most important child health problem following
in-fancy is injury. From age one throughout childhood more children die from injury than any other cause; in fact, more than the six next leading causes combined. Many non-fatal injuries cause permanent disability. With the encouragement of this committee, which last year
re-quested that we develop a special report on injury
pre-vention, and of the American Academy of Pediatrics, we
have developed two special solicitations for grant propos-als related to injury prevention.
It turns out, however, that $500,000 of the total request of $293,084,000, or 0.17%, of NICHD’s budget was being allocated to “the most important child health problem following infancy.” Hardly the dawn of the millennium.
ACADEMIC HUBRIS AND COMMUNITY INVOLVEMENT
In 1964, Freymann’3 wrote a fascinating paper on leadership in American medicine. He noted that from the time it was organized in 1847, until 1920,
the AMA existed primarily to reform and improve
medical education in the United States. The leaders
of the AMA were the great scientist-clinicians of
the era. Abraham Jacobi, for example, served as president in 1913. In a letter that is timely today Jacobi’3 wrote:
If my angry correspondents would
. . .
interest themselves in their county and state societies and in the elections of their various delegates, they would have less reason tocomplain of what some of them term the oligarchy of Chicago and the autocracy of the House of Delegates.
In 1920, most academicians left the AMA. The main reason, according to Freymann, was the emer-gence of full-time teachers and the fact that the medical education reforms had, for the most part, been completed.
William Osler, although not a president, was also active in the AMA. In 1911, he said:
What would the school [Hopkins] have been ifthe clinical
men had not been active in the local and national
socie-ties? Would whole-time men have the same influence in
the profession at large? I doubt it. (Quoted in reference
13.)
Writing in 1964, Freyman&3 said
The result [academicians leaving the AMA] is what one
might expect if the leadership of the American
govern-ment had been left, by abdication of interest and
respon-sibility, in the hands of the ultraconservatives who came
to power in 1921 with Warren G. Harding.
As president of the American Academy of Pedi-atrics this year, Robert Haggerty has done an
ad-mirable job of trying to get the academic and prac-ticing communities to pull on the same oar, espe-cially in the political arena. The relationship be-tween pediatric practitioners and academicians
needs to become even closer, for the sake of mutual
survival, if not common sense. It is more important that the interaction take place at the local and state
levels than at the national level. Specifically, I call
upon my academic colleagues to become involved
in state Academy chapters and local and state
med-ical associations. We can help each other. (I cannot,
in good conscience however, call upon my
col-leagues to join the AMA. Despite the admonition
of Dr Jacobi, that organization does not come close to representing my interests, and seems impervious to change.)
WE CANNOT AFFORD HUBRIS
Universities are under fire from legislators who want to cut costs. Medical schools are urged to cut back on the number of students, except when the
prospective students are the sons and daughters of legislators. Research is under fire from
antiintellec-tuals who demand high-visibility, quick-hit proj-ects, such as heart transplants. Research training money has virtually vanished.
Likewise, practicing pediatricians are under fire. Academicians generally fail to realize the impor-tance of such issues as malpractice insurance costs and vaccine compensation. The value of health
supervision is denigrated. Heavily promoted
“doc-in-the-boxes” bankrolled by large corporations threaten the survival of pediatric practitioners. Im-posed fee schedules are upon us, both from private insurance companies and state and local govern-ment. If no one fights for adequate fees for
chil-drens’ services, we can be certain that those services
will shrink even further.
Finally, because of lack of economic and political
power, the status of children in our society is
selfish-256 PEDIATRICS Vol. 77 No. 2 February 1986 ness in which children suffer. There are all too few of us who devote our professional careers to chil-dren to countenance unnecessary divisions.
No one person’s work is inherently more valuable
than another’s. We cannot afford hubris. We must
work more closely together so that we ourselves
survive and, more importantly, the interest of chil-dren is served.
You are not obliged to complete the task but neither are you at liberty to abstain from it.
Rabbit Tarfon in Ethics of our Fathers
ABRAHAM B. BERGMAN, MD
Department of Pediatrics
University of Washington School of Medicine
and Harborview Medical Center Seattle
REFERENCES
1.
Webster’s New World Dictionary-Second College Edition. New York. Simon & Schuster, 1984, p 6822. Thomas L: The hazards of science. N Engl J Med
1977;296:324-328
:3.
May CD: Can the new pediatrics be practiced? Pediatrics 1959;23:2534.
Simpson AM: A mythology of medical education. Lancet1974;1:399-401
5. Petersdorf RG: Academic medicine-No longer threadbare or genteel. N EngI J Med 1981;303:841-.843
6. Thompson HC: Twentieth-century US child health care-Past, present, future. Am J Dis Child 1984;138:804-809
7.
Bergman AB, Skinner AL: Professor-practitioner exchangeprogram. Pediatr Clin North Am 1969;16:815-820
8.
Balint M: The Doctor, His Patient and the Illness. New York, International University Press, mc, 1957, p 76 9. Education Committee of the Ambulatory PediatricAssoci-ation. Educational Guidelines for Training in General/Am-bulator-v Pediatrics. McLean, VA, Ambulatory Pediatric As-sociation, 1985
10. Rothenberg MB, Rothenberg J: The omnipotence-omnisci-ence syndrome: Medical education advances when interns retreat. Resident Staff Physician 1985;31:81-88
1 1. Bergman AB: The relevance of pediatric research priorities,
abstracted. Clin Res 1970;18:220
12. Bergman AB: The “Discovery” of SIDS. Lessons in the Practice of Political Medicine. Philadelphia, Praeger Pub-lishers, 1986
13. Freymann JG: Leadership in American medicine: A matter of personal responsibility. N EngI J Med 1964;270:710-720 14. Preston SH: Children and the elderly in the U.S. Sci Am
1984;251:44-49
Children
and Car Seats
Almost since the emergence of the First Ride-Safe Ride concept some 15 years ago, loan or rental programs for child car seats in maternity hospitals and community centers have been a popular method of promoting child restraint use. Today there must be hundreds of such programs
through-out the United States. The Dunedin rental program
(Pediatrics 1986;77:167-172) is certainly a unique
approach, but some aspects of it may lack practical application, at least in the United States. For ex-ample, it would be unlikely that we could saturate
a community with free car seats or have available
so broad a staff support system. The fostering of an attitude that views as “socially unacceptable”
allowing children to ride in cars unrestrained should be pursued here. What possibly distinguishes our
two countries also is that a child restraint law may have greater effect on compliance in New Zealand than in the United States. At least this appears to
be borne out as far as belt use is concerned.
Worth noting is the juxtaposition of legislative
intervention in our two countries. In the United States, legislation for child restraint use began with
Tennessee in 1978 and continued state by state until, by 1985, all had approved such a law. Seat belt laws, on the other hand, although introduced time and again in many state legislatures, fared less
favorably. It was not until January 1, 1985, that the
first belt use law went into effect in the State of
New York. At the time of writing, belt use laws
have been approved in 16 states and are in effect
in six. In New Zealand, belt use has been mandatory
since 1972, but the law exempts children younger than the age of 8 years. Interestingly, guidelines for
“model safety belt laws,” formulated by the US Department of Transportation in 1973, excluded
children younger than the age of 6 years, a stipu-lation we strongly opposed. There were no child restraints available at that time that would
accom-modate children older than age 4 years, and we knew then, as we know today, that the use of belts
is preferable even for small children than no re-straint at all. As it happened, the model belt laws
came to nothing.
One would have expected that the belt use laws
in place in New Zealand since 1972 would have raised the level of consciousness on the importance of child occupancy protection, yet at the time the
Dunedin experiment began, child restraint use was low and no child restraint law was yet in effect.
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Academic Hubris
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