Primary care: We need all the help we can get!






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Primarycare:We needall the

helpwe canget!

Primary care has finally been defined to the satisfaction of almost everyone and educational programs to prepare physicians to provide primary care to children have emerged in response to reason, demand, and dictum.1t Ques tions now arise as to who should provide the bulk of that care and how it can best be organized to ensure that the health care needs of all of our children are met. The politics of primary pedi atric care begin then to occupy more of our thought and discussion.

Dodds has reviewed the politics involved at all levels of pediatric care but speaks mostly to the conflicts that exist between general practitioners and pediatricians in the delivery of primary care.4 The Institute of Medicine has recently embarked on a study to assist in the development of a cohesive health manpower policy for primary care based upon: (1) a policy determination of what functions should be served by the primary care system, and (2) the specification of what roles should be played by various categories of health care personnel in the delivery of primary care

services. Two of the policy questions that will be addressed are whether primary care practice should be restricted to specially trained “¿primary care physicians― and what type(s) of physician manpower model(s) should be developed and supported to provide primary care services.

@ The

results of this study, due in 1978, will shape the future development of manpower resources for primary care.

In the meantime, and most certainly thereafter, these issues will be debated. White and Haggerty, who agree on most things, are at opposite poles concerning physician manpower for primary care. White's view is that “¿weneed to strengthen internal medicine and pediatrics, supported by psychiatry and obstetrics, in their concern for the provision of family-centered primary care and forget about the all-purpose family physician,―E; while Haggerty believes that “¿ifthe final purpose of the (medical) school is to help meet the medical care needs of the people, education for family practice must be an integral part of the curricu lum.―@

MacQueen, in his Presidential Address to the American Academy of Pediatrics,M said “¿wewill not support or participate in a restructuring or artificial stratification of American Medicine to conform to the stated expectations of the gener ally trained physician― and proposed, as an attain able national goal, that “¿withinthe next twenty years the great majority of all children in this nation shall have access to the quality care

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provided by pediatricians.― The care he refers to is at all levels including primary care.

In considering these positions, it is helpful to review the available evidence concerning pri mary pediatric practice as it is currently conducted. The National Ambulatory Medical Care Surveyu indicates that 121 million visits were made to physicians' offices by patients under 15 years of age during 1974. Of these, 42% involved pediatricians, 36% family practitioners, and 23% other medical and surgical specialists. Since a reasonable number of the visits to pedia tricians must have been for consultation and subspeciality care and very few, if any, of the visits to family practitioners were of this nature, the distribution of visits for primary care purposes between pediatricians and family practitioners would have been fairly equal.

These figures speak only to those primary care needs that are being addressed and do not include those that for economic, educational, and physi cian accessability reasons remain unaddressed. We are not providing to all of our children the levels of care deemed appropriate by the Amer ican Academy of Pediatrics. Miller states that

A ‘¿Preventive services which should be routine for every child are maintained at marginal levels at best, and at grossly unsatisfactory levels for the disadvantaged.―bo Results of studies of the levels of child health care achieved for specific popula tion groups demonstrate that for most children we fall far short of our goals.' ‘¿â€˜¿

@ These data show

that, in poor urban and rural areas, less than 5% of our children are receiving levels of well-child care consistent with the recommendations of the American Academy of Pediatrics and even in relatively affluent suburban and rural communi ties only one third to two fifths of children receive care at that level. More striking is that over one half of our indigent children receive essentially no well-child care. The percentage of children 1 through 4 years old (beyond infancy and prior to entrance into school) who are fully immunized is a good measure of the frequency with which the first objective of well-child care (prevention of disease) is accomplished. For youngsters in this age group who live in large urban areas in the United States, we do not do very well. In 1974 only 69% were immunized against diphtheria, pertussis, and tetanus, 61% against rubella, 60% against poliomyelitis, and only 63% were protected against rubeola by reason of vaccina tion or history of prior infection.'@ One of the qualities of primary care held to be important is that of continuity of care by a single physician. Andersen and his co-workers report that in 1970

only 25% of poor children had a private physician responsible for their care and 20% had no identi fled regular source of care.'

One of the reasons for our poor performance is the economic barriers that prevent access to primary care services despite federal- and state financed health care programs. Wallace and Goldstein have reported that the extent of coverage for payment of health care for children and youth, even those in high-priority groups, is still very restricted.'@ When economic barriers are removed, as with the implementation of the Medicaid Program, utilization of health services by populations not in the habit of seeking other

than emergency care lags 1@This

phenomenon is a reflection of the need to remove the educational barrier which interferes with adequate utilization of primary care services as well as the financial barrier. We must convince parents of the need to obtain preventive and curative health care for their children through primary educational efforts and with outreach, “¿searchand find―programs.

Most important to the discussions of who should provide prilllary care to children is the issue of accessibility in terms of the numbers and distribution of physicians. Although the doctor shortage debate continues with a variety of ways of addressing the question, the most important consideration in pediatrics is the number of children not receiving accepted levels of care. In

1972 Shonfeld and his colleagues' demonstrated that it would require 32 primary care pediatri cians working full time exclusively on child health supervision to provide well-child care for every 100,000 children under the age of 17 years. Applying their figures to today's child population (70 million under 17 years of age in 1976), should every Fellow of the American Academy of Pedi atrics (14,000) spend his or her entire working day on well-child care, only 63% of those children would receive adequate care using the current child health supervision standards. These calcula tions, of course, do not consider that all Fellows of the American Academy of Pediatrics are not in primary care practice. Obviously such an invest ment in well-child care would be unreasonable, particularly since it would not allow pediatricians time for care of children with acute or chronic illnesses.

The prospects for improvement in physician accessibility for primary care of children are not great. Although the number of pediatricians is predicted to increase from 18,820 in 1970 to 32,150 in 1980 and to 47,830 in 1990, the number of general practitioners will fall from 57,950 in


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1970 to 53,750 in 1980 and to 49,140 in 1990.2 Even though this represents an increase of over 20,000 potential primary care practitioners for children (76,770 to 96,970), and the percentage of general practitioners certified by the American Board of Faniily Practice will increase from 3% to

25%, the ratio of pediatricians and general prac titioners per 100,000 population will actually fall from 37.6 in 1970 to 34.5 in 1990.

These data lead one to conclude that Dr. MacQueen's stated goal of access to quality primary care provided by pediatricians for all of the children in our nation is not obtainable. This realization, however, should not deter us from setting a goal of access to quality primary care for all of our children utilizing family practitioners and other health professionals (pediatric nurse practitioners and child health associates) working in concert with pediatricians. The primary child health care turf does not need protection. Pedia tricians need all the help they can get to realize this goal.

There is no need to argue the quality issue. Family medicine educators point out that their residency programs concentrate on teaching primary care and family-focused continuity of care while most pediatric residency programs do not. A family medicine residency provides three years of education in the approach to patient problem-solving based upon the same physiologic principles utilized by pediatricians and internists. Swisher has estimated a 70% overlap in attitudes, values, and styles of utilizing medical care skills between family niedicine residents and pediatric and internal medicine residents which is perhaps greater in dealing with primary care m2' Pediatricians are involved in training family niedicine residents in their block assignments to inpatient units (minimally four months), in pedi atric electives (up to three months), and through out their three years of training in continuity patient care experiences. These efforts would be ludicrous if we were to adopt an ambivalent attitude toward the worth of primary care deliv eied to children by faniily practitioners. This is especially true since there are no data to show that pediatricians do a better job in delivering primary care to children than do family practi tioners.

If we accept the premises that large segments of our child population are not receiving what we feel to be optimal primary care and that good health care is an inherent right of all citizens and not simply a privilege available to those who can afford it, it becomes obvious that we must review and perhaps revise our criteria for adequate care

and establish methods of delivering primary care that will insure that all children receive that which they need. Pediatricians must maintain their leadership roles in these efforts and develop partnerships with family practitioners and others if we are to succeed.


Department of Pediatrics, University of Rochester

School of Medicine and Dentistry

601 Elrnwood Avenue

Rochester, New York 14642


1. Hansen MF, Reel) KG: An educational program for primary care. J Med Educ 45:1001, 1970

2. Alpert JJ, Charnev E: The Education of Physicians for

Primary Care. DHEW Publication No. (HRA) 74-:3113, 1973.

:3. Silver HK. McAtee PR: A descriptive definition of the

scope and content of primary health care. Pediatrics

56:957, 1975.

4. Dodds RW: A framework for political mapping of

conflict in organized medicine—especially pediat rics. Med Care Rev 27:1035, 1970.

5. The Development of an Integrated Policy for Primary

Care. Washington DC, Institute of Medicine,

. National Academy of Sciences, 1976.

6. \\‘hite KL: Medical care for children. Am j Dis Child


7. Haggert@ RJ: The role of the university in education for

family practice. New Physician 18:45, 1969. 8. MacQueen JC: Presidential address. Read before the

annual meeting of the American Academy of Pedi atrics, Washington DC, October 1975.

9. National Ambulatory Medical Care Survey. National

Center for Health Statistics, 1974.

10. Miller CA: Health care of children and youth in .@merica. Am J Public Health 65:353, 1975. 11. Mindlin RL, Densen PM: Medical care of urban infants:

health supervision. Am J Public Health 61:687,


12. Iloekelman RA, Zimmer AW, Kitzman HJ: Pediatric nurse practitioners and well baby care in a small rural community. In, 1972 ANA Clinical Sessions. New York, Appleton-Century-Crofts, 1973, p 10:3. 13. Hoekeli@ian RA, Peters EN, Zimmer MV: Utilization of available @ve1lbaby care by indigent population

groups. In. Haggerty RJ et al (eds): Child health and the Community. New York, John Wiley & Sons,


@ 185.

14. Statib lIP. Ct (Ii: health supervision of infants on the Cattaragus Indian Reservation, New York. Clin


15. Center for Disease Control: Summary of Immunization Status for Polio, DTP, Measles and Rubella, United States, 1974. Atlanta, Georgia, DHEW, 1975.

16. Anderson R, et a!: Health Services Use: National Trends

and Variations. DHEW, 1972.

17. Wallace HM, Goldstein H: Child health care in the

United States: Expenditures and extent of coverage


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failure with bidirectional shunting at the foramen ovale and ductal level together with pulmonary hypertension.6 7 Strangely, the initial observations on these complications were not to be expanded for many years and attention instead became directed towards the hemodynamic changes of the respiratory distress of the premature infant.@ More recently, the upgrading of neonatal care has resulted in fresh interest in the cardiovascular changes in the premature infant of low birth weight and has brought better understanding of the contribution to morbidity in these babies by a large left-to-right shunt through the ductus arteriosus.9 “¿

A parallel resurgence of interest has occurred for the term infant with cardiorespiratory distress. The group which first came under detailed scm tiny was that of term infants with marked cyanosis mimicking congenital heart disease. Some of these patients had polycythemia,12 and some had primary or secondary pulmonary paren chymal disorders which resulted in hypoxic pulmonary vasoconstriction, but in some theme was no obvious cause for what was termed “¿persistentfetal circulation.― “¿The characteristic feature of the latter type of disorder has been the presence of a low Pao2 value, generally with slightly higher values in arm or temporal artery samples than in those from the abdominal aorta and with variable change from increasing ambient oxygen concentrations. Hemodynamic data indicate the presence of a high pulmonary vascular resistance with right-to-left intracardiac shunting at both atrial and ductal levels but mainly at the latter site.

Another group of term infants with respiratory distress, where cyanosis was less conspicuous, emerged in the literature of the late 1960's and was variously described as type II respiratory distress syndrome, ‘¿4.


@ transient tachypnea of the

newborn,@6 and severe respiratory distress.'@ The characteristic feature of this group of patients was pulmonary hypertension or variable right-to-left or left-to-right shunting at atrial or ductal levels but without evidence of frank heart failure.

The heart size in both these groups was normal or only slightly enlarged on X-ray films and the lung vascular markings were either normal or slightly increased.'@ Attention paid to details in the electrocardiogram was limited in both types of presentation.

An added dimension has been given to the reports of cardiopulmonary distress in term infants since 1970 by the description of cases culminating in congestive heart failure.1926 In addition to respiratory distress, a large liver, with selected comprehensive services. Pediatrics

55:176, 1975.

18. Roghmann KJ, Haggert@ RJ, Lorenz R: Anticipated and

actual effects of Medicaid on the medical care

pattern of children. N EngI J Med 285:1053,


19. Schonfeld HK, Heston JF, Falk IS: Numbers of physi

cians required for primary care. N EngI J Med


20. The Supply of Health Manpower. DHEW Publication No. (HRA) 75-38, 1974.

21. Swisher S: Oral communication, June 1 1, 1976.



the newborn

Since the classic perinatal lamb experiments of Dawes and associates' led to the description of a transitional circulation of the newborn, pediatri cians have responded by an increasing apprecia tion of this concept. Independent studies indicat ing both indirectly and directly the existence of this normal intermediate circulatory pattern for the human were reported shortly thereafter.24 These investigations were later supplemented by elegant studies@so that a very clear understanding of the usual and normal time sequence of the change over from fetal to adult circulatory path ways in the healthy term infant has been with us for over a decade. The essential part of this change is one of a reduction in tone of the pulmonary vascular bed during the first six hours after birth followed by an increase in tone of the ductus arteriosus. Within 24 hours of delivery the healthy term infant has a functionally closed ductus arteriosus and a mean pulmonary arterial pressure substantially below systemic arterial


It was early appreciated that term infants could deviate from this normal change-over through such apparently innocuous events as whether the cord was clamped early or late. More importantly it was recognized that hypoxia could create intense cyanosis due to a return to fetal character istics of the pulmonary vascular bed and the ductus arteriosus or produce congestive heart

318 PEDIATRICSVol. 59 No. 3 March 1977

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Robert A. Hoekelman

Primary care: We need all the help we can get!


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Robert A. Hoekelman

Primary care: We need all the help we can get!

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