Pediatricians must find their voice and speak up

Issue: January 2012

“The test of our progress is not whether we add more to the abundance of those who have much; it is whether we provide enough for those who have too little.”

– Franklin D. Roosevelt, second inaugural address, Jan. 20, 1937

If there is one word that could characterize our experiment in democracy in this country, it would be “voice.” And if there was ever a time where the voice of the primary care pediatrician needs to be heard, it would be now. It is unlikely that physician-dominant primary care will continue. The longer the present economic doldrums continue, the more focus will be applied to the size of health care spending and the perceived inadequate outcomes purchased with such cost. Unfortunately, those likely to decide on measures to alter the current medical landscape will have only a superficial, anecdotal understanding of how health care is actually delivered — unless we are able to find our voice.

William T. Gerson, MD

Here in Vermont, we have embarked on a legislative journey toward a single-payer system. We are early in the process, and I have no preconceived prejudice against altering our health care system. However, I do have some acquaintance with political voice, or lack thereof. The governor recently spoke to the medical staff of the largest hospital in the state and appealed for our involvement. Nice sentiments, but with little outlet for expression. A small panel of five individuals has already been empowered to design the system. I can only hope they get it right.

At least the board of Vermont’s Green Mountain Care has a clear reporting structure and the responsibility to consider the needs of all Vermonters. We all know, however, that not all “voices” in the upcoming discussion will be heard equally. As pediatricians, we know all about what counts in legislative action, and far too often that is not the interests of children.

It seems odd to me that as physicians we are so deferential to authority. I would think our training would have left us with a wariness of dogma. We not only have abdicated the strengths of our individual voices to quasi-representative bodies, but we rarely collectively speak up when these same bodies act in ways in which we so clearly disagree with both their actions and motives.

Who speaks for us? The AAP is enormously important. Rightfully, impressively, and most significantly for its stature and respect, it advocates for the health of children. An ally for those of us in general pediatrics when we speak out in terms of the health care needs of children, not necessarily the needs of those of us practicing pediatrics. For most of us, that is how it should be. If we are to design a system of health care for pediatrics — from medical school training, resident education, general and specialty practice, and hospital care — it must stand or fall on the basis of its ability to care for children and promote their well-being. Our status as a profession rests on this assumption.

Who are the other players to whom we have given over our responsibilities to define our profession? Clearly, we have endowed our medical schools with the power to define who enters and completes the first stage of medical training. They are complex organizations far beyond schools of learning, often encompassing health care systems of their own. Medical schools undoubtedly must be successful operations, as there are new ones coming on line, and many have happily given up their traditional names to honor the vast accumulation of wealth in the hands of a very few. Their prime dedication to the minds of their students is also a matter of some debate.

The Accreditation Council for Graduate Medical Education (ACGME) is responsible for accreditation of the nearly 9,000 residency training programs in the United States. It is a separately incorporated organization whose five institutional member organizations include the American Hospital Association, American Medical Association, American Board of Medical Specialties, Association of American Medical Colleges, and the Council of Medical Specialty Societies.

The ACGME, similar to its member organizations, is a nonprofit organization, which is not to say that it does not generate profits, full-time employment, self-perpetuating leadership and, most importantly, a self-defined political mission that includes self-preservation. Our certifying board, the American Board of Pediatrics, is constructed in a similar fashion. Although we have been lucky in its dedication to openness and diversity, it is not by design an advocacy group for pediatricians.

Voice in those organizations closest to us in practice is often hard to express. Pediatricians, despite how busy we are, need to find a collective means to affect the future model of pediatric education and care.

Our current organizational structure does not give voice to our needs. Although the AAP may be the most logical medium, an academic home would be nice. In whatever setting, acknowledgment of the financial implications of future practice means some degree of awkwardness.

A future that includes modified medical school and graduate medical education and significant non-physician primary care is unlikely to find a welcome tent anytime soon. But the political clock is ticking.

William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. Disclosure: Dr. Gerson reports no relevant financial disclosures.

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