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Pediatrics: The state of our union and implications for the future
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One generation got old
One generation got soul
This generation got no destination to hold
Pick up the cry
Hey now it’s time for you and me
Got a revolution
Got to revolution
Come on now we’re marching to the sea
Got a revolution
Got to revolution
— “Volunteers,” Jefferson Airplane, 1969
Where is the wisdom we have lost in knowledge?
Where is the knowledge we have lost in information?
— “The Rock,” T. S. Eliot, 1934
Baby, that’s no lie.
Some of this generation is millionaires,
I can’t even keep decent clothes to wear.
— “Double Trouble,” Otis Rush, 1958
In part three of a series examining the pediatric “State of the Union,” I will attempt to reflect on the current state of pediatric practice and present a vision forward.
Anxiety and fear; professionalism and respect; education and culture. Change and increased complexity not of care itself, but of the trappings of care. Unclear vison of the future model of care – particularly of office-based practice. Physician or nurse practitioner. Solo, single, team or hybrid? Privately-owned or corporate healthcare organization? Electronic health records, guidelines and meaningful use. Training, hours and compassion. Knowledge, wisdom and information. It is a rough road, but we must take up the cry or we will lose the accumulated wisdom of our heroes.
The long anticipated change in pediatric office practice has indeed occurred. Those morbidities and mortalities hidden in the past by pressing childhood infectious diseases now play an ever-increasing role in daily practice. Mental health issues – anxiety, depression, attention deficit disorder, and serious behavioral disorders overwhelm us. A concern of their ever increasing frequency engenders an unease as to why and if there is something in our current social structures that is failing our youth.
The disparity of access to care afforded by income, the impact of family dysfunction and poverty, and the ignorance of antivaccination proselytizers all cast a pall over practice. Not to mention the corrosive nature of the current state of the electronic health care record. The day-to-day changes that an industrial paradigm has wrought has driven an ethical and compassionate model of medicine aside, and with it, many talented pediatricians.
Back to the future
Remember, as Franklin D. Roosevelt did, that our experiment in democracy calls for revision and revolution. So to our pediatric union. A view forward:
In 25 years — the centenniel of FDR’s speech — we should be able to decrease child poverty by 80%. No child should live in fear of violence, hunger or lack of caring. Currently, almost half of the children attending our public schools live in poverty — an example of our society divided by income and a disgrace. A well-funded public education system should revitalize our communities and strengthen our democracy. The teaching profession, like medicine, is at a crossroad, with their professionalism also challenged by a for-profit corporate model emphasizing testing and data over compassion and wisdom.
William T. Gerson
A coalition of the largest children’s hospitals in this nation will commit themselves to building a network of research both basic and translational welded to models of care provision that will reach every corner of the land. The Eunice Kennedy Shriver National Institute of Child Health and Human Development will be adequately funded to be able to establish the agenda and maintain the required structures. The AAP will continue its advocacy for the well-being of children by reaping the benefits of a focused and enthusiastic membership. The American Board of Pediatrics will be our link to our professional contract with society, enabling a continuous affirmation of pediatric competency as well as investing in the pursuit of truly effective local regional and national quality initiatives that will improve both our daily practice of care and the health of our patients and their families.
Most importantly, we need to find an avenue for the voice of the pediatrician in practice, no matter the exact setting, to mediate the bureaucratic elements that these changes will breed, as all changes seem to do. Feeling alone against the world is a recipe for decay. This is the infrastructure we need to invest in as much as roads and bridges and certainly more than any weapon system.
We must remember
Every member of the armed forces who served during WWII received a victory medal. On the obverse is Liberation looking to the dawn, one foot resting on a helmet with the hilt of a shattered sword in her right hand and the fragmented blade in her left hand, the inscription “WORLD WAR II” positioned immediately beneath. On the reverse are the inscriptions: “Freedom from Fear and Want” and “Freedom of Speech and Religion,” separated by a palm branch.
A pediatric equivalent for those taking up the fight might be the infant in swaddling clothes that is the logo of the AAP based on bas-reliefs sculpted by Andrea Della Robbia that adorn the “Ospedale degli Innocenti,” or Foundling Hospital in Florence, Italy. The hospital is the oldest known institution continuously devoted to the welfare of children and its building is felt by some to be the first truly Renaissance structure. The obverse might be John Enders, pediatric researcher, the father of modern vaccines and Nobel laureate (along with his colleagues and pediatricians Weller and Robbins) for the discovery of the ability to grow poliovirus in tissue culture. Enders could have one hand balancing childhood mortality and the other crushing a mythological figure of ignorance. In combining the justice of caring and an inherently progressive improvement of societal well-being by pediatric research, such a commitment could be confirmed.
In a dual set of obligations will we, as citizens of this nation, continue to carry forward Liberation’s message and, as pediatricians, remain dedicated to the health and well-being of all children? I hope so and will be excited to enlist and join the barricades of such a revolution. The next generation needs a “destination to hold” and proudly call home.
For more information:
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. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.