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Crossroads of care: Models of care and training for general pediatricians
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“I went down to the crossroads, fell down on my knees.
Asked the Lord above for mercy, ‘Save me if you please.’ ”
— Eric Clapton (Robert Johnson) “Crossroads,” 1968
“Nothing will sustain you more potently than the power to recognize in your humdrum routine, as perhaps it may be thought, the true poetry of life ...”
— William Osler, MD, “The Student Life,” in “Aequanimitas,” 1904
“One small voice can change the world
But you’d better be strong.”
— Carole King “One Small Voice,” 1983
I was recently asked to predict the future at a recent gathering of my residency class at Boston Children’s Hospital for our 30th reunion. I began on a doleful note: “As a practicing general pediatrician in private practice ... ” I had to stop to interject that I am not sure that there is a future for that animal. Certainly the private part, and as the models for care are refined, I question if general pediatric practice as it is now known, for better or worse, will survive.
While not necessarily ready to fall and pray, pediatrics as a discipline is at a crossroads. On the practice side, it is starkly challenged by walk-in care centers of the old business world as defined by Urgent Care, CVS and Wal-Mart and by hospital buyouts for strategic profit motives. As disruptive as they may be — these incursions may be dwarfed by the potential impact of a new corporate model led by Apple Health and Google Fit.
General pediatrics is also under attack from within by the fragmenting tug of subspecialization, a retreat from hospital care and a call for expansion of our practice to generational care. Even more sadly, we are being forced to finance our own potential demise with the burdensome demands of a multitude of trespasses — EMR, meaningful use, blueprints, maintenance of certification, medical home documentation, and conflicts with the public health bureaucracy over immunization schedules, refrigerator and freezer requirements, and even the definition of who is our patient. Without evidence-based data to support our model of visit schedules and anticipatory guidance, I would venture a wild guess that you are feeling stressed and vulnerable.
How do we learn?
I believe in the “all I really needed to know was how to think and that I learned in residency” school of thought. The rest is refinement. As I looked around at my fellow residency class I saw capital “p” Pediatricians. I would trust any of them to care for my grandchildren. While few are in general practice, and despite our varied travels, we still speak a common language forged by how we learned.
Less and less are those who claim to define the future of pediatrics speaking that common pediatric language. I fear now that decisions being made on models of care and training lack the voice of those who are passionate about what I do: care for patients and their families, striving to do justice to the ever-fascinating world of medicine and a tradition of excellence in care during a shared training that emphasized teaching and responsibility and modeled professionalism.
My fellow residents now represent the full spectrum of pediatrics from bench research to primary care. However, even after 3 decades, we still spoke to each other in a language oddly enough familiar as a weekend sign-out between senior residents. That language was infused by our mentors with a deep passion for expanding our knowledge in the pursuit of one compassionate goal, the improved well-being of all children.
It is no longer acceptable to have local definitions of medical school or postgraduate medical education. Power has devolved from a faculty charged with the future education of pediatricians to a faculty taxed by a dean, wed to relative value units, and in debt to a medical school or hospital whose idea of mission is limited to financial spreadsheets and business models. What is lost is a shared investment in the success of each other as pediatricians. If I had forgotten the importance of that simplicity, I remembered it at my reunion.
Battered by marketplace forces, distanced from our colleagues and puzzled by our current training paradigm, as that general pediatrician, I view the current discussion of the future of pediatrics as disappointedly being conducted in a language inherently biased by the academic milieu in which it is now founded, funded and discussed. The very same environment, I would add, that has both homogenized medicine and birthed a medical education bureaucracy unrivaled in its philistine acceptance of faddish education psychology.
Voice
We are in a crisis. Many of us belong to the last group to begin training before Diagnosis Related Groups tipped the balance of academic medicine’s almost century of commitment to teaching house officers in favor of the business of medicine and its capitulation to the medical business complex. We need to revolt and create a new active voice.
It is a voice tempered by the past, but excited about the future. It is a voice respectful of and inclusive of general pediatrics and girded by a redefined commitment to the true mission, the overarching historical force of the children’s hospital, of pediatrics and pediatric subspecialties: to improve the well-being of the children and their families in our immediate communities. To be sure, some children’s hospital communities extend worldwide. However, their origins still reside in their individual communities; breaking from their local commitments divorces them from their creators and, in doing so, invalidates the privileges granted to them by those communities.
There is, as Osler understood, a sustaining “true poetry of life.” The old model of education, training and care was a better model but lost its meter to a bureaucracy and a financial construct that devalued its core commitment to professionalism. The finances of medicine are again changing and with that comes opportunity. Perhaps that active voice could advocate for a better model. One like the old, remembering that “one small voice can change the world” and that they are all our children.
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- 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.