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A tale of two professions: A pediatrician’s place in the school health care model
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Forsan et haec olim meminisse iuvabit. (A joy it will be one day, perhaps, to remember even this). — The Aeneid, Virgil
And schooldays were the happiest days of your life But we never appreciate the good times we have until it’s too late Now I wish, I hadn’t strayed And I’d go back if I could only find a way Schooldays. — The Kinks (Ray Davies), “Schooldays,” 1975
ΔxΔp ≥ ℏ/2. — Heisenberg’s uncertainty principle
I began last month with a description of my trip to the Vermont State House as a voice for children in the school setting. The Vermont State House is a unique site for advocacy: Sitting on a sharp hillside in Montpelier, the only state capital still without a McDonald’s, the seat of power in Vermont is imbued with a deep respect for the past and a basis for a better union in the future.
A statue of Ethan Allen, leader of the Green Mountain Boys and one of the founders of the Vermont Republic, sculpted by Aristide Piccini, graces the portico. A portrait of Montpelier native George Dewey on the bridge of his flagship during the Battle of Manilla Bay and portraits of two native Vermonters U.S. presidents, Chester A. Arthur and Calvin Coolidge, greet entering visitors. Citizen legislators toil under its golden dome. “Freedom and Unity” is our state motto.
In recognition of the importance of nurturing community, Vermont’s original constitution called for the creation of a school in every town. As we advocate as pediatricians for the well-being of all children, we need to march with teachers to ensure a community-based, sustainable social commitment that addresses the physical and emotional needs of children from birth to adulthood as well as that of their families. The centrality of school to community dates to our founding. Respect for the past is part of who I am, and the past has its claims, but so does the future.
Forsan et haec olim meminisse iuvabit: Only in the light of the future does the past live again.
Models
Community claims center stage in our discussion of education and health care reform begun in last month’s commentary. The obvious conclusion is that a school-based social/mental health and medical model is best adapted to future success. Where should the pediatrician sit? Office? School? Both? Where should periodic visits occur and when? And with whom? Parenting coach, social worker, mental health therapist, nurse, special educator? Pediatrician? Unclear.
No rational body today would design a school model or a health model to serve the best interest of children and adolescents while sustainably serving the community and have it look anything like what we have today. The voices of classroom teachers, just as with office-based general pediatricians, need to be appreciated at the levels of decision-making.
Voice
In pediatrics, as within all primary care, that voice is currently drowned out by power structures within the medical industrial complex. Education is unfortunately buttressed by similar corresponding winds, now including the federal government as it has advanced an agenda of reform, based upon testing and benchmarks all designed on good intentions, in conference rooms far afield from the classroom, promulgated and financed by billionaires with profits to corporate entities distant from the community served. The voice of the classroom teacher is rendered moot. Sound familiar?
Community
What is our community? For most Vermonters, it is our children, our schools and our neighbors. For many of you, it is additionally your larger neighborhoods and cities. As pediatricians, we are linked with teachers as we ask, “What about this child?” To truly be successful with that child, we need to broaden support to the family, school, neighborhood and community.
It is not just money. In many ways the money is being spent now just not always in the most beneficial way. Paying to provide high school degrees to imprisoned youths — the largest high school currently in Vermont is the Community High School of Vermont, run by our state department of corrections — is necessary but perhaps avoidable with a redirection to prevention, identification and remediation. This reality makes a mockery of the deinstitutionalization of children and young adults of 40 years ago by imprisoning the same today.
School and office
With a true community focus, our schools would be the centers for the necessary social and mental health services we try to episodically create for our patients in our offices. Family-based education and training could be co-located. Food shelves and nutritional education could coexist. Early intervention and community day care could be coordinated — we know that early trauma is an enormous risk for significant developmental and mental health difficulties. Where the pediatric office sits is less crucial than how it coordinates.
The coordination of support over time and by family in a community setting is a better model. If freedom and unity are defined on a community level, it is that community that is responsible for solving the problems of poverty and violence. Neither a better school model, nor a better medical model, or even both in tandem, is sufficient to ensure the well-being of our children. It requires a broad societal commitment to be both effective and sustainable.
The Latin phrase above importantly contains the concept of “perhaps.” Likely because it may not be a joy, it may be misery to remember — especially if we do not do what is right today. Let’s hope that some, as in The Kinks’ song, will want to return to school, but at the very least, support their community school now.
I leave you with Heisenberg’s uncertainty principle. Not that particle physics directly relates, but to emphasize the humbling social implication of the principle — the more clearly we identify one element of an equation, the more ill-defined the other element may become. Unfortunately, the social sciences lack precise measurements. Clarity of all elements, however, requires respectful communication at the community level reflecting the tension of Freedom and Unity.
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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.