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Voyage of pediatric care: Visiting the precedent for today’s pediatrician
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Tell me
of the things you feel
of the visions inside your head/
why this
synthesis
whenever you are near
truth is
delirious.
— K.D. Lang, “What Better Said,” 2000
Soul is a feeling, feeling deep within
Soul is not the color of your skin
Soul is the essence, essence from within
It is where everything begins.
Soul is what you’ve been through
What’s true for you
Where you going to
What you’re gonna do.
Soul is your station for the folk of your nation
Something that you wear with pride
Soul can be your vision or something that is hidden
It’s not something that you gotta hide.
Soul is what you’ve been through
What’s true for you
Where you going to
What you’re gonna do.
— Van Morrison, “Soul,” 2008
Yes we have no bananas.
We have no bananas today.
— Frank Silver and Irving Cohn, “Yes! We Have No Bananas,” 1922
I wish to tell you the future of primary care pediatrics and the role of pediatricians in that future. While I have no crystal ball, nor any bananas, I do have strong feelings. I intend, over the next few columns to lead you through a story line that defines pediatric primary care and makes the case that pediatricians deserve the “primary” in primary care. This synthesis, as voiced in the K.D. Lang tune is truthful, hopefully not delusional, and visible whenever those dear enough to me (fellow pediatricians) are present.
My story line is a long one and will touch on what it means to be a physician. It will touch on our social contract with society that dates to Hippocrates and Plato, to the discovery of childhood in the 18th century, to Sir William Osler at the turn of the 20th century, and to the birth and development of pediatrics over the last 150 years, often focused on children’s hospitals and the pediatric practices that fed them.
Advocacy
More importantly, I will describe the grounding in advocacy for the well-being of all children that has marked this journey, particularly for American pediatrics, and has created great progress and enthusiasm over the last century and a half. I will, however, temper that progress with thoughts on the tension of public health and private health, as well as that of the modern medical establishment that permeates the last several decades and threatens the cohesiveness of that story line. I will attempt to show that when unbalanced, that tension creates confusion, especially among general primary care pediatricians, but also among thought leaders and the general public.
The primary care model we are familiar with now grew out of a public health model at the turn of the 20th century. The private physician/patient duality of health care in all its sanctity is ancient, but morphed into its current form with the transformation of American medicine under Osler and the founding of the Johns Hopkins University School of Medicine, and the influence of the Flexner Report on medical education at the end of the 19th and early 20th century.
The scientific transformation of medicine in the second half of the 20th century, including the creation of a vital pediatric branch, culminated in a revolution that influenced the direction of children’s hospitals and with that pediatric postgraduate education and importantly pediatric practice in the community. We all, practitioners and the public alike, have immeasurably benefited from that revolution.
The revolution of practice and the development of pediatric solo and group practices, often with close relationships with children’s hospitals, blossomed in the 1960s onward with a clear patient and family focus. Acute, life-threatening infectious diseases in the shadows of the preceding polio epidemics were the raison d’être of practice. Success with the treatments of fatal and now chronic and even curable disease was also an important influence: blue-baby syndrome, leukemia, diabetes and invasive bacterial disease. Premature birth led to NICUs, and advances in intensive care medicine led to PICUs. The great age of pediatric subspecialty practice — many of us were lucky to be witnesses to the first-generation founders — profoundly changed the shape of pediatric education, training and practice and has continued to define a positive change in the well-being of all of our children.
During the transformational times, public health and private health pediatricians spoke the same language. They trained in the same trenches and exalted in the same heroes and mentors — in fact, sometimes they were the same person. Times have changed, and that common language of compassionate care has not continued to be shared — and thus now a different view of the future if you have an MPH or are in general pediatric practice. A simplification, of course, but an avenue for voice is lacking for that of the general pediatrician, a mistake I believe, and an unfortunate lost opportunity for the future and persistence of improved care and the ultimate well-being of our patients and their families.
Community and soul
The way forward is actually to embrace the true essence of medicine and to rebuild our communities —including pediatric practices — to reflect omnipresent threats to our children. Thus, the current need for a synthesis of our professional pediatric soul with the twin heads of public and private health. It will also answer the mystery of how we as a society gained a medical profession without biologic efficacy and how we earned both children’s hospitals and pediatric primary care without pediatricians.
The answer lies in our communities and the spirituality of the patient visit. A voyage that extends from the Athenian polis to the American neighborhood.
As physicians we draw our professional soul from our community base, and as general pediatricians and advocates for the well-being of all children, our work begins and ends in those same communities. Soul is the essence: what is true for you, what you have been through, where everything begins, and it is what defines what you are going to do. Soul is revealed in the patient encounter. It’s a grand voyage, you’ll see. Hang on.
- 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.