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Voyage of pediatric care: Examining historic roots of the pediatrician’s role
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Who are you? Who, who, who, who? — The Who, Pete Townshend, “Who Are You,” 1978
Who am I to stand and wonder, to wait While the wheels of fate slowly grind my life away? Who am I? Who am I? — Country Joe and the Fish, Country Joe McDonald, “Who Am I,” 1967
Whoever you are, now I place my hand upon you, that you be my poem, I whisper with my lips close to your ear, I have loved many women and men, but I love none better than you. — Walt Whitman, Leaves of Grass, “To You,” 1891
My friend Mort Wasserman, MD, MPH, a Vermont pediatrician and founder of the PROS (Pediatric Research in Office Settings) Network, spoke recently about the future of pediatric primary care, posing the question: “As pediatricians, what are we part of?” I will use the refrain, altered to speak directly to you, as “who are you” and “who am I.” Either way the question is the same: As general pediatricians in office practice, how do we define our future?
As Mort takes the public health perspective, I will use his position as a literary foil to my perspective from the office setting. I began this tapestry in last month’s column: How do we remain physicians and advocates for children and keep our soul and reimagine our community?
Do we need pediatricians to provide primary care?
The current paradigm suggests that physicians need not be the sole purveyors of primary care. Advanced practice nurses, innovations in care delivery, new uses of telehealth and e-communication, including hand-held point of service technology are all touted as alternatives. Are the new models an adequate substitute for the long-term relationships between pediatricians and their patients and families? I don’t think so.
One thing I do believe is indispensable is that the importance of having a medical advocate who puts the needs of children first has not diminished in this changing environment. But is that person in your examination room or in the consult room, or even worse, in the board room? The consequence of the compassionate laying-on of hands is as critical today as in the past.
How did we get here? What am I a part of?
Our search for the essence of medicine, of health care, takes us back thousands of generations. In The Republic, Plato has Socrates ask Thrasymachus:
“Is the physician, taken in that strict sense of which you are speaking, a healer of the sick or a maker of money? And remember that I am now speaking of the true physician. A healer of the sick,” he replied.
“Then, I continued, no physician, in so far as he is a physician, considers his own good in what he prescribes, but the good of his patient; for the true physician is also a ruler having the human body as a subject ... .”
In doing so, Plato/Socrates defines forever forward a physician as a healer of the sick whose interest is not his own, but that of the patient.
From a pediatric perspective, fast-forward to the philosophers John Locke and Jean-Jacques Rousseau at the turn of the 18th century, to the romantics William Blake and William Wordsworth to Charles Dickens and even Lewis Carroll by the middle of the 18th century as an image of childhood as innocent, even creative, began to erase the notion of sin and peril. Social justice replaced a religious paradigm as the motivating force of the modern era. Education and guidance, of children and their parents, became the tools for ensuring the health of community.
Sir William Osler, MD, physician and founding force of the transformation of modern medicine, speaking to medical students at the turn of the 20th century, linked the ancient to the contemporary: “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.” Osler’s more modern prescription set the tone for the 20th century physician and is no less powerful in the 21st century. It promises to practitioners, if adhered to, that broad charity can bring the greatest of blessings, peace of mind, a realization, and maybe, the promise of the prayer of Socrates for the beauty in the inward soul and for unity of the outer and the inner man. Even better, it successfully navigates the dichotomy of unity and freedom both individually and as a community; freedom and unity, a theme that marked the creation of our current Republic.
The future
At our level as practitioners, what does this mean? It is a force both amazingly simple and incredibly powerful. I believe it is best articulated by James Spence, MD, FRCP, British pediatrician, and a founder of social pediatrics, who wrote in 1949 that “[t]he essential unit of medical practice is the occasion when, in the intimacy of the consulting room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation, and all else in medicine derives from it.”
At times I question if general pediatric practice, as it is now known, for better or worse, will survive. General pediatrics is at a crossroads, starkly challenged by 24-hour, walk-in care centers of the old business world, by models of care that eliminate or significantly alter the role of pediatricians – usually the product of designs by public health experts, by hospital buyouts for strategic profit motives, by the disruptive effects of payment reform with unpredictable annual swings in payments that makes one yearn for “employee status.” Finally, general pediatrics is challenged by the unfulfilled promise of new business models of health embodied by Apple, Google, and their ilk.
There is a future in the Athenian model in its modern avatar for a safe and sustainable future for medical practice. It resides in the hands, the whisper, and the love expressed by Walt Whitman and articulated in the community practice of pediatrics. Who am I? — I am the soul of a practicing general pediatrician. Who are you?
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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.