When the first issue of Pediatric News was published 50 years ago, I was starting the second half of my first year in medical school. Over the ensuing 50 years, I have lived through and witnessed some dramatic changes in pediatrics. Here are just a few of the transitions that I’ve observed and Pediatric News has covered:
The birth of interventional neonatology
When I was an intern at Duke University Medical Center in Durham, N.C., a paper appeared in the New England Journal of Medicine describing the use of a simple continuous positive pressure apparatus for the treatment of respiratory distress syndrome entitled, “Treatment of idiopathic respiratory-distress syndrome with continuous positive airway pressure,” (1971 Jun 17;284[24]:1333-40). After seeing the paper, George Brumley, MD, the head of nursery, immediately had the hospital engineers build us our own setup, and we became part of what could arguably be called the revolution that turned neonatology into an interventional specialty.
Courtesy Dr. William G. Wilkoff
Dr. William G. Wilkoff
From meningitis to mental health
Although it came gradually, one of the most significant changes over the last 50 years has been the shift in the mix of pathology presenting to the general pediatrician. In the 1970s and 1980s, the threat of invasive bacterial disease, usually from Haemophilus influenzae, was always hanging over us. It was not unusual for a single community pediatrician to see four or five cases of meningitis in a year. The introduction of effective vaccines and more potent antibiotics lessened the threat of serious bacterial infection, and in its place came a flood of mental health complaints, including anxiety (25% prevalence among 13- to 18-year-olds, depression (13% prevalence among 12- to 17-year-olds) and attention-deficit/hyperactivity disorder (ADHD) (9% prevalence among 13- to 18-year-olds). The result is the impression that, at times, being a general pediatrician today feels like being a more than part-time psychiatrist/psychologist.
Mental retardation and autism
In the 1970s and 1980s, the diagnosis of autism was usually reserved for children with serious communication difficulties. Many physicians and the lay public expected that a child who was diagnosed with autism would have no speech at all. The prevalence of the condition in the last quarter of the century was felt to be about 1 in 2,000.
The more common diagnosis during that period was mental retardation. However, as the result of insensitive stereotyping, “mental retardation” has become an offensive term and has vanished from the pediatric lexicon.
Autism, however, has flourished, and a recent estimate cited by the CDC pegs its prevalence at 1 in 68. Based on my observations, I expect that much, if not most, of this increase is the result of expanded diagnostic criteria and relabeling.
Chicken scratches to mouse clicks
In keeping with a long tradition in medicine, my office notes when I began in practice were unreadable by anyone except a very few my long-term coworkers. My scribbles were brief and often included sketches of wounds and body parts. Their primary purpose was to remind me what had transpired at that office visit and to record the biometrics. Unfortunately, as the cloud of malpractice crept over the landscape, with it came the nonsensical mantra, “if it wasn’t documented, it didn’t happen.”
With the introduction of computers, medical records became inflated and often inaccurate, documents to be used primarily for data collection and risk management. The physician now is tasked with being the data entry clerk who must keep her eyes on the computer screen at the expense of a meaningful interaction with the patient. Sadly, the physician-unfriendliness of electronic medical records has driven many older and experienced pediatricians into premature retirement, robbing general pediatrics of their accumulated wisdom.
A part-time job
In 1975, there were 22,730 practicing pediatricians, of whom 23% were women. In 2011, there were 80,992 pediatricians, of whom 56.6% were women. The percentage of women practicing pediatrics continues to climb, with the most recent figure being 58%. From the patient perspective, this shift in gender dominance has been well received.
At the same time, there has been a trend toward more pediatricians of both genders pursuing part-time employment. The model of the physician being the owner/operator of a medical practice that was flourishing when I began in practice has been replaced by one in which the physician is an employee of a much larger entity, which is pressured from all sides to cut costs. To make matters worse, the Medical Home model that currently is in vogue is proving to be a more expensive vehicle for delivering health care. The patient now is asked to view his physician as the director of a team and may see him or her only infrequently, at the expense of the therapeutic benefits of familiarity.
When I was in medical school, the tuition was around $2,500/year, and I graduated with a debt of about $3,000 – with an interest rate so low that I was in no rush to pay it off. Now a student entering medical school can expect to pay around $60,000/year – an amount that has far outstripped inflation.
These realities combine to create a potentially unsustainable economic climate for pediatricians. I have had a wonderful 50 years being a pediatrician. But I can’t promise the same level of enjoyment to the next generation of pediatricians, unless someone can figure how to cut the expense of medical school and/or make part-time employment fit into a health care delivery system that must contain costs to survive.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com.