2009 Joseph W. St Geme Jr Leadership Award Address: The Whole—and the Sum of Its Parts
2009; American Academy of Pediatrics; Volume: 125; Issue: 1 Linguagem: Inglês
10.1542/peds.2009-1644
ISSN1098-4275
Autores Tópico(s)Adolescent and Pediatric Healthcare
ResumoI am tremendously honored to receive this award. To receive a leadership award named for Dr St Geme and to be associated with the previous awardees is a privilege and honor that I would say leaves me speechless, but you are not that lucky. Receiving the award in Baltimore is even sweeter, as my wife Ellen and I lived in Baltimore for 21 years, and it remains a special place for us: it is where we met, fell in love, got married, and raised our children. It is also where I received standard advice about preparing for an academic career: find a niche and ensure protected time to establish myself. The more I looked at each subspecialty, however, the more it became clear to me that I have the “curse of the generalist”: instead of wanting to know more and more about less and less, as the quip goes, I wanted to know more and more about more and more. As I looked at individual subspecialties, I saw gaps between them and envisioned a potential niche as a generalist bridging those gaps.During medical school, I had a rotation at Sinai Hospital of Baltimore and experienced the milieu of a community teaching hospital. It was different in many ways from the milieu at Johns Hopkins, and I found the differences fascinating. The differences were described in publications at the time, but I did not know that yet. I only knew that the institutions felt different and separate rather than feeling like integrated parts of an expanded whole. I became attracted to the potential to bridge gaps for the same 3 reasons I was attracted to pediatrics in the first place: intellectual stimulation; satisfaction (from what we accomplish); and fun (from the process—fun with a purpose). Don't minimize the importance of fun!I was lucky enough to be invited by Evan Charney to join him at Sinai Hospital—the same Sinai Hospital I had enjoyed as a medical student—to oversee the care of hospitalized children and help redesign a residency program. He afforded me the opportunity to be a “clinician-educator” and a “hospitalist,” though those terms did not exist yet (and I was assured by advisors that academic positions for clinician-educator generalists and hospitalists did not exist). In retrospect, it was precisely the kind of position for which I had received 4 years of special training: 2 years as director of the physician-development activity in the Centers for Disease Control and Prevention's (CDC) training program and 2 years of chief residency. So I eagerly accepted Dr Charney's offer. We started with a very small number of full-time faculty, and fun it was! In fact, I remember having the conscious thought while driving to work one morning, “I wonder how many other people going to work today are looking forward to it as much as I am?” Sadly, I'm sure the answer was “very few.”I remain attracted to bridging gaps, and we have no shortage of gaps to bridge. In the few minutes I have, I will not address huge critical gaps, such as health disparities or insurance-coverage inequities; to attempt to do so in such a short time would be a grave injustice. Let me address, instead, some gaps that have resulted from our own planning and which we have the ability to bridge. I will touch on 4 areas: education; institutions; faculty; and communication among ourselves.We speak of a continuum of education and learning, but the fact is that medical student education, resident education, and continuing education reside in 3 distinct worlds with various degrees of connectedness (Table 1). There are different accrediting bodies, different credentialing bodies, and even different organizations for individuals involved in 1 or the other. Does it matter? I believe it matters a great deal. When, as a residency program director, I collaborated with Al Scheiner, who directed medical student education in pediatrics, I faced the difficulty of not being able to build on what we provided our medical students, since not all of our residents came from our medical school. They all came highly recommended but with very different experiences on which to build. There was clearly a disconnect in the so-called continuum of education, and there still is—one that does not serve us, our trainees, or pediatrics well. It is time to take the fourth year of medical school back from travel agents and bridge the gap between the clerkship and residency. I am delighted to report that the Council on Medical Student Education in Pediatrics (COMSEP) and the Association of Pediatric Program Directors (APPD) met together just a few days ago. It was the first combined meeting of the 2 organizations—the culmination of some 10 years of lobbying the leaders of the 2 organizations. As my reward for this lobbying effort, I was given the opportunity to deliver the keynote address. The combined meeting was filled with intellectual stimulation and satisfaction. And fun. Figure 1 is a photograph taken at the end of the keynote address, when Bruce Morgenstern joined me on stage, and, as the “COMSEP-APPD Blues Brothers,” we preached collaboration to the tune of Proud Mary. This may seem like just whimsy, but the individuals in the photograph include 3 present or past presidents of COMSEP and 3 present or past presidents of APPD. If they could dance together with practiced choreography in front of a packed audience in a convention center, I am confident they will succeed in collaborating and taking back the fourth year of medical school!Data from the Agency for Healthcare Research and Quality document that fewer than one quarter of hospitalized children are in children's hospitals.1 “Children's hospitals” were self-defined by the reporting institutions and included not only freestanding children's hospitals but hospitals within a hospital and other variations; three quarters of hospitalized children are not in such institutions. Among the nearly 5000 community hospitals in the country (4912), approximately 2000 (2112 [43%]) have dedicated pediatric inpatient units,2 but 91% reported in a CDC/National Center for Health Statistics survey that they regularly admit children.3 Only around half of hospitalized children are in teaching hospitals; half are not.1 Of the 1000 teaching hospitals in the country, 621 have dedicated pediatric units, but again, a higher number admit children (822).2 And, only 398 of the teaching hospitals have pediatric residents (Jerry Vasilias, PhD, personal communication, June 4, 2008). So, however you slice it, there are many hospitals with children, including hospitals with nonpediatric trainees. Who is thinking about the care of those children? Are the children safe? Are they receiving good care? And, are the nonpediatric trainees at those teaching hospitals learning what we would want them to learn about the care of children? I'm not answering no to any of those questions. I'm answering I don't know. And when I say to myself, “I don't know,” I am intellectually stimulated. The literature about children's services in community hospitals is not vast,4–6 and there is work to be done. I can personally vouch that directing pediatric services in a community teaching hospital not only is intellectually stimulating but can also be tremendously satisfying. And, when you have great colleagues around you as I have had, it is great fun, too.The gap here is between town and gown. This is truly a gap of our own making or, at least, a direct legacy from our forebears in academic medicine. It probably did not originate with the Flexner report, nearly 100 years ago, but it certainly was institutionalized by it. The report stated that “a clinical professor should develop, preferably in close connection with the hospital, a consulting practice, assured thus that his time will not be sacrificed to trivial ailments” [italics added for emphasis].7 I have taken the liberty of emphasizing “sacrificed” and “trivial” in this statement, because I believe that words matter. “Trivial” came, in the minds of many in academia, to apply not only to the ailments but also to the individuals who treat them. Flexner did make a concession, however: “There is room in medical school for the nonproductive, assimilative teacher of wide learning, continuous receptivity, critical sense and responsive interest” [italics added for emphasis].7 “There is room… .” “Nonproductive… .” Words matter. So what has happened? We accept a model of how education experiences should be structured, at least as they apply to the teaching of subspecialties (Table 2): learners should be supervised by a trained, experienced physician who practices the subspecialty, and teaches it, in an appropriate setting. No one would consider establishing a separate neonatal intensive care unit for resident learning with various faculty members, who are uninvolved in the care of the patients, coming around at half-day intervals to answer questions. For primary care, we have not taken sufficient advantage of the resource of our own experts in pediatric primary care, pediatricians who practice primary care and can teach it in the appropriate setting—their offices. There is no need for us to accept the conventional wisdom that it takes 6 to 12 months for a graduate to learn how to practice pediatrics after completing a 3-year residency. We should recognize that as an indictment of our preparation of those graduates. Having them taught in the same model as used for subspecialties results in graduates who can hit the ground running, something we demonstrated in 2 institutions under the leadership of Evan Charney.8 I had the privilege to partner with Tom DeWitt in designing and conducting a faculty development program for community practitioner-preceptors,9 and there are now materials readily available to help programs and practitioners get started.10 There are also graduates of the Ambulatory Pediatric Association's (now the Academic Pediatric Association) National Faculty Development Scholars Program in every region of the United States with the skills to help.11I am referring here to communication between generalists and subspecialists; between hospitalists and community pediatricians; and across generations. Subspecialists complain that patients are referred to them without a specific question articulated, and in turn, generalists complain that they do not receive education or a collaborative plan from subspecialists.12 This poor communication limits both patient care and continuing education. We can nip the problem in the bud in our training programs by having attending pediatricians require trainees to articulate a question before requesting consultation and requiring subspecialists to ask what the question is before rendering the results of their consultation to the trainees. There is a special case, however: communication with mental health colleagues. This communication gap may not be of our making, but it is one we need to address. I'm delighted that individuals such as Ben Siegel, Jane Foy, and others at the American Academy of Pediatrics are working on this and that there are individuals such as John Straus in Massachusetts and Marian Earls in North Carolina directing much-needed demonstration projects.Communication between hospitalists and community pediatricians is a growing problem. A beautifully worded definition of “community pediatrics” appeared in the April 2005 issue of Pediatrics.13 In the same issue, 7 pages later, was another beautifully worded statement, this time about hospitalist programs.14 I have again taken the liberty to emphasize some words: “hospitalist program[s] should be designed to meet the unique needs of the patients, families, and physicians in the community it serves,” they “should include in their design provision for appropriate outpatient follow-up,” and they “should provide for timely and complete communication between the hospitalist and the physicians responsible” [italics added for emphasis]. So how are we doing? In terms of the timely and complete communication, a survey of hospitalists programs revealed that communication with primary care or referring physician was defined or expected in 87%.15 The defined or expected pattern included “on admission” in 61%, “during the stay” in 54%, “on discharge” in 43%, and “providing a discharge summary” in 71%. Not even sending a discharge summary 29% of the time? We are creating more gaps. Our trainees are getting a message that hospital pediatrics and community pediatrics are mutually exclusive careers. If they are, we have created a gap that needs to be addressed for the sake of children and, I think, for the sake of our own house of pediatrics as well.Finally, communication across generations. Those of us born before 1945 were followed by the baby boomers, and we did just fine together. With generation X came the introduction of some valuable electronic tools, such as e-mail. Some challenges started to emerge, the beginning of “interesting times,” as the curse goes. We are now seeing a lack of satisfaction being expressed by pediatricians at a rate that troubles me16 (Table 3). As we see more and more of our workforce working part-time with that portion of the workforce being the younger segment, rather than the traditional expectation of the older segment looking to cut back17 (Fig 2), we need to address gaps in expectation, satisfaction, and engagement in our profession, as these will certainly affect the future of pediatrics.In summary… Okay, those of you who know me are trying to figure out how I got this far in the presentation without any music. In fact, you probably haven't heard anything I've said for the past 10 minutes waiting for the music and growing increasingly anxious. Let me relieve your anxiety. For those who don't know me and question the respectability of inserting music into such an august meeting as this one, let me cite as my vindication the observations of noted neurologist, Oliver Sacks, the author of Awakenings. Dr Sacks has observed that individuals with aphasia may retain the ability to sing songs from their youth.18 The lyrics stay with them. So let me leave you with these lyrics as a challenge to each of us and all of us in pediatrics: “Come together.” When? “Right now.” And I invite all of you to take the next 2 words personally and commit yourself: “Over me.”19Thank you again for this great honor.
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