Book Review

The New Pediatrics: A profession in transition

N Engl J Med 1997; 336:230January 16, 1997

Article

The New Pediatrics: A profession in transition
(Social Problems and Social Issues series.) By Dorothy Pawluch. 175 pp. Hawthorne, N.Y., Aldine de Gruyter, 1996. $41.95. ISBN: 0-202-30534-1

My first surprise on opening this slender book was that it was written by a single author, a sociologist. This fact aroused my interest as an academic neonatologist and my hope that the topic of pediatrics would be presented from a social perspective. (The book is one of a series entitled Social Problems and Social Issues.) The introduction makes clear that the focus of the book is the new practice of pediatrics, defined as responsibility for the “problematic behaviors of children and teenagers.” With this in mind I could recover from my surprise at the omission of topics such as neonatal–perinatal medicine, which is the largest subspecialty in pediatrics; major advances in cardiac surgery; organ transplantation; effective immunization against poliomyelitis, measles, and Haemophilus influenzae; and the impact of Benjamin Spock and T. Berry Brazelton on aspects of child care.

My second surprise was the attention paid to the dissatisfied pediatrician syndrome, which was first noted in the 1950s. Surely, the changing emphasis in pediatrics — from infant feeding in the early part of the 20th century to the use of antibiotics in the 1940s and subsequently to the biochemical bases of disease, intravenous therapy, and the package of services known as intensive care (among others) — caused a shift in practice that demanded continuing education for practitioners in order for them to keep up with relevant new knowledge. The introduction of an emphasis on prevention (anticipatory guidance) and new conditions was yet another step in the natural progression of the specialty, as some old challenges, such as poliomyelitis, were eliminated thanks to medical research.

Were pediatricians dissatisfied or thrilled to see infant and child mortality fall steeply from 1900 to 1950, a decline attributed to a major extent to public health practices? Neonatal mortality fell equally steeply from 1950 to 1990, in part because of the application of new knowledge that led to better techniques and therapies for mothers and infants. The author makes no mention of the role of legalized abortion in reducing neonatal deaths.

Finally, I was surprised to see so much weight given to the idea that nurse practitioners and family practitioners pose a threat to pediatricians, and so little awareness of the exciting aspects of the practice, with its continuing new challenges brought about by changing lifestyles of parents, divorce, and the impact of television. Surely, the needs of parents and children are not met solely by pediatricians and other pediatric specialists. These specialists, in collaboration with others, share a responsibility to provide anticipatory guidance and to keep themselves up to date on the diagnosis and treatment of disease. It is also their professional responsibility to describe new conditions and to try to discover the causes and means of preventing existing diseases.

Throughout the book the author has documented her views with quotations from pediatricians obtained from the medical literature and in many instances from personal interviews. Her emphasis is selective, and accurate as far as it goes.

I think I speak for many pediatricians who enjoy their ever-changing profession. Of some interest from a social perspective is the high percentage of female residents in pediatrics in the United States in 1996 (4494 of 7394 residents, or 61 percent). In comparison, only 32 percent of residents in internal medicine (6685 of 20,693) were women. Evidence of increasing interest in pediatrics by senior medical students is shown by the fact that 9.6 percent chose pediatric residencies in 1988, as compared with 11.2 percent in 1995 and 11.6 percent in 1996. There has been a similar increase in interest in general pediatrics.

Disgruntled pediatricians? A more accurate description of our current trainees would be that they see a challenging career ahead. They might be amused by Pawluch's inclusion of an astounding comment made in 1937 by John Lovett Morse, one of my predecessors as professor of pediatrics at Harvard Medical School:

The other end of life now offers the greatest field of development. There are more old people than there used to be, and almost all of them are ill in some way, or, at any rate, are wearing out; they like many visits; they are more interesting than children; the doctor is not blamed when they die; and the estate pays the bill. . . . My advice to young physicians is, therefore, to take up geriatrics, not pediatrics.

Maybe Dr. Pawluch will want to update her views about the new pediatrics. I hope so, since her well-written and well-researched viewpoint reflects only part of the story. At the very least, her viewpoint is provocative.

Mary Ellen Avery, M.D.
Harvard Medical School, Boston, MA 02115