American Pediatric Society Presidential Address 1997: The Ever-Whirling Wheel of Change

The ever-whirling wheele of Change, the which all mortall things doth sway.

Edmund Spenser; The Faerie Queene; Book VII, Canto 6, Stanza 1

It has been said in many different ways that nothing is permanent except change. Change is constant and inevitable, whether we like it or not. We are reminded of change by the colors of leaves in their seasons, the evolution of our children's lives, and what we look like in the mirror. It is clear from early writings that change has been a prominent concept since man first began to wonder about the meaning of life.

On the other hand, progress, that is, change toward something better, has not been an obvious concept. With few exceptions, ancient writers thought that mankind revolved in a cycle through a series of stages⁽¹⁾. The concept of progress remained extraneous to general Western thought until the sixteenth century, at the end of the Renaissance⁽¹⁾, perhaps deterred by the dogmas of medieval Christianity, veneration of Greek and Roman thought as the ideal, and feudalism⁽¹⁾.

Through much of this same period there was no real change, much less progress, in the teaching and practice of medicine in western Europe. The principal text books of anatomy and physiology remained those of a single individual, Galen, for almost 1500 years, from the second to the sixteenth century^{(2, 3)}. Medical school classes consisted of the professor, impeccably dressed in hat and gown, reading Galen's precepts from an elevated, throne-like chair (a cathedra), as if these precepts were commandments written on tablets by God. Bored medical students chatted irreverently down below, behind butchers or barber-surgeons who exposed anatomical parts as guided by the text⁽²⁾(Fig. 1).

Figure 1

An illustration from the Fasciculus Medicinae of Johannes de Ketham, Venice, 1493-94, in the collection of Yale University, Harvey Cushing/John Hay Whitney Medical Library. The illustration portrays the principal method of teaching in Western medical schools for almost 1500 years. The professor, sitting in a throne-like chair (cathedra), read in Latin from a text taken mostly from Galen. Students, standing below, watched passively as barber-surgeons exposed anatomical parts.

Although Galen preached the importance of anatomical accuracy based on observation, he interpreted what he saw in the light of his personal philosophy and theology. In addition, lacking a concept of progress that might promote change, Galen and his successors treated his writings as if they were so conclusive that further research was unnecessary⁽³⁾. Our academic medical predecessors of this period derived prominence from their skill in making whatever they observed in nature conform to Galen's teachings. Thus, free thinking and experimentation were inhibited in medical schools, and Western medicine advanced little in 1500 years. Consider the comment of Leonardo da Vinci toward the end of this period: “Strive to preserve your health, and in this you will the better succeed in proportion as you keep clear of the physicians”⁽²⁾.

Galenic orthodoxy was finally unraveled in the middle of the sixteenth century by Vesalius, who insisted that the teaching of medicine should be based on experience. He condemned teaching by readers who appear,“...like jackdaws aloft in their high chair, with egregious arrogance croaking things they have never investigated but merely committed to memory from the books of others”⁽²⁾. In the face of 1500 years of tradition. Vesalius had the courage to insist that students must see, feel, and decide for themselves.

Thus, Vesalius led academic medicine in a giant step forward. The practice of medicine, on the other hand, remained primitive; and wise men still kept clear of physicians. Consider this comment by Voltaire in the 18th century:“Doctors are men who prescribe medicine of which they know little to cure diseases of which they know less in human beings of which they know nothing”⁽⁴⁾.

So then, when did the practice of medicine achieve a level of quality appropriate for its critical importance to man's well being? Certainly, antisepsis, anesthesia, vaccination, sanitation, clean public water, and antibiotics moved us in that direction. But within our professional lifetimes standard pediatric care-with the best of intentions-has included the unproven practices of withholding feedings to newborn infants for up to 48 hours, giving magnesium sulfate enemas to babies with hyaline membrane disease to relieve pulmonary edema, administering immunoglobulin to prevent neonatal sepsis, and placing babies to sleep on their abdomens. And which of the practices we all endorse now might turn out to be as misguided as these?

So as our children ask in the car, “Are we there yet?” The answer, of course, is no. Change in clinical medicine comes slowly, even when the new intervention has been proven to work. Too often we prefer the status quo. It is interesting to note, in fact, that some of the practices and attitudes of the medical dark ages have survived into contemporary times. We share the human failings of our predecessors. Faculty who are sure they are right can still pronounce ex cathedra without an apparent need for substantiating data. Study sections and manuscript reviewers can still reject new ideas if they do not conform to dogma. Anyone who has made rounds at more than one medical school knows that fashion can still dictate local“standards of care.” And wise men should still fear doctors who do not practice evidence-based medicine.

One example of our resistance to change seems particularly unfortunate to me and warrants special mention. Specifically, academic medicine has been painfully slow to assign real value to prevention compared with cure. We all agree that prevention makes eminent sense, from the standpoint of both health and, usually, costs. Prevention is a fundamental principle in pediatrics. However, medical schools rarely consider how they should teach prevention or what they should teach. Residencies do better in this regard but still place relatively little emphasis on prevention. We assume that prevention is primarily the purview of governmental public health agencies at national and local levels, and we emphasize the patch-up. One of the most satisfying aspects of our discipline is the potential to improve the health and well being of our patients over a lifetime. The leading causes of death in North America can be prevented, or at least delayed, and in most cases efforts to prevent will be more effective if begun in childhood or adolescence.“One of our most pressing social needs,” said George Bernard Shaw,“is a national staff of doctors...whose prosperity shall depend not on the nation's sickness but on its health”⁽⁵⁾. In the words of Pasteur, “When meditating over a disease, I never think of finding a remedy for it, but, instead, a means of preventing it”⁽⁶⁾. Emphasizing prevention will clearly require a major change in attitude and priorities.

Although academic medicine has allowed itself so far to undervalue prevention, we may not be able to ignore pressures for change coming from the outside. The forces demanding change in clinical medicine are more numerous and powerful now than at any time in history. Some are happy in prospect: new knowledge gained from research in biology and medical science is itself sufficient to argue the concept of human progress. New discoveries drive further discoveries, faster and faster, continuously extending the horizon by revealing new areas of ignorance not previously imagined. Biomedical research has never been more exciting or more productive, and eventually our capacity to help our patients will be transformed.

Advances in the technology of information transfer will force us to change how we both teach and practice medicine. Increasing numbers of patients, as well as lawyers, will have easy access to more information than any doctor can possibly remember. This may have the beneficial effect for individual physicians and for medicine in general of pointing clearly to what we do not know, but the process of enlightenment could be painful.

To reduce the economic drain of high medical costs, leaders in industry and government have attempted to reform the business of medicine. The resulting“managed” systems of delivery, focused on economic goals with secondary consideration for the quality of care delivered, have forced us to change academic medicine and clinical practice, as you know well. In some academic medical centers only the threat of fiscal stress has allowed corporate interests and dollar-first attitudes to expand their influence in ways that threaten the core academic functions. Challenges like this to academic medicine will only increase as society changes rapidly around us⁽⁷⁾: The poorer countries of the world are accounting for a larger and larger share of the world's population. Immigration into developed countries is on the rise; one in six children born in the United States today has a foreign-born mother. The increased life span and higher average age of the population mean fewer workers to support the economy and higher health costs. The old motors of economic growth-land, capital, and natural resources-have been replaced by the education and training, organization, and motivation of a country's people. Good health is obviously fundamental to productivity, yet 40 million Americans have no health insurance, whereas the high cost of medical care is considered among the most serious weaknesses of the U.S. economy⁽⁷⁾. It is clear that powerful economic, demographic, and cultural forces will continue to pressure academic medical centers from the outside.

Thus, the practice of medicine exists presently in a state of uncomfortable disequilibrium, and the prospect for relief seems remote. We have to change, whether we want to or not. It is important to remember, however, that all changes are not of the same importance. How the delivery of care is organized, how it is paid for, even how much is paid, are not, after all, essential in themselves to our function as physicians. There is something more at the heart of what it is to be a doctor, namely, the responsibility to deliver to our patients the best possible health care, including treatment and prevention, whatever the circumstances or the setting. This ultimate responsibility gives us an elemental principle to guide the responses we must make to the pressures of health care reform.

In academic medicine we have additional basic responsibilities, to educate our students to deliver the highest quality care and to transmit to them the moral values that we hold fundamental to our profession. We also have the responsibility to translate new discoveries in basic biology and technology into improvements in the day-to-day practice of medicine and to derive new standards of excellence based on these advances.

In describing the far-reaching new changes that challenge organized medicine, I am thinking, of course, of pediatrics and of the children we serve. How will we respond? And how can the American Pediatric Society (APS) contribute to this response? In the past several months, the APS has strengthened its organizational infrastructure so that the Society is now in a much better position to help address the new challenges to academic pediatrics and child health. We have created an APS database of names and paired interests obtained from a questionnaire, and a newsletter and web site shared with the Society for Pediatric Research. The APS Council convented a special task force in February which created an APS Strategic Plan. The Plan was published in the recent newsletter⁽⁸⁾ and is shown in less detail in Table 1.

Table 1 APS Strategic Plan, 1997

The plan contains three major goals: to strengthen the academic functions of academic pediatrics against the disruptive forces of fiscal change, to develop academic pediatric leaders for the future, and to position the Society to participate effectively, as individual members or as a Society, in support of issues of high importance to academic pediatrics and child health. Additional efforts include strengthening the Society's ability to raise money to support broadened activities, and organizing the writing of a history of individual pediatric subspecialties. Work groups established to address these goals met for the first time at our national meeting. It was a significant beginning, and specific plans and functions will be developed in the months that follow. The newsletter will communicate the initiatives of these new work groups, and additional part-time staff in the APS office will support work group activities.

This plan is just a first step, of course. It describes a way to begin using the talent and broad experience that are so abundant in the APS. No other organization has more pediatricians in positions of influence, more who are proven leaders. Most retain the drive to improve pediatrics that led them into positions of leadership in the first place. It is time for this elite organization to change in response to the new challenges that face our discipline. It is time to harness the unique strength of the American Pediatric Society for the good of pediatrics. It is time to change.

Why should we bother? The answer, of course, is children. The goal of what we do in academic pediatrics and in the APS, in one way or another, is healthy children. We have so many successes in child health to celebrate, so much progress; but we have so much yet to do. In the last 10 years in the United States, low birth weight has actually increased by 9%, and deaths due to prematurity/low birth weight have increased by 21%⁽⁹⁾. This country's infant mortality rate remains 25th among developed countries⁽⁹⁾. We cannot effectively prevent autoimmune disease, asthma, autism, or most birth defects. We have hardly begun to translate new discoveries in basic science into improvements in pediatric care.

Children need to have academic pediatrics at the very top of its form, converting the energy of change into progress. Children need doctors educated in science-based medicine who see the opportunities to influence health for a lifetime. And children need the strong, active, creative participation of the members of this Society in efforts to strengthen academic pediatrics and to improve child health.